Committee Chair Talks New CHEST Lung Cancer Screening Guidelines

By Peter Mazzone, MD, MPH

The new lung cancer screening guidelines presented at CHEST 2017 have now been confirmed and published in CHEST. Unlike our previous guideline, this version includes recommendations for implementation of low-dose CT screening, from how to select patients appropriately to how to manage abnormal results. We also updated some of the core recommendations and have provided less formal statements based on expert consensus where evidence does not support formal guidelines.

Our rigorous, systematic review of the most recent literature regarding lung cancer screening helped the panel develop six graded recommendations and nine ungraded, consensus-based statements. Noteworthy updates to existing core recommendations include:

• An increase in the age of screen-eligible patients from 74 to 77.
• A recommendation against LDCT for individuals:
  • At low risk for lung cancer
  • With comorbidities that substantially shorten life expectancy
  • Unable to tolerate evaluation of findings
  • Unable to tolerate treatment of early-stage lung cancer
• A recommendation against routine screening for the cohort of patients deemed high risk based on clinical risk prediction calculators given the high incidence of comorbidities that negatively influence morbidity from evaluation and treatment of findings. We noted that LDCT should be considered in some individuals in this cohort who might be healthy enough to benefit from screening.
• A note that all symptomatic patients should receive a full diagnostic evaluation. Debates about the harms and benefits of screening primarily focus on asymptomatic patients.

While we have seen an increase in favorable outcomes utilizing a centralized management approach at Cleveland Clinic, the guidelines recognize that screening programs come in many forms. Increasing access to high quality screening programs is a priority for improving patient outcomes, and the panel has provided statements to guide programs regarding:

• Incorporating evidence-based tobacco cessation
• Ensuring compliance with annual screening exams
• Offering effective shared decision-making visits prior to LDCT
• Performing the LDCT properly
• Reporting exam results in a consistent, structured manner
• Developing an optimal approach to nodule management and incidental findings
• Utilizing reporting tools to collect data important to quality improvement initiatives

As guideline chair, my hope is that the new recommendations and statements will allow high quality screening programs that respect patient values to proliferate. When high quality programs screen patients, the balance of benefit and harms tips toward lung cancer screening — cancers are detected sooner, and fewer unnecessary interventions occur.

Dr. Mazzone is Director of the Lung Cancer Program and Lung Cancer Screening Program for the Respiratory Institute.