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L u n g C a n c e r S c re e n i n g

with Low-Dose Computed

Tom o g r a p h y f o r Pr i m a r y C a re
P ro v i d e r s
Thomas B. Richards, MDa,*, Mary C. White, a
ScD ,
Ralph S. Caraballo, PhDb

KEYWORDS
Lung neoplasms Screening Computed tomography Primary health care
Practice guidelines Smoking cessation Shared decision making

KEY POINTS
The US Preventive Services Task Force recommends annual low-dose computed tomog-
raphy (LDCT) screening for lung cancer for persons at high risk for lung cancer, based on
the age and smoking history of the individual.
Lung cancer screening with LDCT does not prevent lung cancer, nor does it eliminate the
need to extend smoking cessation referral and support to current smokers screened for
lung cancer.
Several organizations have recommended that lung cancer screening with LDCT be con-
ducted as part of structured, high-volume, high-quality programs by a multidisciplinary
team skilled in the evaluation and treatment of lung cancer.
It is important for primary care providers to know the resources available in their commu-
nities for lung cancer screening with LDCT and smoking cessation, and the key points to
be communicated to patients for informed and shared decision-making discussion about
lung cancer screening.

The findings and conclusions in this report are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.
Disclosures, Funding Sources, and Conflicts of Interest: None.
a
Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and Prevention, Building 107, F-76, 4770
Buford Highway Northeast, Atlanta, GA 30341-3717, USA; b Office of Smoking and Health,
National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, Building 107, F-79, 4770 Buford Highway Northeast, Atlanta, GA
30341-3717, USA
* Corresponding author. Epidemiology and Applied Research Branch, Division of Cancer Preven-
tion and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention, Building 107, F-76, 4770 Buford Highway Northeast, Atlanta,
GA 30341-3717.
E-mail address: TRichards@[Link]

Prim Care Clin Office Pract 41 (2014) 307–330

[Link] [Link]
0095-4543/14 Published by Elsevier Inc. Open access under CC BY-NC-ND license.

Descargado para Anonymous User (n/a) en Colegio Medico Del Peru de [Link] por Elsevier en diciembre 10, 2018. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados.
308 Richards et al

POPULATION MEASURES OF LUNG CANCER

Occurrence
Each year in the United States 206,000 people are told that they have lung cancer, and
160,000 die of this disease.1 Lung cancer represents 14% of all invasive cancers diag-
nosed each year and 28% of all cancer deaths in the United States population.1 The
overall 5-year relative survival of patients with lung cancer is less than 18%.2 More
than half of lung cancers have distant metastasis at the time of diagnosis, and the
5-year relative survival after distant metastasis is less than 5%.2 The average life ex-
pectancy of a patient with lung cancer is shortened by about 14 years.3

Cost
The total national cost of lung cancer care in 2010 was estimated at more than US$12
billion, and the cost could grow to exceed $18 billion by the year 2020.4 The deduct-
ibles and copays incurred by individual patients with lung cancer can exceed well over
$1000 per month.5 Lung cancer screening with low-dose computed tomography
(LDCT) at the patient’s own expense can result in decreased intention to undergo
screening and a lower adherence to attend an annual follow-up.6 Some health care
facilities have developed initiatives to provide the initial examination for lung cancer
screening with LDCT at no cost to the patient.7 National estimates of additional annual
health expenditures related to lung cancer screening are still in the early stages, make
different assumptions, and have come to varying conclusions.8–12 The costs of an
initial LDCT examination for lung cancer screening have been advertised at $99 to
$1000.13 The additional costs associated with follow-up evaluation and the treatment
of abnormalities can be substantial; the implementation of lung cancer screening with
LDCT has been estimated to increase the annual national health care expenditures by
$1.3 to $2.0 billion if the screening rates were to reach 50% to 75% among those
eligible for screening.11

Patterns Across Age, Sex, and Time

During the period 2005 to 2009, the incidence of lung cancer in the United States was
highest among those aged 75 years and older, and decreased with decreasing age.14
In all age groups except persons younger than 44 years, incidence rates of lung cancer
were higher among men than among women; this difference being greatest among
those aged 75 years and older, and narrowed with decreasing age.14 In men, age-
adjusted death rates for lung cancer increased until 1990 and then began to
decrease.15,16 In women, age-adjusted death rates for lung cancer peaked in 2004
and have had a lower rate of decline than for men.16 These trends in incidence and
mortality are thought to reflect changes in smoking patterns over time.17,18

Disparities
Disparities exist in the incidence and death rates of lung cancer within the United
States population by race, ethnicity, and geography. Among men, the incidence
and death rates are highest among blacks than among other racial and ethnic groups.1
Among women, the incidence and death rates are similar between whites and blacks
and highest among whites in comparison with other groups.1 At all ages for both men
and women, Asian and Pacific Islanders and Hispanics have lower incidence and
death rates than other groups.1 Incidence of lung cancer varies between states,14,19
and is highest in the South and lowest in the West.20 Large geographic differences
have been demonstrated in incidence rates of lung cancer for American Indian and
Alaska Native populations, with the highest rates in the Plains and Alaska.21 Research

suggests that multiple factors may be associated with tobacco use, including socio-
economic status, education, cultural beliefs, and environmental influences.22–24 Differ-
ences in the prevalence of exposures to other carcinogens and risk factors may also
explain some of the observed differences in incidence rates between whites and
blacks.25 In addition, differences in access to and the use of health care services, in
addition to the quality of treatment, have been shown to contribute to disparities in
outcomes of lung cancer.26,27 In a recent study, fatalistic beliefs including the concern
that radiation exposure from a computed tomography (CT) scan could cause lung can-
cer and anxiety related to CT scans were reported to be strongly associated with a
decrease in the intention to undergo screening among black and Hispanic adults in
comparison with nonminority adults.28

Histology
Lung cancer refers to a group of cancers that form in the lung; different types have
traditionally been distinguished by the differences in the morphologic appearance
observed under a light microscope. Genetic and genomic criteria are needed to better
understand and predict the varying biologic behavior of the different types.29 Often in
public health statistics, nearly all lung cancer is presented as 2 categories: non–small
cell carcinoma (85% of the total lung cancer cases) and small cell carcinoma (14%).2
Non–small cell carcinomas are further classified as adenocarcinoma (41% of the total
lung cancer cases), squamous cell and transitional cell carcinoma (21%), large-cell
carcinoma (3%), and non–small cell not otherwise specified (20%).2 Data from
selected cancer registries in the 1960s and 1970s showed an increase in the rates
of adenocarcinoma, and by the 1980s adenocarcinoma had become more common
than squamous cell carcinoma among both men and women.30 The incidence of small
cell lung cancer has decreased over time; whereas 73% of cases of small cell lung
cancer were initially in men, the male-to-female ratio is now 1:1.22.31 Details on the
histology of lung cancer are important considerations for its clinical management.
For example, surgical resection is the primary treatment for stage I and II non–small
cell lung cancer in patients with small surgical risk.32 By contrast, localized-stage
small cell lung cancer is treated with concurrent chemoradiotherapy.33

ETIOLOGY
Tobacco
Cigarette smoking is the major cause of lung cancer in the United States and world-
wide.34–36 During the period 2005 to 2009 in the United States, excluding deaths
from second hand smoke, 84% of annual deaths from lung cancer in men and 76%
in women were attributed to cigarette smoking.35 Only a fraction of smokers develop
lung cancer in their lifetime and lung cancer can develop in non-smokers, indicating
that other factors in addition to smoking play a role in its development.18,37,38 The
most effective preventive measures are to never start smoking or to stop cigarette
smoking as soon as possible. In 2012, 18% (42 million) of United States adults aged
18 years upward were current cigarette smokers.39 The risk of lung cancer increases
with both the duration and intensity of smoking,34 but the number of years smoked
is a stronger predictor of lung cancer than the number of cigarettes smoked per day.40
Over the course of a lifetime, the risk of developing lung cancer can be 20 times or
greater for smokers than for lifetime nonsmokers.34 Smokers who quit smoking
continue to have a higher risk than lifetime nonsmokers of developing lung cancer,
but this risk diminishes over time.38,41 More than half of all adult current smokers
have attempted to quit for at least 1 day in the past year.42 Charts to demonstrate

the harms of cigarette smoking have been developed for use by physicians to discuss
these issues with patients.43 The charts show the 10-year risks of dying of lung cancer
considering age, sex, and smoking status (current smoker, former smoker, and life-
time nonsmoker). The charts are available online in several formats, and can be posted
in clinic offices for easy reference or distributed among patients.43

Secondhand Smoke
Secondhand smoke is the term used to describe sidestream smoke (the smoke
released from the burning end of a cigarette) and exhaled mainstream smoke (the
smoke exhaled by the smoker). Secondhand smoke is a recognized cause of lung
cancer; however, the secondhand smoke-attributable mortality for lung cancer is
4%.35 The increase over the background risk of lung cancer among nonsmokers living
with a smoker has been estimated to be 20% to 30%.35 According to data from the
National Health and Nutrition Examination Survey, during 2007 to 2008 approximately
88 million nonsmokers aged 3 years or older in the United States were exposed
to secondhand smoke. The prevalence of exposure was higher for children (aged
3–11 years) and youth (aged 12–19 years) than for adults aged 20 years or older.35
During 2005 to 2009 in the United States, 7330 deaths from lung cancer were attrib-
uted to exposure to secondhand smoke among nonsmokers.35

Radon
The US Environmental Protection Agency (EPA) publication “A Citizen’s Guide to
Radon” is an excellent resource for any questions about radon.44 Selected highlights
are as follows. Radon is a radioactive gas produced by the natural decay of uranium in
soils, rocks, and water. Radon gas can seep into buildings through cracks in founda-
tions, accumulate in indoor air, and thereby increase the risk of lung cancer for both
smokers and nonsmokers.45 In the United States, an estimated 1 in 15 American
homes have high levels of radon. The EPA and the Surgeon General recommend
testing all homes for radon. Test kits can be obtained from state radon programs,
home improvement and hardware stores, and other sources.44,46 Radon is measured
in picocuries per liter of air (pCi/L). On average, radon levels are 0.4 pCi/L for outdoor
air and 1.3 pCi/L for indoor air. The EPA recommends radon mitigation to 2 pCi/L or
less if indoor air levels remain at least 4 pCi/L.44 A certified or qualified radon
contractor should design and install the radon-reduction system.44 The design de-
pends on the house, but a common example is a soil-suction system to prevent radon
from entering the home, whereby a pipe system and fans are used to draw radon gas
from below the home and vent it to the outside.44

Occupational Exposures
Many chemical and physical agents have been demonstrated to cause lung cancer
among working populations. Some of the most frequently mentioned occupational
lung carcinogens include asbestos, beryllium, cadmium, chloromethyl ethers, chro-
mium (hexavalent, hereafter abbreviated VI), nickel, diesel exhaust, radon, and sil-
ica.36,47 Industries with higher levels of exposure to lung carcinogens include
mining, construction, manufacturing, agriculture, and certain service sectors. The
number of adult workers in the United States exposed to carcinogens at work has
been estimated to be many millions.48 Tens of thousands of chemicals used in indus-
tries have never been evaluated for their carcinogenicity, and many of these chemicals
are found in the general environment and consumer products.48 Special occupational
standards have been established for only a relatively small number of lung carcino-
gens, including asbestos, arsenic, chromium(VI), cadmium, and formaldehyde.49

These standards were established after lengthy regulatory proceedings that consid-
ered many factors in addition to the health risk, including the feasibility of controlling
the exposures and limits in the monitoring technology.

Outdoor Air Pollution

The combustion of fossil fuels by motor vehicles and other sources releases fine par-
ticulate matter, diesel exhaust, and other pollutants into the atmosphere. A growing
body of evidence links outdoor air pollution with increased rates of lung cancer in
the general population.50,51 In 2013, the International Agency for Research on Cancer
(IARC), a special agency of the World Health Organization, classified outdoor air
pollution as carcinogenic to humans and found sufficient evidence to conclude that
exposure to outdoor air pollution causes lung cancer.52 Particulate matter, a major
component of outdoor air pollution, was evaluated separately and was also classified
by the IARC as carcinogenic to humans. In 2007, 13.6% of the general United States
population resided in counties that exceeded the air pollution standard for fine parti-
cles, and minority groups were more likely than whites to live in these areas.53 In addi-
tion, an estimated 1.8 million tons of mobile sources of toxic emissions in the air were
reported in 2005 in the United States; a Healthy People 2020 objective is to reduce this
figure to 1 million tons.54

Additional Risk Factors

Several other factors are associated with the increased risk of lung cancer. Examples
include family history of lung cancer; chronic obstructive lung disease; fibrotic lung
disorders such as pneumoconiosis; and human immunodeficiency virus (HIV)
infection.36,55

LUNG CANCER SCREENING TESTS

Computed Tomography Lung Examinations
LDCT tests (sometimes abbreviated as low-dose CT) can be used to screen individ-
uals at high risk for lung cancer. The individual lies still on a table, and the LDCT scan-
ner rotates around the individual as the table passes through the center of the scanner.
The entire chest is scanned in about 7 to 15 seconds during a single breath-hold. The
scanner may include more than 1 source of x-rays. The x-ray sources follow a path
similar to a helix or spiral as they rotate around the patient (some publications use helix
and others use spiral; these terms are interchangeable). Rows of detectors are used to
capture the x-ray information corresponding to multiple cross sections (thin slices) of
the lung. Computers can create images from the x-ray information and assemble the
images into a series of 2-dimensional slices of the lung at very small intervals.
Additional evaluation is needed to confirm that lung cancer is present if an LDCT
scan reveals a pulmonary nodule.56–59 Pulmonary nodules with a low probability of
cancer may be followed with repeat LDCT screening over a period of time for
growth-rate evaluation.13 For nodules with a moderate probability of lung cancer,
higher-dose diagnostic LDCT scans are often used in combination with positron emis-
sion tomography scans to evaluate the possibility of cancer metastasis. Biopsies may
also be obtained. Depending on the results, patients are further evaluated for
treatment.
A national consensus has not yet been developed for a standardized reporting sys-
tem for lung cancer screening with LDCT equivalent to the Breast Imaging Reporting
and Data System for mammography reporting.60 A Lung Reporting and Data System
equivalent has been proposed.7

National Surveys of Practice Patterns

Recent national survey information on lung cancer screening is limited. In a national
survey of 962 practicing primary care physicians in 2006/2007, 55% had ordered
chest radiography for lung cancer screening and 22% had ordered LDCT scans.61,62
In the 2010 National Health Interview Survey, 2.5% of adults reported undergoing
chest radiography in the prior year to check for lung cancer, and 1.3% reported under-
going chest CT to check for lung cancer.63

National Lung Screening Trial

The National Lung Screening Trial (NLST) was a randomized controlled trial to
compare the effects of helical LDCT and standard chest radiography on the death
rates for lung cancer among individuals at high risk for lung cancer in the United
States.64,65 The NLST was conducted at 33 locations and enrolled 53,454 adults start-
ing in 2002. Eligible participants were between 55 and 74 years of age at the time of
randomization with a history of cigarette smoking of at least 30 pack-years, and former
smokers if they had quit within the previous 15 years. Half of the participants were
randomly assigned to lung cancer screening with LDCT, and the other half to
screening with single-view posteroanterior chest radiography. Subjects were
screened annually for 3 years. In 2011, the NLST reported a 20% reduction in mortality
from lung cancer among individuals screened by LDCT when compared with individ-
uals screened by chest radiography.65 Table 1 summarizes selected NLST benefits
and harms. The benefits of lung LDCT screening for reducing deaths from lung cancer
was greater among older, heavier smokers who greatly exceeded the minimum eligi-
bility requirements for screening than among younger, less heavy smokers closer to
the minimum eligibility requirements.66,67 Two annual LDCT screenings resulted in a
decrease in the number of advanced-stage cancers diagnosed and an increase in
the number of early-stage lung cancers diagnosed.68

Cancer Intervention and Surveillance Modeling Network

The Cancer Intervention and Surveillance Modeling Network (CISNET) used data from
the NLST and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening trial to
compare multiple scenarios of lung cancer screening.69 All scenarios followed a
cohort of 100,000 persons aged 45 to 90 years until death from any cause. Variations
included the frequency of screening (annual, every 2 years, or every 3 years); age to
begin screening (age 45, 50, 55, or 60 years); age to end screening (age 75, 80, or
85 years); minimum pack-years for screening eligibility (10, 20, 30, or 40 years); and
maximum years since quitting for screening eligibility (10, 15, 20, or 25 years). Five
models, developed by investigators at 5 different institutions, were used in the ana-
lyses, and estimates were averaged across the 5 models. CISNET analyses of the
number of deaths from lung cancer included 7.5 years of follow-up compared with
the 6.5 years in the NLST. With the additional year, the estimated lung cancer–specific
reduction in mortality was 14%, rather than the 20% reduction reported in 2011 by the
NLST. Annual screening resulted in the greatest reduction in mortality (11%–21%
reduction), in comparison with biennial screening (6.5%–9.6% reduction) and triennial
screening (6% reduction). The CISNET modelers concluded that the optimal balance
of benefits and harms would be provided by starting annual screening at age 55 years,
and ending screening at the age of 80 years for smokers with at least 30 pack-years
and for former smokers no more than 15 years since quitting.69 The CISNET identifi-
cation code for this scenario was A55-80-30-15. Table 2 summarizes selected bene-
fits and harms for this scenario projected by CISNET.

Table 1
Selected benefits and harms of lung cancer screening reported by the National Lung Screening
Trial for all 3 rounds, comparing low-dose computed tomography (LDCT) with chest
radiographya

LDCT Chest Radiography

Participants
No. of participants 26,722 26,732
Adherence to 3 rounds of screening 95% 93%
Person-years 144,103 143,368
Benefits
Lung cancer deaths 356 443
Rate of death from lung cancer per 100,000 247 309
person-years
Relative reduction in mortality from lung cancer 62/309 5 20% —
with LDCT
Risk of Harms
Percentage of tests classified as positive 24.2% 6.9%
Percent of positive results that were false positives 96.4% 94.5%
Rate of at least 1 complication after the most invasive 1.4% 1.6%
screening related diagnostic procedureb
Percentage of positive screening tests associated with
a major complication from invasive screening
related diagnostic proceduresb when:
Lung cancer not diagnosed 0.06% 0.02%
Lung cancer diagnosed 11.2% 8.2%
Deaths within 60 d after the most invasive 16 10
screening-related diagnostic procedureb
a
The NLST conducted screening from August 2002 to September 2007, and followed up the partic-
ipants through December 31, 2009. Analysis of the number of deaths from lung cancer includes
deaths that occurred from the date of randomization through January 15, 2009 (6.5 years’
follow-up).
b
Invasive procedures include mediastinoscopy or mediastinotomy, thoracoscopy, or thoracotomy.
Data from National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced
lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;
365(5):395–409.

Overdiagnosis of lung cancer is defined as the detection of indolent lung cancer that
would not have become clinically apparent.70 Overdiagnosis is possible using lung
cancer screening with LDCT, but estimates of the frequency have varied. The NLST
Overdiagnosis Writing Team estimated the upper bound on the probability of over-
diagnosis to be 18.5% (95% confidence interval 5.4%–30.6%) for cases identified
by LDCT screening.70 The CISNET modelers estimated overdiagnosis to be present
in 9.9% of all screen-detected cases for scenario A55-80-30-15.69

European Studies
In Europe, several randomized controlled trials are in various stages of progress.71–76
In general, compared with the NLST, the European trials have studied a smaller num-
ber of subjects and have used different screening intervals, numbers of rounds, and
methods. For example, some of the European studies have used 3-dimensional scans
in addition to 2-dimensional scans. Moreover, volume-doubling time is being used in

Table 2
Selected benefits and harms of lung cancer screening with annual low-dose computed
tomography (LDCT) screening reported by the Cancer Intervention and Surveillance Modeling
Network

Screening Scenario
Scenario identification code A55-80-30-15
Frequency of screening Annual
Smoking requirement Ever-smokers with at least 30 pack-years,
and no more than 15 y since quitting
for former smokers
Start screening at age 55 y
End screening at age 80 y
Study Cohort
Cohort size 100,000 persons
Cohort age range 45–90 y
Proportion of cohort that receive screeninga 19%
Benefits
Lung cancer detected at an early stage 50.5%
(stage I or II)
Lung cancer mortality reductionb 14.0%
Lung cancer deaths averted 521
Harms
Total no. of screenings with LDCT 286,813
No. of overdiagnosed casesc 190
Overdiagnosis, % of all casesc 3.7%
Overdiagnosis, % of screening detected casesc 9.9%
No. of lung cancer deaths related to 24
radiation exposure
LDCT scans per lung cancer death averted 550
a
The Cancer Intervention and Surveillance Modeling Network (CISNET) assumed that only eligible
persons (19%) in the cohort were screened, whereas the NLST screened almost all enrolled persons
in the LDCT arm.
b
CISNET analysis of the number of deaths from lung cancer included 7.5 years of follow-up
compared with the 6.5 years of follow-up reported in the National Lung Screening Trial.
c
Overdiagnosis refers to slow-growing or indolent lung cancers.
Data from de Koning HJ, Meza R, Plevritis SK, et al. Benefits and harms of computed tomography
lung cancer screening strategies: a comparative modeling study for the US Preventive Services Task
Force. Ann Intern Med 2013; [Link]

some European trials to assess change in nodule size over time between 2 scans.77
The probability that a nodule is malignant is low if the volume-doubling time is
400 days or more.77,78

SCREENING RECOMMENDATIONS
Task Force Recommendation
In 2013, the US Preventive Services Task Force (Task Force) recommended “annual
screening for lung cancer with low-dose computed tomography in adults ages 55 to
80 years who have a 30 pack-year smoking history and currently smoke or have
quit within the past 15 years.”79,80 The Task Force also recommended that “screening

should be discontinued once a person has not smoked for 15 years or develops a
health problem that substantially limits life expectancy or the ability or willingness to
have curative lung surgery.”79,80 Approximately 10 million people in the United States
would qualify for lung cancer screening with LDCT based on these NLST age and
smoking criteria.63

Recommendations of Others
Many organizations in the United States updated their recommendations on lung can-
cer screening following the 2011 NLST report (Table 3).81–86 Although differences
exist between organizations, many recommend eligibility criteria similar to those of
NLST; they also recommend smoking cessation services or referral, and performance
of screening in facilities with access to multispecialty expertise for follow-up
management.

Table 3
Lung cancer screening recommendations

Organization Groups Eligible for Screening Year

American Association for 1. Age 55–79 y with 30 pack-year smoking history 2012
Thoracic Surgery81 2. Long-term lung cancer survivors who have
completed 4 y of surveillance without recurrence,
and who can tolerate lung cancer treatment to
detect second primary lung cancer until the age
of 79 y
3. Age 50–79 y with a 20 pack-year smoking history
and additional comorbidity that produces a
cumulative risk of developing lung cancer 5%
in 5 y
American Cancer Society82 Age 55–74 y with 30 pack-year smoking history, 2013
either currently smoking or have quit within the
past 15 y, and who are in relatively good health
American College of Age 55–74 y with 30 pack-year smoking history 2013
Chest Physicians83 and either continue to smoke or have quit within
the past 15 y
American College of Chest Age 55–74 y with 30 pack-year smoking history 2012
Physicians and American and either continue to smoke or have quit within
Society of Clinical Oncology84 the past 15 y
American Lung Association85 Age 55–74 y with 30 pack-year smoking history 2012
and no history of lung cancer
National Comprehensive 1. Age 55–74 y with 30 pack-year smoking history 2012
Cancer Network86 and smoking cessation <15 y
2. Age 50 y and 20 pack-year smoking history
and 1 additional risk factor (other than
secondhand smoke)a
US Preventive Services Age 55–80 y with 30 pack-year smoking history 2013
Task Force79,80 and smoking cessation <15 y
a
Additional risk factors include cancer history, lung disease history, family history of lung cancer,
radon exposure, occupational exposure, and history of chronic obstructive pulmonary disease or
pulmonary fibrosis. Cancers with increased risk of developing new primary lung cancer include
survivors of lung cancer, lymphomas, cancer of the head and neck, and smoking-related cancers.
Occupational exposures identified as carcinogens targeting the lungs include silica, cadmium,
asbestos, arsenic, beryllium, chromium(VI), diesel fumes, and nickel.

ORGANIZATIONAL CHARACTERISTICS THAT FACILITATE BEST PRACTICE

Structured Screening Program
In the section labeled “Other Considerations,” the Task Force’s 2013 recommendation
statement encourages standardization of LDCT screening and the follow-up of
abnormal findings, and the development of a registry to collect the data needed to
enable continuous improvement in screening program quality over time.80 Several or-
ganizations in the United States have recommended that lung cancer screening and
follow-up be conducted as part of a structured, high-volume, high-quality program
including a multidisciplinary team skilled in the evaluation and treatment of lung cancer
(Box 1).81–86 A national consensus on the standards for structured programs does not
exist at present; depending on the elements required, the availability of lung cancer
screening services with LDCT might be limited to larger, urban health care markets,
where specialists are more likely to practice.87
The Lung Cancer Alliance has published a National Framework for Excellence in
Lung Cancer Screening and Continuum of Care.88 The principles of this framework
include: clear information on eligibility and risks and benefits; compliance with stan-
dards for best practices from the National Comprehensive Cancer Network and the
International Early Lung Action Program; a multidisciplinary team for a coordinated
continuum of care; comprehensive smoking cessation; reporting results expeditiously
to patients and physicians; participation in outcome data collection; and providing
information on how screened individuals can advance research.
The American College of Radiology (ACR) offers a Computed Tomography accred-
itation program that includes evaluation of personnel qualifications, equipment spec-
ifications, and quality control.89 A searchable list of locations with ACR CT
accreditation is available on the ACR Web site.90 A practice guideline for radiologists
is being developed by the ACR and the Society of Thoracic Radiology.91 The American
Lung Association has recommended that hospitals and screening centers establish
ethical policies for advertising and promoting lung cancer screening services with
LDCT.85

Quality Control
In its “Clinician Fact Sheet,” the Task Force states that the effectiveness of lung cancer
screening depends on accurate interpretation of LDCT images and resolving most false-
positive results without invasive procedures, in addition to limiting screening to people
at high risk.79 Consistent quality of LDCT images is critical to identifying abnormalities

Box 1
Structured lung cancer screening

Formal program
Access to a multidisciplinary clinical team and clinical resources to provide diagnosis, follow-up
treatment, and long-term patient management related to lung screening
Patient eligibility criteria consistent with Task Force recommendations
Informed and shared decision-making discussions before initial screening
Smoking cessation program
American College of Radiology certification in computed tomography
Staff and resources for data collection to monitor program quality
Participation in American College of Radiology data registry program

and tracking changes in suspicious findings over time while avoiding excessive expo-
sure.92,93 Quality control and accreditation programs are needed to monitor the equip-
ment performance and adherence to imaging protocols.92,93 A centralized database
may be helpful in identifying and flagging deviations from established protocols. In
the NLST, quality assurance included a centralized review of a random sample of
1504 LDCT examinations. Quality defect rates ranged from 0% to 7.1%.93

Radiation Exposure and Dose

In the NLST, each LDCT resulted in an estimated effective dose of 1.5 millisievert
(mSv) per examination.64 In a 2013 survey of 15 academic medical centers in the
United States, the average mean effective radiation dose for LDCT screening was re-
ported as less than 1 mSv at 5 centers (33%), 1 to 2 mSv at 7 centers (47%), 2 to 3 mSv
at 2 centers (13%); 1 respondent did not know the dose.91
At least 1 radiology journal no longer accepts research articles that describe radia-
tion as “low dose” because improvement in LDCT technology continually decreases
the amount of radiation exposure considered low dose.94 As an alternative, the
following measures were suggested: volume CT dose index, dose length product, a
measure of patient dimensions (effective diameter), and size-specific dose estimate
on a per-patient basis.94
Methods are needed to track both the amount of radiation exposure during an indi-
vidual examination and the total cumulative dose received by an individual over time.95
Development of a multidisciplinary committee to reduce the radiation dose, repeat
rate, and variability in quality of the LDCT image at a medium-sized community hos-
pital has been described.96

Follow-up of Abnormal Results

In the section titled “Other Considerations,” the Task Force’s 2013 recommendation
statement supports the establishment of protocols for follow-up of abnormal results
such as the clinical practice guidelines in oncology for lung cancer screening by the
National Comprehensive Care Network.59 In the NLST, an LDCT screening examina-
tion was considered positive for potential lung cancer if there were noncalcified pul-
monary nodules with a long-axis diameter of 4 mm or more in the axial plane.97
Approximately 27% of initial screening examinations were positive.97 Several different
groups have developed recommendations for the follow-up management of solid and
subsolid nodules (subsolid nodules are common with peripheral adenocarci-
noma).56–59 Many nodules are benign, but it may take 1 to 2 years to rule out cancer.
The nodule size is one of the key decision parameters in the follow-up management
algorithms. To reduce the number of false positives, increasing the minimum nodule
size for positive results to 7 to 8 mm has been suggested.98 Research is ongoing to
accurately estimate the probability of a lung nodule detected by LDCT screening being
malignant.56,99,100

SMOKING CESSATION

Smoking prevention and cessation remain the fundamental strategies to drastically

reduce the number of cases of lung cancer in the United States and elsewhere.
Several studies conclusively show that smoking cessation lowers the risks for lung
cancer among smokers.34,35,101 However, the risk for lung cancer remains greater in
former smokers than in lifetime nonsmokers.101,102
A small number of studies have been conducted to determine whether lung cancer
screening with LDCT increases the chances of smoking cessation or changes

perceptions about quitting.103–108 The limited available data seem to indicate that pa-
tients who receive LDCT screening, similarly to those who do not, have other factors
that may better predict smoking cessation. For smokers, the factors associated with
nicotine dependence at the time of the LDCT screening such as the number of cigarettes
smoked per day and the time smoking the first cigarette in the morning, as well as other
factors such as having 1 or more smoking-related diseases (eg, emphysema, chronic
pulmonary obstructive disease), are likely to be better predictors of quit attempts and
smoking cessation than receiving LDCT screening. For former smokers, the time
passed since they last smoked a cigarette and having 1 or more smoking-related dis-
eases are likely to be better predictors of relapse than receiving LDCT screening.
Under “Other Considerations,” the 2013 Task Force recommendation statement
indicates that lung cancer screening with LDCT should not be viewed as an alternative
to tobacco cessation, and current smokers should be informed of their continued risk
for lung cancer and be offered cessation treatments before referral.80 A potential area
for future research might be whether the expanded use of lung cancer screening with
LDCT in community practice will be associated with increased attention to smoking
cessation messages given by health professionals; in 2010, only 48.3% of adult
smokers had been advised by a health professional to quit.42 A smoking cessation
message provided in a clear, strong, and personalized manner by a health profes-
sional increases abstinence by current smokers.109 Former smokers, particularly
those who have recently quit, may also potentially benefit from counseling that ac-
knowledges the patient’s success and addresses any problems associated with
cessation; emphasizes the importance of continued abstinence when they are
referred for lung cancer screening with LDCT; and underscores the availability of sup-
port to resume abstinence if they relapse.109
Information is available for physicians and other health care practitioners on how to
help their patients quit smoking. The US Public Health Services 2008 update of the
Clinical Practice Guideline on Treating Tobacco Use and Dependence109 (hereafter
referred to as the 2008 Tobacco Use Guideline) provides guidance on intervening
with smokers who want to quit or who have recently quit, and includes motivational
messages for those not currently willing to make an attempt to quit. Effective treat-
ments include individual, group, and telephone counseling, as well as 7 medications
approved by the Food and Drug Administration. The effectiveness of the treatment
increases with increasing intensity. Multiple counseling sessions are more effective
than a brief single counseling session, and therapy combining counseling and medi-
cations is more effective than either component alone.
In addition to the proven strategies to encourage and support smoking cessation by
health professionals, the 2008 Tobacco Use Guideline also points out that these stra-
tegies have not yet been fully implemented in health care settings, and that health care
administrators, insurers, and purchasers have an important role to play in helping to
ensure that tobacco use is systematically assessed and treated with evidence-
based strategies at every clinical encounter.109 Examples of potential interventions
by the health care system include automated systems to identify smokers and an
expanded insurance coverage of evidence-based treatment for tobacco use (both
medication and counseling). The 2008 Tobacco Use Guideline also acknowledges
that additional research would be helpful for specific population groups (eg, smokers
who have low socioeconomic status and limited formal education).109
Quitting smoking at any age improves health, and reduces the risk of lung cancer
and other diseases.110,111 It is never too late to help patients to quit smoking.
A Web site at the Centers for Disease Control and Prevention ([Link]
tobacco/campaign/tips/quit-smoking/) includes tips from former smokers and

resources for smokers who are ready to quit, and the National Cancer Institute (NCI)
Web site ([Link]) includes practical cessation information as well as in-
formation on how to sign up for SmokefreeTXT, which is a mobile text-messaging pro-
gram for help to quit smoking. In addition, the NCI has a toll-free number that connects
smokers to their state quitline, which smokers can call to talk to a coach for help to quit
smoking: 1-800-QUIT-NOW (1-800-784-8669) or, for assistance in Spanish, 1-855-
DÉJELO-YA (1-855-335-3569) (Box 2).

INFORMED AND SHARED DECISION-MAKING DISCUSSIONS

In the section “Other Considerations,” the 2013 Task Force recommendation state-
ment indicates that the decision to begin screening should be made through a shared
decision-making process whereby patients and providers discuss the potential bene-
fits, harms, and uncertainties of screening.80 In its “Clinician Fact Sheet,” the Task
Force provides potential discussion points for 3 patient scenarios: patients who fit
all screening criteria; patients who are outside the screening criteria; and patients
who fit all screening criteria but have a significant comorbid condition.79
Other organizations recommending lung cancer screening with LDCT also have
suggested an informed and shared decision-making process before referral for
screening.81–86 Studies suggest that primary care providers need to tailor their
approach to informed and shared decision making for each patient, for example by
asking each patient for his or her input on the desired level of participation.112,113 Pa-
tients vary in their preference for participation in the decision-making process, with
some preferring an active or collaborative role and others favoring a passive role. A
patient’s preference may also change over time, and a mismatch between patients’
preferred and actual roles is common.112,113 A taxonomy has been proposed to cate-
gorize the harms that might occur during lung cancer screening with LDCT, including
physical harms, psychological harms, financial strain, and opportunity costs.114

Box 2
Resources for smoking cessation

Resources for Patients

Anyone can reach the state tobacco quitline by calling 1-800-QUITNOW
Support for quitters
[Link]
[Link]
Tips from former smokers
[Link]
Resources for Clinicians and Other Health Providers
Treating tobacco use and dependence
[Link]
tobacco/clinicians/presentations/2008update-overview/[Link]
Charts that show the 10-year risks of dying from lung cancer
[Link]
Telephone quitlines
[Link]

Higher-Risk Individuals
Tables 4 and 5 list selected examples of potential items for consideration during
informed and shared decision-making discussions with patients, organized according
to the Task Force’s previously suggested “5 As” framework: assess, advise, agree,
assist, and arrange.115 One of the more important topics to be addressed is that
lung cancer screening with LDCT may involve a process over an extended period of
time, rather than a single scan.83,116 For example, after a pulmonary nodule is identi-
fied, evaluation to determine whether the nodule is benign or malignant may require
additional CT scans, more invasive procedures, additional cost, and follow-up for 1
to 2 years.116 The informed and shared decision-making discussion needs to occur
before referral to LDCT screening, because many patients might assume that they

Table 4
Selected examples of items to be considered in informed and shared decision-making
discussions about screening for cancer with low-dose computed tomography (LDCT)

Steps Components
Assess Availability: Is an organized, high-volume, high-quality lung cancer screening
program available with a multidisciplinary team skilled in lung cancer evaluation
and treatment?
Eligibility: Does the patient meet lung screening eligibility criteria?
Time: Is time available for informed and shared decision-making discussions with the
patient?
Knowledge: What is the patient’s level of knowledge about lung cancer and lung
cancer screening? What is the patient’s literacy level?
Preferences: Does the patient prefer an active, shared, or passive role in the decision-
making discussions?
Advise Purpose: Annual LDCT screening can detect lung cancer at an early stage in
asymptomatic high-risk individuals. Lung cancer screening should be thought of as
a process rather than a single test
Smoking cessation: Current smokers should STOP SMOKING. Screening should not be
viewed as an alternative to smoking cessation. Avoiding cigarettes can lower the
risk of lung cancer, emphysema, heart disease, and vascular disease
Benefits: LDCT may reduce the risk of dying from lung cancer in heavy smokers. For
individuals meeting the minimum eligibility requirements, benefits of screening
are greater in individuals who have been heavier smokers
Harms: There is a significant chance of false alarms (false positives) with LDCT
screening. Repeat testing over 1–2 y may be required to evaluate if a screen
detected abnormality increases in size. In some cases, an invasive procedure (eg,
needle biopsy, bronchoscopy, or thoracotomy) is needed to determine whether the
abnormality is lung cancer. Invasive diagnostic procedures may result in major
complications, and are more common in patients who have lung cancer. Death
within 60 d has occurred after an invasive diagnostic procedure, but is rare
Radiation exposure: Provide estimated radiation exposure for your location with 1
LDCT lung screening scan, and the cumulative lifetime total radiation with repeat
annual screening
Patient costs: How much does the patient need to pay for a scan? What is the cost of
patient copayments for follow-up consultations and procedures?
Scientific uncertainties: Negative screening results do not absolutely rule out the
chance for lung cancer incidence. LDCT will not detect all lung cancers or all lung
cancers early, and not all patients who have a lung cancer detected by LDCT will
avoid death from lung cancer
Research: How can screened individuals donate images and biospecimens to advance
research in the prevention, diagnosis, and treatment of lung cancer?
Alternatives: LDCT is the only screening test shown to lower the chances of dying of
lung cancer. Chest radiography should not be used for lung cancer screening

Table 5
Informed and shared decision-making discussions

Steps Components
Agree Provider needs to help individuals clarify their preferences and willingness to be
screened
Decide to screen with LDCT every year: Individual assigns higher value to potential
benefits than to potential harms
Decide against LDCT screening: Individual assigns higher value to potential harms
than to the potential benefits
Assist Costs: Help individuals determine if they have to pay for the initial LDCT scan and
how much
Referral: Provider identifies screening facilities with appropriate expertise, refers
individual for screening, and informs individual how to schedule the screening
test or that the screening clinic will contact the individual
Arrange Smoking cessation: Provider should provide smoking cessation or refer current
smokers to smoking cessation programs
Results: How and when will the LDCT results be communicated to patients?
Follow-up: When will the informed-shared decision-making process about LDCT
screening be revisited in the future?
Update Preferences and decisions: Assess any change over time in patient preferences and
decisions before referral for the next annual LDCT screening
Document Documentation: Clearly document the informed and shared decision-making
process and decisions to safeguard against potential medicolegal consequences
(eg, if a case of lung cancer is detected before a decision has been made about
lung cancer screening; or if the individual has major complications from lung
cancer screening). Documentation may potentially need to cover more than 1
visit (eg, initial discussion with patient, follow-up discussions between patient
and support staff, and educational materials provided to patient)

have cancer when told that the LDCT scan has revealed a nodule.116 Patients with sig-
nificant comorbid conditions should be informed that they may be at greater risk for
harm with screening,79 and screening is not recommended if the comorbid conditions
substantially limit life expectancy or the ability to undergo curative lung surgery.80
Lower-Risk Individuals
Primary care providers need to be prepared to answer questions about lung cancer
screening with LDCT from individuals who do not meet the criteria for lung cancer
screening with LDCT. Several examples include heavy smokers who are younger
than the recommended age to begin screening, current or former smokers with fewer
pack-years of smoking, individuals with other risk factors for lung cancer (eg, chronic
obstructive lung disease), and healthy adults who have never smoked.79 In its “Clinical
Fact Sheet” scenarios, the Task Force recommends that health providers inform pa-
tients in lower risk categories about the potential harms of screening and that there is
not enough evidence to recommend screening for individuals at lower risk for lung
cancer.79 The American Cancer Society also recommends informing individuals in
lower risk categories that screening is not recommended at this time because there
is too much uncertainty regarding the balance of benefits and harms (Box 3).82

HEALTH CARE CHANGES

Reimbursement for Grade A or B Preventive Services
The Patient Protection and Affordable Care Act requires most health insurance plans
to cover preventive services at no additional cost to the patient if the Task Force

Box 3
Resources for patients about lung cancer screening

American Cancer Society. Patient Page. Testing for lung cancer in people at high risk. CA Cancer
J Clin 2013;63(2):118–9. [Link]
sionals/acsguidelines/lungcancerscreeningguidelines/index
American Lung Association. Lung cancer CT screening for early detection. One pager. http://
[Link]/lung-disease/lung-cancer/lung-cancer-screening-guidelines/lung-cancer-one-
[Link]
American Lung Association. Provides guidance on lung cancer screening. Full Report. Appendix
I. American Lung Association Toolkit. Making an individual decision to be screened. http://
[Link]/lung-disease/lung-cancer/lung-cancer-screening-guidelines/
National Cancer Institute. Patient and physician guide: National Lung Screening Trial. http://
[Link]/newscenter/qa/2002/NLSTstudyGuidePatientsPhysicians
National Cancer Institute. Lung cancer screening (PDQ). Patient version. [Link]
gov/cancertopics/pdq/screening/lung/Patient/page1/AllPages
National Comprehensive Cancer Network. NCCN guidelines for patients. Lung cancer
screening. Version 1. 2014. [Link]
National Framework for Excellence in Lung Cancer Screening and Continuum of Care. Lung
Cancer Alliance. [Link]
US Preventive Services Task Force. Consumer fact sheet. Understanding Task Force
recommendations. Screening for lung cancer. [Link]
[Link]

grades the preventive service recommendation as A (strongly recommended) or B

(recommended).117 Both tobacco cessation (graded A) and lung cancer screening
with LDCT (graded B) would qualify for insurance coverage at no additional cost.

Patient-Centered Medical Home

The patient-centered medical home is a model to improve the delivery of primary care
by greater involvement of the patient in care plans, coordinated and comprehensive
team-based care, improved patient access to care after hours and by e-mail and
phone, and a commitment to quality improvement and population health manage-
ment.118 In the context of lung cancer screening with LDCT, the primary care
patient-centered medical home will remain important even if the primary care provider
refers patients to a structured program that offers lung cancer screening and follow-up
management. Several examples of potential activities for the primary care provider
include identification of patients eligible for lung cancer screening with LDCT,
informed and shared decision-making discussions with patients before referral, pro-
motion of smoking cessation, management of comorbid conditions that are not
addressed by specialists, and eliminating barriers to timely care.119,120

Electronic Health Records

If electronic health records (EHRs) include information on patient age and pack-years
of smoking, EHRs may be used to identify individuals who meet the eligibility criteria
for lung cancer screening with LDCT. Computer algorithms may be designed to use
with EHRs to provide patients with cellphone reminders about the need to schedule
their annual lung cancer screening with LDCT and the importance of smoking cessa-
tion.121,122 An integrated system of EHRs may also facilitate the retrieval of information

from multiple providers to evaluate the performance and quality of a lung cancer
screening program with LDCT, notify the responsible clinicians about abnormal imag-
ing results that need follow-up, and improve the early recognition of patients with lung
cancer.121,122
Accountable Care Organizations
The Patient Protection and Affordable Care Act encourages groups of providers to
collaborate, manage, and coordinate the care of patients through accountable care
organizations (ACOs).117 ACOs that meet quality performance standards are eligible
to receive payments for shared savings. Bekelman and colleagues123 have suggested
that cancer specialists in larger, urban health care markets may want to develop Can-
cer Care Groups to provide guideline-concordant, patient-centered, coordinated care
among cancer specialists and primary care providers. Activities related to lung cancer
screening with LDCT would seem reasonable for ACOs to consider, especially if lung
cancer screening with LDCT and follow-up is managed as part of a structured program
with a multidisciplinary team.

SUMMARY

Annual LDCT screening for lung cancer cannot prevent lung cancer, but can reduce
mortality from lung cancer in persons at high risk based on the age and smoking his-
tory of the individual. Lung cancer screening can supplement, but not replace, efforts
to address the primary prevention of lung cancer through the control of tobacco and
other known risk factors associated with lung cancer. Considerations for primary care
providers may include the resources available in their communities for lung cancer
screening with LDCT and for smoking cessation, and the key points that need to be
addressed in the informed and shared decision-making discussions with patients.
Lung cancer screening with LDCT is a rapidly evolving area. Examples of upcoming
areas of potential importance may include the following: decisions from Centers for
Medicare and Medicaid Services about reimbursement and billing codes; ACR recom-
mendations on quality control and reporting of LDCT findings; results from additional
analyses of the NLST data; results from European studies, especially on the use of
volume-doubling time to evaluate whether pulmonary nodule sizes have changed
over time; and whether a national consensus can be developed with standard algo-
rithms for patient management.

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