Lung Screening Benefits and Challenges: A Review of The Data and Outline for Implementation

Lung cancer is the leading cause of cancer-related deaths worldwide, accounting for almost a fifth of all cancer-related deaths. Annual computed tomographic lung cancer screening (CTLS) detects lung cancer at earlier stages and reduces lung cancer-related mortality among high-risk individuals. Many medical organizations, including the U.S. Preventive Services Task Force, recommend annual CTLS in high-risk populations. However, fewer than 5% of individuals worldwide at high risk for lung cancer have undergone screening. In large part, this is owing to delayed implementation of CTLS in many countries throughout the world. Factors contributing to low uptake in countries with longstanding CTLS endorsement, such as the United States, include lack of patient and clinician awareness of current recommendations in favor of CTLS and clinician concerns about CTLS-related radiation exposure, false-positive results, overdiagnosis, and cost. This review of the literature serves to address these concerns by evaluating the potential risks and benefits of CTLS. Review of key components of a lung screening program, along with an updated shared decision aid, provides guidance for program development and optimization. Review of studies evaluating the population considered “high-risk” is included as this may affect future guidelines within the United States and other countries considering lung screening implementation.     

螺旋CT低剂量扫描筛查早期肺癌的研究

肺癌是目前世界上常见的恶性肿瘤之一.肺癌的早期发现、早期诊断和早期治疗是降低肺癌病死率,提高肺癌长期生存率的惟一途径.胸部X线片检查由于经济、射线量小、无创,与痰细胞学检查一起成为筛查肺癌的首选检查手段,但发现小肿瘤的敏感性较差.CT筛查肺癌可能促进早期肺癌发现、降低肺癌病死率,但CT常规剂量扫描由于放射剂量大,每次接受检查不符合体检筛查要求.由于空气与肺病变有较高对比,故降低放射剂量仍可能获得良好的胸部CT图像.低剂量CT接受的放射剂量仅是传统CT剂量的1/6.LDCT的筛查阳性结果是胸部X线片筛查的3倍;LDCT筛查发现恶性病变是胸部X线片筛查的4倍,LDCT筛查发现的工期肺癌是胸部X线片的6倍.LDCT筛查肺癌存在的争议:①LDCT筛查肺癌能否降低肺癌病死率;②LDCT筛查肺癌的假阳性率高及过诊问题;③LDCT筛查肺癌的误漏诊问题.     

Circulating microRNA signature as liquid-biopsy to monitor lung cancer in low-dose computed tomography screening

Liquid biopsies can detect biomarkers carrying information on the development and progression of cancer. We demonstrated that a 24 plasma-based microRNA signature classifier (MSC) was capable of increasing the specificity of low dose computed tomography (LDCT) in a lung cancer screening trial. In the present study, we tested the prognostic performance of MSC, and its ability to monitor disease status recurrence in LDCT screening-detected lung cancers.Between 2000 and 2010, 3411 heavy smokers enrolled in two screening programmes, underwent annual or biennial LDCT. During the first five years of screening, 84 lung cancer patients were classified according to one of the three MSC levels of risk: high, intermediate or low. Kaplan-Meier survival analysis was performed according to MSC and clinico-pathological information. Follow-up MSC analysis was performed on longitudinal plasma samples (n = 100) collected from 31 patients before and after surgical resection.Five-year survival was 88.9% for low risk, 79.5% for intermediate risk and 40.1% for high risk MSC (p = 0.001). The prognostic power of MSC persisted after adjusting for tumor stage (p = 0.02) and when the analysis was restricted to LDCT-detected cases after exclusion of interval cancers (p < 0.001). The MSC risk level decreased after surgery in 76% of the 25 high-intermediate subjects who remained disease free, whereas in relapsing patients an increase of the MSC risk level was observed at the time of detection of second primary tumor or metastatic progression.These results encourage exploiting the MSC test for lung cancer monitoring in LDCT screening for lung cancer.     

人群肺癌筛查的研究进展

肺癌5年生存率仅为19.7%,但早期肺癌的5年生存率可达80%以上。采用低剂量螺旋CT(low-dose computed tomography,LDCT)进行肺癌筛查,对于肺癌的早期诊断十分重要。在有限的卫生经济条件下,筛查前通过预测模型对人群进行分层管理,可提高肺癌早期检出率。全文就利用LDCT进行肺癌筛查、肺癌预测模型应用以及存在问题进行综述。     

The Effect of Primary Care Physician Knowledge of Lung Cancer Screening Guidelines on Perceptions and Utilization of Low-Dose Computed Tomography

Introduction

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) is recommended by the U.S. Preventive Services Task Force (USPSTF) in high-risk patients, but a minority of eligible people are screened. It is not clear whether knowledge of USPSTF recommendations among primary care physicians (PCP) affects utilization of LDCT.

低剂量螺旋CT对肺内结节的诊断价值

目的 探讨低剂量螺旋CT(LDCT)扫描对肺内结节的诊断价值.方法 前瞻性随诊分析2002～2010年在我院行LDCT的302例患者的临床资料,胸部X线、常规剂量CT(SDCT)及LDCT的结果.结果 行LDCT检查者分两组:肺内结节待查组:共230例,男性120例(52.2%),女性110例(47.8%),中位年龄为...     

2014—2018年成都市龙泉驿区肺癌高危人群队列筛查结果及发病影响因素分析

摘 要：［目的］ 分析2014—2018年四川省成都市龙泉驿区肺癌高危人群队列筛查结果及发病相关影响因素。［方法］ 2014年4月至2018年7月,纳入年龄50~74岁,吸烟≥20包年（若现在已戒烟,戒烟时间不超过5年）者为调查对象,通过问卷调查收集调查对象的基本信息和危险因素,并对其开展每年1次的低剂量螺旋CT（LDCT）检查。首年筛查（基线筛查）阳性者按要求进入下一步检查,不需要行临床干预的阳性者及阴性者每年仍进行LDCT检查（年度复查）。通过主动随访,以及当地肿瘤随访登记、死因监测、病案首页系统被动匹配,获得筛查人群肺癌确诊、死亡等终点结局。计算不同特征人群的基线筛查、年度复查阳性率,并采用多因素Poisson回归分析肺癌发病的相关因素。［结果］ 1 131名筛查人群平均年龄为（60.95±6.26）岁,男性（占95.58%）、小学及以下文化程度者（占41.11%）居多,吸烟量中位数为32包年。连续参加2、3、4、5轮筛查的随访率分别为83.27%、71.98%、63.60%和57.86%。基线筛查阳性率（9.11%）高于年度复查（6.15%）。年龄越大,基线筛查阳性率越高（P趋势=0.045）。吸烟量大（P趋势=0.002）、不使用抽油烟机（P=0.003）、既往有呼吸系统疾病史者（P=0.003）的年度复查阳性率高。 5年间,筛查队列肺癌发病密度为625.26/10万。多因素Poisson回归模型分析结果显示,与50~59岁组相比,60~69岁和70~74岁人群肺癌发病风险较高,IRR（95%CI）值分别为3.94（1.34~11.58）和4.90（1.11~21.67）;与小学及以下文化程度、吸烟量20~29包年、基线筛查为阴性相比,高中或中专、吸烟量40~49包年、基线筛查结果为阳性人群的肺癌发病风险更高,IRR（95%CI）值分别为3.14（1.09~9.03）、4.29（1.30~14.16）和13.13（5.84~29.53）;与仅参加1次筛查相比,参与3次和4次的人群肺癌发病风险的降低差异有统计学意义,IRR（95%CI）值分别为0.26（0.09~0.75）和0.21（0.07~0.63）。［结论］ 基线筛查与年度复查阳性率及其影响因素不同;高危人群肺癌发病风险与LDCT基线筛查结果和筛查次数密切相关。     

哈尔滨非吸烟女性肺癌病因学研究

在哈尔滨市进行的１２０例非吸烟女性肺腺癌及等量人群对照的病例对照研究，结果显示大量燃煤，室内空气污染，长期暴露于煤尘，煎炸食物次数较多，家族癌症高发，是具有统计学意义的肺腺癌危险因素，而个人高经济收入，较大的居住面积和大量摄取胡萝卜对肺腺癌有保护作用     

What has the meta-analysis contributed to today's standard of care in the treatment of thoracic malignancies?

Meta-analyses dealing with the treatment of thoracic malignancies (non-small cell lung cancer, small cell lung cancer and mesothelioma) are reviewed including those performed in the context of a systematic review of the literature or based on individual patients data. Their results have been used as an effective tool for resolving various clinical questions, providing more reliable evidence for some clinical practice: (neo)adjuvant chemotherapy after surgery for resectable NSCLC, radiochemotherapy for patients with unresectable limited NSCLC and limited SCLC, advantage of chemotherapy for advanced NSCLC and identification of the most active drugs. However, it is important to understand the limits of their methodology in order to avoid inappropriate interpretations.     

Modeling excess lung cancer risk among screened arm participants in the Mayo Lung Project

BACKGROUND:

The Mayo Lung Project (MLP) was a randomized clinical trial designed to test whether periodic screening by chest x‐ray reduced lung cancer (LC) mortality in men who were high‐risk smokers. Among MLP participants, there were more deaths from LC in the screening arm both at the trial's end and after long‐term follow‐up. Overdiagnosis was cited widely as an explanation for the MLP results, whereas a role for excess LC risk attributable to undergoing numerous chest x‐ray screenings largely was unexamined. The authors of this report examined the consistency of the MLP data with a modified 2‐stage clonal expansion (TSCE) model of excess LC risk.

METHODS:

By using a simulation model calibrated to the initial MLP data, the authors examined the expected statistical variance of LC incidence and mortality between the screening and control arms. A Bayesian estimation framework using a modified version of the TSCE model to evaluate the role of excess LC risk attributable to chest x‐ray screening was derived and applied to the MLP data.

RESULTS:

Simulation experiments indicated that the overall difference in LC deaths and incidence between the study arm and the control arm was unlikely (P = .0424 and P = .0104, respectively) assuming no excess risk of LC. The authors estimated that the 10‐year excess LC risk for a man aged 60 years who smoked and who received 10 chest x‐ray screenings was 0.574% (P = .0021).

CONCLUSIONS:

The excess LC risk observed among screening arm participants was found to be statistically significant with respect to the TSCE model framework in part because of the incorporation of key risk correlates of age and screen frequency into the estimation framework. Cancer 2010. Published 2010 American Cancer Society     

肺癌的筛查

肺癌的筛查目前仍是一个有争议的问题.本文讨论了肺癌筛查的必要性和可行性,对肺癌筛查的历史和现状以及新的影像学和分子生物学技术在肺癌筛查和早期诊断中的价值和应用前景进行了回顾.利用生物标志物进行肺癌的筛查仍处于研究阶段,尚需前瞻性的研究对其效果进行评价.低剂量螺旋CT是目前最有希望用于人群肺癌筛查的新技术.肺癌的筛查应根据不同的卫生资源情况利用多种筛查技术采取不同的筛查策略在肺癌高危人群中进行.