INTRODUCTION: : Guidelines recommend that patients with clinical stage IIIA non-small cell lung cancer (NSCLC) undergo histologic confirmation of pathologic lymph nodes. Studies have suggested that invasive mediastinal staging is underutilized, although practice patterns have not been rigorously evaluated.

METHODS: : We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients with stage IIIA NSCLC diagnosed from 1998 through 2005. Invasive staging and use of positron emission tomography (PET) scanning were assessed using Medicare claims. Multivariable logistic regression was used to identify patient characteristics associated with use of invasive staging.

RESULTS: : Of 7583 stage IIIA NSCLC patients, 1678 (22%) underwent invasive staging. Patients who received curative intent cancer treatment were more likely to undergo invasive staging than patients who did not receive cancer-specific therapy (30% versus 9.8%, adjusted odds ratio, 3.31; 95% confidence interval, 2.78-3.95). The oldest patients (age, 85-94 years) were less likely to receive invasive staging than the youngest (age, 67-69 years; 27.6% versus 11.9%; odds ratio, 0.46; 95% confidence interval, 0.34-0.61). Sex, marital status, income, and race were not associated with the use of the invasive staging. The use of invasive staging was stable throughout the study period, despite an increase in the use of PET scanning from less than 10% of patients before 2000 to almost 70% in 2005.

CONCLUSION: : Nearly 80% of Medicare beneficiaries with stage IIIA NSCLC do not receive guideline adherent mediastinal staging; this failure cannot be entirely explained by patient factors or a reliance on PET imaging. Incentives to encourage use of invasive staging may improve care.

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RATIONALE AND OBJECTIVES: The increasing use of computed tomography (CT) has been accompanied by rising concerns over potential radiation-related health risks, especially cancer, and a need to minimize such risks.

MATERIALS AND METHODS: We conducted 2186 low-dose helical chest CT scans among 1235 nuclear weapons workers at elevated risk of lung cancer, setting the CT scanner tube current at 30 mAs for all participants with BMI <35 kg/m(2) and permitting technologists to raise mAs levels for participants with BMI ≥35 kg/m(2). Dose-length product (DLP) was recorded from the CT scanner, permitting calculation of effective dose. Phantom-based estimates of effective dose were also made. A chest radiologist recorded acceptability of image quality.

RESULTS: The study population was significantly overweight: 79% exceeded a body mass index (BMI) >25 kg/m(2) and 37.1% exceeded a BMI ≥30 kg/m(2). Nearly 90% of CT scans were performed using a tube current setting of 30 mAs and had a mean DLP-based effective dose of 1.3 mSv. The phantom-based estimate of effective dose was lower at 1.1 mSv. Among participants with a BMI ≥35 kg/m(2), 92% were scanned at 40 or 50 mAs, which was associated with a DLP-based effective dose of 1.6 and 2.0 mSv, respectively. Image quality was satisfactory in 99.8% of scans.

CONCLUSION: Application of simple BMI-based guidelines and DLP tracking of low-dose helical chest CT scans in a lung cancer screening program minimizes radiation dose, even in a largely overweight population.

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The International Association for the Study of Lung Cancer (IASLC) Board of Directors convened a computed tomography (CT) Screening Task Force to develop an IASLC position statement, after the National Cancer Institute press statement from the National Lung Screening Trial showed that lung cancer deaths fell by 20%.

The Task Force's Position Statement outlined a number of the major opportunities to further improve the CT screening in lung cancer approach, based on experience with cancer screening from other organ sites.The IASLC CT Screening Workshop 2011 further developed these discussions, which are summarized in this report. The recommendation from the workshop, and supported by the IASLC Board of Directors, was to set up the Strategic CT Screening Advisory Committee (IASLC-SSAC).

The Strategic CT Screening Advisory Committee is currently engaging professional societies and organizations who are stakeholders in lung cancer CT screening implementation across the globe, to focus on delivering guidelines and recommendations in six specific areas:

1. identification of high-risk individuals for lung cancer CT screening programs;
2. develop radiological guidelines for use in developing national screening programs;
3. develop guidelines for the clinical work-up of "indeterminate nodules" resulting from CT screening programmers;
4. guidelines for pathology reporting of nodules from lung cancer CT screening programs;
5. recommendations for surgical and therapeutic interventions of suspicious nodules identified through lung cancer CT screening programs;
6. and integration of smoking cessation practices into future national lung cancer CT screening programs.

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The findings from the National Cancer Institute's National Lung Cancer Screening Trial (NLST) were recently published in the New England Journal of Medicine. The trial demonstrated that lung cancer mortality can be reduced by annual screening with low-dose computed tomography (CT). It is possible that widespread lung screening in high-risk groups can save many lives. Screening is associated not only with benefits but also possible harms. A number of observational single arm lung cancer screening trials with CT were carried out in the 1990s and during the past decade. These demonstrated that low-dose CT could identify cancers at early treatable stages and that survival was prolonged.

The NLST was launched in 2002 and it is the first randomized controlled trial that has published definitive results. The trial included over 53,000 adults, aged 55-74 years, at high risk for lung cancer with at least a 30-pack-year history of smoking. It included current or former smokers. There were three rounds of annual CT screening. The control arm received three rounds of annual chest radiographs. The NLST demonstrated a 20% difference in lung cancer death rate between the CT arm and the chest radiograph arm with a 6.7% reduction in deaths from any cause. However, 40% of individuals in the CT arm experienced at least one abnormal CT scan during the study. Most of these abnormalities required only additional imaging (e.g. to determine if a nodule was growing) but some required more invasive procedures such as bronchoscopy or lung biopsy. A large percentage of abnormalities were false-positive readings. Such false-positive findings can lead to potential harm such as anxiety but also the additional costs of follow-up, radiation exposure and exposure to invasive procedures. In addition 7.5% of patients in the NLST study were judged to have a clinically significant abnormality other than an abnormality in the lungs, such as cardiac or upper abdominal findings.

Additional publications from the NLST can be expected in the next year dealing with issues such as cost effectiveness and quality of life as well as radiation risk. In addition, many national societies are developing guidelines for lung cancer screening based on the preliminary results of the NLST.

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