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'''Lung cancer screening''' refers to [[cancer screening]] strategies used to identify early [[lung cancer]]s before they cause symptoms, at a point where they are more likely to be curable. Screening studies for lung cancer have only been done in high risk populations, such as smokers and workers with occupational exposure to certain substances. In the 2010s recommendations by medical authorities are turning in favour of lung cancer screening, which is likely to become more widely available in the advanced economies.
'''Lung cancer screening''' refers to [[cancer screening]] strategies used to identify early [[lung cancer]]s before they cause symptoms, at a point where they are more likely to be curable. Screening studies for lung cancer have only been done in high risk populations, such as smokers and workers with occupational exposure to certain substances. In the 2010s recommendations by medical authorities are turning in favour of lung cancer screening, which is likely to become more widely available in the advanced economies.

For individuals with high risk of developing lung cancer, [[computed tomography]] (CT) screening can detect cancer and give a person options to respond to it in a way that prolongs life.<ref name="ACCPandATSfive">{{Citation |author1 = American College of Chest Physicians |author1-link = American College of Chest Physicians |author2 = American Thoracic Society |author2-link = American Thoracic Society |date = September 2013 |title = Five Things Physicians and Patients Should Question |publisher = American College of Chest Physicians and American Thoracic Society |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |page = |url = http://www.choosingwisely.org/doctor-patient-lists/american-college-of-chest-physicians-and-american-thoracic-society/ |accessdate = 6 January 2013}}</ref> This form of screening reduces the chance of death from lung cancer by an [[Absolute risk reduction|absolute amount]] of 0.3% ([[Relative risk reduction|relative amount]] of 20%).<ref>{{cite journal | last=Jaklitsch | first=MT | coauthors=Jacobson FL, Austin JH et al. | title=The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups | journal=Journal of Thoracic and Cardiovascular Surgery |date=July 2012 | volume=144 | issue=1 | pages=33&ndash;38 | pmid=22710039 | doi=10.1016/j.jtcvs.2012.05.060}}</ref><ref>{{cite journal | last=Bach | first=PB | coauthors=Mirkin JN, Oliver TK et al. | title=Benefits and harms of CT screening for lung cancer: a systematic review | journal=JAMA: the Journal of the American Medical Association |date=June 2012 | volume=307 | issue=22 | pages=2418–2429 | pmid=22610500 | doi=10.1001/jama.2012.5521}}</ref> High risk people are those age 55-74 who have smoked a pack of cigarettes daily for 30 years including time within the past 15 years.<ref name="ACCPandATSfive"/>

CT screening is associated with a high rate of [[False positives and false negatives|falsely positive]] tests which may result in unneeded treatment.<ref name=Ab2013>{{cite journal|last1=Aberle|first1=D. R.|last2=Abtin|first2=F.|last3=Brown|first3=K.|title=Computed Tomography Screening for Lung Cancer: Has It Finally Arrived? Implications of the National Lung Screening Trial|journal=Journal of Clinical Oncology|volume=31|issue=8|year=2013|pages=1002–1008|issn=0732-183X|doi=10.1200/JCO.2012.43.3110}}</ref> For each true positive scan there are more than 19 falsely positives scans.<ref>{{cite journal |author=Bach PB, Mirkin JN, Oliver TK, et al. |title=Benefits and harms of CT screening for lung cancer: a systematic review |journal=JAMA |volume=307 |issue=22 |pages=2418–29 |date=June 2012 |pmid=22610500 |doi=10.1001/jama.2012.5521 |url=}}</ref> Other concerns include [[Ionizing radiation|radiation exposure]]<ref name=Ab2013/> and the cost of testing along with the follow up of tests.<ref name="ACCPandATSfive"/> Research has not found two other available tests - [[sputum]] [[cytopathology|cytology]] or [[chest radiograph]] (CXR) screening tests - to have any benefit.<ref name="Manser 2004">{{Cite journal | last=Manser | first=RL | coauthors=Irving LB, Stone C et al. | title=Screening for lung cancer | journal=Cochrane Database of Systematic Reviews | issue=1 | pages=CD001991 | year=2004 | pmid=14973979 | doi=10.1002/14651858.CD001991.pub2 }}</ref>

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Screening studies for lung cancer have only been done in high risk populations, such as smokers and workers with occupational exposure to certain substances. In the 2010s recommendations by medical authorities are turning in favour of lung cancer screening, which is likely to become more widely available in the advanced economies. In December 2013 the [[United States Preventive Services Task Force|U.S. Preventative Services Task Force]] (USPSTF) changed its long-standing recommendation that there is insufficient evidence to recommend for or against screening for lung cancer to the following: "The USPSTF recommends 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. 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".<ref>{{cite web |url=http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm |title=Lung Cancer Screening |year=2013 |publisher=[[United States Preventive Services Task Force|U.S. Preventative Services Task Force]]}}</ref> The English [[National Health Service]] was in 2014 re-examining the evidence for screening.<ref>{{cite journal|last1=Baldwin|first1=DR|last2=Hansell|first2=DM|last3=Duffy|first3=SW|last4=Field|first4=JK|title=Lung cancer screening with low dose computed tomography.|journal=BMJ (Clinical research ed.)|date=2014 Mar 7|volume=348|pages=g1970|pmid=24609921|accessdate=23 July 2014}}</ref>


==Medical uses==
==Medical uses==
Lung cancer screening ideally would be used to detect lung cancer early in its development. Currently lung cancer screening is only recommended for people who are at high risk of developing lung cancer soon.
Lung cancer screening ideally would be used to detect lung cancer early in its development. Currently lung cancer screening is only recommended for people who are at high risk of developing lung cancer soon.<ref name="ACCPandATSfive"/> High risk people are those age 55-74 who have smoked a pack of cigarettes daily for 30 years including time within the past 15 years, and in that population, the test is recommended annually.<ref name="ACCPandATSfive"/>


==Technique==
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==Risks of Screening==
For individuals with high risk of developing lung cancer, [[computed tomography]] (CT) screening can detect cancer and give a person options to respond to it in a way that prolongs life.<ref name="ACCPandATSfive">{{Citation |author1 = American College of Chest Physicians |author1-link = American College of Chest Physicians |author2 = American Thoracic Society |author2-link = American Thoracic Society |date = September 2013 |title = Five Things Physicians and Patients Should Question |publisher = American College of Chest Physicians and American Thoracic Society |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |page = |url = http://www.choosingwisely.org/doctor-patient-lists/american-college-of-chest-physicians-and-american-thoracic-society/ |accessdate = 6 January 2013}}</ref>
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There are a variety of risks that are inherent to lung cancer screening which must be weighed carefully against the known benefits. Any risk assessment must also factor in risks associated with subsequent work-up and management of suspicious results. Risks include radiation exposure, false positive findings, false reassurance from false negative findings, [[overdiagnosis]], short term anxiety/distress, and increased rate of incidental findings.<ref>{{cite journal | author=Humphrey LL, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, Zakher B, Fu R, Slatore CG | title=creening for Lung Cancer With Low-Dose Computed Tomography: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation |journal=Annals of Internal Medicine |issue=ePub ahead of print |year=2013 |pmid=23897166 | doi=10.7326/0003-4819-159-6-201309170-00690 | volume=159 | pages=411–20}}</ref> Radiation exposure from repeated screening studies could actually induce [[carcinogenesis|cancer formation]] in a small percentage of screened subjects, so this risk should be mitigated by a (relatively) high prevalence of lung cancer in the population being screened.


Research has not found two other available tests - [[sputum]] [[cytopathology|cytology]] or [[chest radiograph]] (CXR) screening tests - to have any benefit.<ref name="Manser 2004">{{Cite journal | last=Manser | first=RL | coauthors=Irving LB, Stone C et al. | title=Screening for lung cancer | journal=Cochrane Database of Systematic Reviews | issue=1 | pages=CD001991 | year=2004 | pmid=14973979 | doi=10.1002/14651858.CD001991.pub2 }}</ref>
==Society and culture==
===Practice guidelines===
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[[Clinical practice guideline]]s previously issued by the [[American College of Chest Physicians]] in 2007 recommended against routine screening for lung cancer because of a lack of evidence that such screening was effective.<ref name="pmid17873156">{{cite journal |author=Alberts WM |title=Diagnosis and Management of Lung Cancer Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) |journal= Chest|volume=132 |issue=3_suppl |pages=1S–19S |year=2007 |pmid=17873156 |doi=10.1378/chest.07-1860 |author2=American College of Chest Physicians}}</ref> The newest ACCP guidelines take into account findings from the [[National Lung Screening Trial]] and state: "For smokers and former smokers who are age 55 to 74 and who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years, we suggest that annual screening with low-dose CT (LDCT) should be offered over both annual screening with CXR or no screening, but only in settings that can deliver the comprehensive care provided to National Lung Screening Trial participants (Grade 2B)".<ref>{{cite journal|last=Detterbeck|first=Frank C.|author2=Lewis SZ |author3=Diekemper R |title=Executive summary: Diagnosis and management of lung cancer, 3rd ed: american college of chest physicians evidence-based clinical practice guidelines|journal=Chest|date=1 May 2013|volume=143|issue=5S}}</ref>


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==Risks of Screening==
⚫
In December 2013 the [[United States Preventive Services Task Force|U.S. Preventative Services Task Force]] (USPSTF) changed its long-standing recommendation that there is insufficient evidence to recommend for or against screening for [[lung cancer]] to the following: "The USPSTF recommends 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. 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".<ref>{{cite web |url=http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm |title=Lung Cancer Screening |year=2013 |publisher=[[United States Preventive Services Task Force|U.S. Preventative Services Task Force]]}}</ref> The English [[National Health Service]] was in 2014 re-examining the evidence for screening.<ref>{{cite journal|last1=Baldwin|first1=DR|last2=Hansell|first2=DM|last3=Duffy|first3=SW|last4=Field|first4=JK|title=Lung cancer screening with low dose computed tomography.|journal=BMJ (Clinical research ed.)|date=2014 Mar 7|volume=348|pages=g1970|pmid=24609921|accessdate=23 July 2014}}</ref>
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CT screening is associated with a high rate of [[False positives and false negatives|falsely positive]] tests which may result in unneeded treatment.<ref name="ACCPandATSfive"/> For each true positive scan there are more than 19 falsely positives scans.<ref>{{cite journal |author=Bach PB, Mirkin JN, Oliver TK, et al. |title=Benefits and harms of CT screening for lung cancer: a systematic review |journal=JAMA |volume=307 |issue=22 |pages=2418–29 |date=June 2012 |pmid=22610500 |doi=10.1001/jama.2012.5521 |url=}}</ref> Other concerns include [[Ionizing radiation|radiation exposure]] and the cost of testing along with the follow up of tests.<ref name="ACCPandATSfive"/> False reassurance from false negative findings, [[overdiagnosis]], short term anxiety/distress, and increased rate of incidental findings are other risks.<ref>{{cite journal | author=Humphrey LL, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, Zakher B, Fu R, Slatore CG | title=Screening for Lung Cancer With Low-Dose Computed Tomography: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation |journal=Annals of Internal Medicine |issue=ePub ahead of print |year=2013 |pmid=23897166 | doi=10.7326/0003-4819-159-6-201309170-00690 | volume=159 | pages=411–20}}</ref> Radiation exposure from repeated screening studies could actually induce [[carcinogenesis|cancer formation]] in a small percentage of screened subjects, so this risk should be mitigated by a (relatively) high prevalence of lung cancer in the population being screened.<ref name="ACCPandATSfive"/>


Research has not found two other available tests - [[sputum]] [[cytopathology|cytology]] or [[chest radiograph]] (CXR) screening tests - to have any benefit.<ref name="Manser 2004">{{Cite journal | last=Manser | first=RL | coauthors=Irving LB, Stone C et al. | title=Screening for lung cancer | journal=Cochrane Database of Systematic Reviews | issue=1 | pages=CD001991 | year=2004 | pmid=14973979 | doi=10.1002/14651858.CD001991.pub2 }}</ref>
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Following the National Cancer Institute's National Lung Screening Trial, guidelines were released initially in 2012 by the [[National Comprehensive Cancer Network]], an alliance of twenty one cancer centers in the United States. Their consensus guidelines, which are regularly updated, support screening as a process, not a single test, and discuss risks and benefits of screening in high risk individuals within a comprehensive multidisciplinary program. Screening is only recommended for individuals defined as high risk meeting specific criteria. More details can be found in their patient guidelines.<ref>http://www.nccn.org/patients/patient_guidelines/lung_screening/index.html</ref> While lung cancer screening programs have been supported by the NCCN,<ref>http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#lung_screening</ref> International Association for the Study of Lung Cancer (IASLC),<ref>http://iaslc.org/</ref> American Cancer Society,<ref>http://www.cancer.org/cancer/news/news/new-lung-cancer-screening-guidelines-for-heavy-smokers</ref> The American Society of Clinical Oncology (ASCO),<ref>http://chicago2013.asco.org/asco-releases-clinical-evidence-review-lung-cancer-screening</ref> and other organizations, the screening CT is not typically covered by most insurers at the present time.{{When|date=July 2014}}{{cn|date=July 2014}}


===Research===
==History==
In 2011 the [[National Lung Screening Trial]] found that CT screening offers benefits over other screenings.<ref>{{cite journal|title=Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening|journal=New England Journal of Medicine|volume=365|issue=5|year=2011|pages=395–409|issn=0028-4793|doi=10.1056/NEJMoa1102873}}</ref> This study was recognized for providing supporting evidence for using CR screening to screen for lung cancer and for encouraging others to reflect on the merits and drawbacks of other types of screening.<ref>{{cite journal|last1=Aberle|first1=D. R.|last2=Abtin|first2=F.|last3=Brown|first3=K.|title=Computed Tomography Screening for Lung Cancer: Has It Finally Arrived? Implications of the National Lung Screening Trial|journal=Journal of Clinical Oncology|volume=31|issue=8|year=2013|pages=1002–1008|issn=0732-183X|doi=10.1200/JCO.2012.43.3110}}</ref> Research has not shown that two other available tests - [[sputum]] [[cytopathology|cytology]] or [[chest radiograph]] (CXR) screening tests - have any benefit.<ref name="Manser 2004">{{Cite journal | last=Manser | first=RL | coauthors=Irving LB, Stone C et al. | title=Screening for lung cancer | journal=Cochrane Database of Systematic Reviews | issue=1 | pages=CD001991 | year=2004 | pmid=14973979 | doi=10.1002/14651858.CD001991.pub2 }}</ref>
Efficacy of screening is primarily assessed by how significantly a screening test decreases mortality. The effect can be measured by calculating either lung cancer-specific mortality or all-cause mortality, which may provide a more accurate risk assessment by factoring in risks incurred with intervention. Studies tend to demonstrate an increased survival time in patients who undergo frequent screening, but this can be misleading measure of screening efficacy because of [[Lead time bias|lead time bias.]] Simply detecting a tumor at an earlier stage may not necessarily lead to improved survival. For example, plain chest X-ray screening resulted in increased time from diagnosis of cancer until death and those cancers being detected by screening tended to be earlier stages. However, these patients continued to die at the same rate as those who are not screened.


===Tests not found to show benefit===
====Chest X-Ray====
Lung cancer screening programs that utilize plain [[chest radiography|chest x-rays]] (CXR) and [[sputum]] analysis programs have generally not been found effective in reducing mortality from lung cancer.<ref name="pmid14973979">{{cite journal |author=Manser RL, Irving LB, Stone C, Byrnes G, Abramson M, Campbell D |title=Screening for lung cancer |journal=Cochrane database of systematic reviews (Online) |issue=1 |pages=CD001991 |year=2004 |pmid=14973979 |doi=10.1002/14651858.CD001991.pub2 |editor1-last=Manser |editor1-first=Renée}}</ref> The Mayo Lung Project, followed over 9000 male smokers over 45 years of age who smoked 1+ packs/day from 1971 to 1986 and compared intensive CXR and sputum screening every three times per year compared to less frequent annual screening. The results showed that more frequent screening resulted in higher resectability rate (more early-stage detection), but made no difference in mortality from lung cancer. CXR screening were found to detect 6 times as many new cancers as sputum tests.<ref>Sanderson DR. "Lung Cancer Screening: The Mayo Study". Chest. 1986;89(4_Supplement)</ref>
Lung cancer screening programs that utilize plain [[chest radiography|chest x-rays]] (CXR) and [[sputum]] analysis programs have generally not been found effective in reducing mortality from lung cancer.<ref name="pmid14973979">{{cite journal |author=Manser RL, Irving LB, Stone C, Byrnes G, Abramson M, Campbell D |title=Screening for lung cancer |journal=Cochrane database of systematic reviews (Online) |issue=1 |pages=CD001991 |year=2004 |pmid=14973979 |doi=10.1002/14651858.CD001991.pub2 |editor1-last=Manser |editor1-first=Renée}}</ref> The Mayo Lung Project, followed over 9000 male smokers over 45 years of age who smoked 1+ packs/day from 1971 to 1986 and compared intensive CXR and sputum screening every three times per year compared to less frequent annual screening. The results showed that more frequent screening resulted in higher resectability rate (more early-stage detection), but made no difference in mortality from lung cancer. CXR screening were found to detect 6 times as many new cancers as sputum tests.<ref>Sanderson DR. "Lung Cancer Screening: The Mayo Study". Chest. 1986;89(4_Supplement)</ref>


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Studies have explored other means of testing including breath tests and blood test to detect for lung cancer but none thus far have been clinically validated to be useful to be applied in screening.<ref>{{cite journal | author=Conrad DH, Goyette J, Thomas PS |title=Proteomics as a Method for Early Detection of Cancer: A Review of Proteomics, Exhaled Breath Condensate, and Lung Cancer Screening |journal=Journal of General Internal Medicine |volume=23 |issue=Suppl. 1 |pages=78–84 |year=2008 |pmid=18095050 | doi=10.1007/s11606-007-0411-1 | pmc=2150625 }}</ref><ref>{{cite journal |journal=Cancer Cell |date=Sep 13, 2011 |volume=20 |issue=3 |pages=289–99 |title=Lung cancer signatures in plasma based on proteome profiling of mouse tumor models |author=Taguchi A, Politi K, Pitteri SJ, Lockwood WW, Faça VM, Kelly-Spratt K, Wong CH, Zhang Q, Chin A, Park KS, Goodman G, Gazdar AF, Sage J, Dinulescu DM, Kucherlapati R, Depinho RA, Kemp CJ, Varmus HE, Hanash SM |pmid=21907921 |doi=10.1016/j.ccr.2011.08.007 }}</ref>
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====CT scans====

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===CT scans===
A [[computed tomography]] (CT) scan can uncover tumors not yet visible on an X-ray. This led to CT scanning being actively evaluated as a screening tool for lung cancer in high-risk patients.
A [[computed tomography]] (CT) scan can uncover tumors not yet visible on an X-ray. This led to CT scanning being actively evaluated as a screening tool for lung cancer in high-risk patients.


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In contrast, a March 2007 study in the ''[[Journal of the American Medical Association]]'' (JAMA) found no mortality benefit from CT-based lung cancer screening.<ref name="pmid17341709">{{cite journal |author=Bach PB, Jett JR, Pastorino U, Tockman MS, Swensen SJ, Begg CB |title=Computed tomography screening and lung cancer outcomes |journal=JAMA |volume=297 |issue=9 |pages=953–61 |year=2007 |pmid=17341709 |doi=10.1001/jama.297.9.953}}</ref> 3,200 current or former smokers were screened for 4 years and offered 3 or 4 CT scans. Lung cancer diagnoses were 3 times as high, and surgeries were 10 times as high, as predicted by a model, but there were no significant differences between observed and expected numbers of advanced cancers or deaths.<ref name=Crestanello_2004>{{cite journal |author=Crestanello JA |title=Thoracic surgical operations in patients enrolled in a computed tomographic screening trial |journal=Journal of Thoracic and Cardiovascular Surgery |volume=128 |issue=2 |pages=254–259 |year=2004 |pmid=15282462 |doi=10.1016/j.jtcvs.2004.02.017 |author-separator=, |author2=Allen MS |author3=Jett J |author4=Cassivi SD |display-authors=4 |last5=Nichols Iii |first5=Francis C. |last6=Swensen |first6=Stephen J. |last7=Deschamps |first7=Claude |last8=Pairolero |first8=Peter C.}}</ref> Additional controversy arose after a 2008 ''[[New York Times]]'' reported that the 2006, pro-CT scan study in the ''[[New England Journal of Medicine]]'' had been funded indirectly by the parent company of the [[Liggett Group]], a [[tobacco company]].<ref name="nytimes">[http://www.nytimes.com/2008/03/26/health/research/26lung.html?pagewanted=1&_r=1&hp Cigarette Company Paid for Lung Cancer Study], by Gardiner Harris. Published in the ''[[New York Times]]'' on March 26, 2008.</ref>
In contrast, a March 2007 study in the ''[[Journal of the American Medical Association]]'' (JAMA) found no mortality benefit from CT-based lung cancer screening.<ref name="pmid17341709">{{cite journal |author=Bach PB, Jett JR, Pastorino U, Tockman MS, Swensen SJ, Begg CB |title=Computed tomography screening and lung cancer outcomes |journal=JAMA |volume=297 |issue=9 |pages=953–61 |year=2007 |pmid=17341709 |doi=10.1001/jama.297.9.953}}</ref> 3,200 current or former smokers were screened for 4 years and offered 3 or 4 CT scans. Lung cancer diagnoses were 3 times as high, and surgeries were 10 times as high, as predicted by a model, but there were no significant differences between observed and expected numbers of advanced cancers or deaths.<ref name=Crestanello_2004>{{cite journal |author=Crestanello JA |title=Thoracic surgical operations in patients enrolled in a computed tomographic screening trial |journal=Journal of Thoracic and Cardiovascular Surgery |volume=128 |issue=2 |pages=254–259 |year=2004 |pmid=15282462 |doi=10.1016/j.jtcvs.2004.02.017 |author-separator=, |author2=Allen MS |author3=Jett J |author4=Cassivi SD |display-authors=4 |last5=Nichols Iii |first5=Francis C. |last6=Swensen |first6=Stephen J. |last7=Deschamps |first7=Claude |last8=Pairolero |first8=Peter C.}}</ref> Additional controversy arose after a 2008 ''[[New York Times]]'' reported that the 2006, pro-CT scan study in the ''[[New England Journal of Medicine]]'' had been funded indirectly by the parent company of the [[Liggett Group]], a [[tobacco company]].<ref name="nytimes">[http://www.nytimes.com/2008/03/26/health/research/26lung.html?pagewanted=1&_r=1&hp Cigarette Company Paid for Lung Cancer Study], by Gardiner Harris. Published in the ''[[New York Times]]'' on March 26, 2008.</ref>


===National Lung Screening Trial===
The [[National Cancer Institute]] funded a $300m study, the National Lung Screening Trial (NLST), which began in 2002, to compare the effectiveness of CT scan screening versus X-ray screening.<ref name=WSJresults /><ref name=Henschke>[http://www.nytimes.com/2006/10/31/health/31prof.html?pagewanted=2&ref=research When It Comes to Lung Cancer, She Doesn’t Believe in Waiting] by Denise Grady. Published in ''[[The New York Times]]'' on 31 October 2006</ref> This study, too, raised concern in the media over potential conflicts of interest related to the tobacco company, although this time on the contra-CT scan side: on October 8, 2007, the ''[[Wall Street Journal]]'' reported that at least two lead investigators of the study had conflicts of interest arising from their serving as paid, expert defense witnesses for the tobacco industry – one of them had given testimony asserting that promoting CT screening was "reckless or irresponsible", and another had provided an expert report warning that CT screening "may do more harm than good."<ref name="wsj">[http://online.wsj.com/article/SB119179920110451468.html?pagewanted=1&_r=1&hp Critics Question Objectivity Of Government Lung-Scan Study], by David Armstrong. Published in the ''[[Wall Street Journal]]'' on October 8, 2007</ref>
{{main|National Lung Screening Trial}}
The National Lung Screening Trial was a United States-based [[clinical trial]] which recruited [[research participants]] between 2002-2004.<ref name="clinicaltrials.gov entry">{{cite web |url= http://clinicaltrials.gov/show/NCT00047385%20entry%20at%20ClinicalTrials.gov |title=National Lung Screening Trial (NLST) Screening - Full Text View - ClinicalTrials.gov |author=National Cancer Institute |authorlink=National Cancer Institute |work=clinicaltrials.gov |year=2014 [last update] |accessdate=23 July 2014}}</ref> It was sponsored by the [[National Cancer Institute]] and conducted by conducted by the [[American College of Radiology]] Imaging Network and the Lung Screening Study Group.<ref name="clinicaltrials.gov entry"/> The major research in the trial was to compare the efficacy of low-dose helical [[computed tomography]] (CT screening) and standard [[chest X-ray]] as methods of lung cancer screening.<ref>[http://www.cancer.gov/clinicaltrials/noteworthy-trials/nlst National Lung Screening Trial]</ref>


The trial led to a recommendation in the United States that CT screening be used on people at high risk for developing lung cancer in an effort to detect the cancer earlier and reduce mortality.<ref name=Ab2013>{{cite journal|last1=Aberle|first1=D. R.|last2=Abtin|first2=F.|last3=Brown|first3=K.|title=Computed Tomography Screening for Lung Cancer: Has It Finally Arrived? Implications of the National Lung Screening Trial|journal=Journal of Clinical Oncology|volume=31|issue=8|year=2013|pages=1002–1008|issn=0732-183X|doi=10.1200/JCO.2012.43.3110}}</ref>
The National Cancer Institute' National Lung Screening Trial involved over 53,000 former and current heavy smokers aged 55 to 74, who either received three CT scans or three X-rays annually.<ref name=WSJresults /> Deaths in either group were then logged for up to five years.<ref name=WSJresults /> As of October 2010, 354 people in the CT scan group had died from lung cancer, versus 442 people in the X-ray group; in other words, deaths in the CT scan group of patients were 20.3% lower than in the X-ray group.<ref name=WSJresults>[http://online.wsj.com/article/BT-CO-20101104-717833.html UPDATE: US Lung Cancer Screening Study Shows Benefit With CT Vs. X-Ray], by Jennifer Corbett Dooren. Published in the ''[[Wall Street Journal]]'' on November 4, 2010</ref> The study's review board concluded that this difference was [[statistical significance|statistically significant]] and recommended terminating the study.<ref name=WSJresults /> The director of the National Cancer Institute's director, Harold Varmus, said that early analysis results appeared to indicate that CT scans detected more lung cancers, at an earlier and more treatable stage, and that CT scans could therefore somewhat reduce the number of deaths in patients at high risk of lung cancer.<ref name=WSJresults /> Researchers associated with the study cautioned that the preliminary results did not constitute sufficient grounds to make the general public undergo CT scans and that further research and analysis of the data was necessary.<ref name=WSJresults /> The benefits of screening would have to be balanced against the risks associated with [[false positive]]s – suspicious CT scan findings that in the end prove not to be cancer-related (although if the randomized data holds this demonstrates the benefits of screening outweigh the negatives of false positives on mortality) – and there is as yet no data showing how CT scan screening would benefit other sections of the population, such as people who had only smoked for shorter periods of time.<ref name=WSJresults />


====Other methods====
==Society and culture==
⚫
[[Clinical practice guideline]]s previously issued by the [[American College of Chest Physicians]] in 2007 recommended against routine screening for lung cancer because of a lack of evidence that such screening was effective.<ref name="pmid17873156">{{cite journal |author=Alberts WM |title=Diagnosis and Management of Lung Cancer Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) |journal= Chest|volume=132 |issue=3_suppl |pages=1S–19S |year=2007 |pmid=17873156 |doi=10.1378/chest.07-1860 |author2=American College of Chest Physicians}}</ref> The newest ACCP guidelines take into account findings from the [[National Lung Screening Trial]] and state: "For smokers and former smokers who are age 55 to 74 and who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years, we suggest that annual screening with low-dose CT (LDCT) should be offered over both annual screening with CXR or no screening, but only in settings that can deliver the comprehensive care provided to National Lung Screening Trial participants (Grade 2B)".<ref>{{cite journal|last=Detterbeck|first=Frank C.|author2=Lewis SZ |author3=Diekemper R |title=Executive summary: Diagnosis and management of lung cancer, 3rd ed: american college of chest physicians evidence-based clinical practice guidelines|journal=Chest|date=1 May 2013|volume=143|issue=5S}}</ref>
⚫
Studies have explored other means of testing including breath tests and blood test to detect for lung cancer but none thus far have been clinically validated to be useful to be applied in screening.<ref>{{cite journal | author=Conrad DH, Goyette J, Thomas PS |title=Proteomics as a Method for Early Detection of Cancer: A Review of Proteomics, Exhaled Breath Condensate, and Lung Cancer Screening |journal=Journal of General Internal Medicine |volume=23 |issue=Suppl. 1 |pages=78–84 |year=2008 |pmid=18095050 | doi=10.1007/s11606-007-0411-1 | pmc=2150625 }}</ref><ref>{{cite journal |journal=Cancer Cell |date=Sep 13, 2011 |volume=20 |issue=3 |pages=289–99 |title=Lung cancer signatures in plasma based on proteome profiling of mouse tumor models |author=Taguchi A, Politi K, Pitteri SJ, Lockwood WW, Faça VM, Kelly-Spratt K, Wong CH, Zhang Q, Chin A, Park KS, Goodman G, Gazdar AF, Sage J, Dinulescu DM, Kucherlapati R, Depinho RA, Kemp CJ, Varmus HE, Hanash SM |pmid=21907921 |doi=10.1016/j.ccr.2011.08.007 }}</ref>

In December 2013 the [[United States Preventive Services Task Force|U.S. Preventative Services Task Force]] (USPSTF) changed its long-standing recommendation that there is insufficient evidence to recommend for or against screening for [[lung cancer]] to the following: "The USPSTF recommends 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. 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".<ref>{{cite web |url=http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm |title=Lung Cancer Screening |year=2013 |publisher=[[United States Preventive Services Task Force|U.S. Preventative Services Task Force]]}}</ref> The English [[National Health Service]] was in 2014 re-examining the evidence for screening.<ref>{{cite journal|last1=Baldwin|first1=DR|last2=Hansell|first2=DM|last3=Duffy|first3=SW|last4=Field|first4=JK|title=Lung cancer screening with low dose computed tomography.|journal=BMJ (Clinical research ed.)|date=2014 Mar 7|volume=348|pages=g1970|pmid=24609921|accessdate=23 July 2014}}</ref>

⚫
Following the National Cancer Institute's National Lung Screening Trial, guidelines were released initially in 2012 by the [[National Comprehensive Cancer Network]], an alliance of twenty one cancer centers in the United States. Their consensus guidelines, which are regularly updated, support screening as a process, not a single test, and discuss risks and benefits of screening in high risk individuals within a comprehensive multidisciplinary program. Screening is only recommended for individuals defined as high risk meeting specific criteria. More details can be found in their patient guidelines.<ref>http://www.nccn.org/patients/patient_guidelines/lung_screening/index.html</ref> While lung cancer screening programs have been supported by the NCCN,<ref>http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#lung_screening</ref> International Association for the Study of Lung Cancer (IASLC),<ref>http://iaslc.org/</ref> American Cancer Society,<ref>http://www.cancer.org/cancer/news/news/new-lung-cancer-screening-guidelines-for-heavy-smokers</ref> The American Society of Clinical Oncology (ASCO),<ref>http://chicago2013.asco.org/asco-releases-clinical-evidence-review-lung-cancer-screening</ref> and other organizations, the screening CT is not typically covered by most insurers at the present time.{{When|date=July 2014}}{{cn|date=July 2014}}


== References ==
== References ==
{{Reflist}}
{{reflist|25em}}


{{DEFAULTSORT:Lung Cancer Screening}}
{{DEFAULTSORT:Lung Cancer Screening}}

Revision as of 19:44, 23 July 2014

Lung cancer screening refers to cancer screening strategies used to identify early lung cancers before they cause symptoms, at a point where they are more likely to be curable. Screening studies for lung cancer have only been done in high risk populations, such as smokers and workers with occupational exposure to certain substances. In the 2010s recommendations by medical authorities are turning in favour of lung cancer screening, which is likely to become more widely available in the advanced economies.

For individuals with high risk of developing lung cancer, computed tomography (CT) screening can detect cancer and give a person options to respond to it in a way that prolongs life.[1] This form of screening reduces the chance of death from lung cancer by an absolute amount of 0.3% (relative amount of 20%).[2][3] High risk people are those age 55-74 who have smoked a pack of cigarettes daily for 30 years including time within the past 15 years.[1]

CT screening is associated with a high rate of falsely positive tests which may result in unneeded treatment.[4] For each true positive scan there are more than 19 falsely positives scans.[5] Other concerns include radiation exposure[4] and the cost of testing along with the follow up of tests.[1] Research has not found two other available tests - sputum cytology or chest radiograph (CXR) screening tests - to have any benefit.[6]

Screening studies for lung cancer have only been done in high risk populations, such as smokers and workers with occupational exposure to certain substances. In the 2010s recommendations by medical authorities are turning in favour of lung cancer screening, which is likely to become more widely available in the advanced economies. In December 2013 the U.S. Preventative Services Task Force (USPSTF) changed its long-standing recommendation that there is insufficient evidence to recommend for or against screening for lung cancer to the following: "The USPSTF recommends 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. 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".[7] The English National Health Service was in 2014 re-examining the evidence for screening.[8]

Medical uses

Lung cancer screening ideally would be used to detect lung cancer early in its development. Currently lung cancer screening is only recommended for people who are at high risk of developing lung cancer soon.[1] High risk people are those age 55-74 who have smoked a pack of cigarettes daily for 30 years including time within the past 15 years, and in that population, the test is recommended annually.[1]

Technique

For individuals with high risk of developing lung cancer, computed tomography (CT) screening can detect cancer and give a person options to respond to it in a way that prolongs life.[1]

Research has not found two other available tests - sputum cytology or chest radiograph (CXR) screening tests - to have any benefit.[6]

Risks of Screening

CT screening is associated with a high rate of falsely positive tests which may result in unneeded treatment.[1] For each true positive scan there are more than 19 falsely positives scans.[9] Other concerns include radiation exposure and the cost of testing along with the follow up of tests.[1] False reassurance from false negative findings, overdiagnosis, short term anxiety/distress, and increased rate of incidental findings are other risks.[10] Radiation exposure from repeated screening studies could actually induce cancer formation in a small percentage of screened subjects, so this risk should be mitigated by a (relatively) high prevalence of lung cancer in the population being screened.[1]

Research has not found two other available tests - sputum cytology or chest radiograph (CXR) screening tests - to have any benefit.[6]

History

In 2011 the National Lung Screening Trial found that CT screening offers benefits over other screenings.[11] This study was recognized for providing supporting evidence for using CR screening to screen for lung cancer and for encouraging others to reflect on the merits and drawbacks of other types of screening.[12] Research has not shown that two other available tests - sputum cytology or chest radiograph (CXR) screening tests - have any benefit.[6]

Tests not found to show benefit

Lung cancer screening programs that utilize plain chest x-rays (CXR) and sputum analysis programs have generally not been found effective in reducing mortality from lung cancer.[13] The Mayo Lung Project, followed over 9000 male smokers over 45 years of age who smoked 1+ packs/day from 1971 to 1986 and compared intensive CXR and sputum screening every three times per year compared to less frequent annual screening. The results showed that more frequent screening resulted in higher resectability rate (more early-stage detection), but made no difference in mortality from lung cancer. CXR screening were found to detect 6 times as many new cancers as sputum tests.[14]

Studies have explored other means of testing including breath tests and blood test to detect for lung cancer but none thus far have been clinically validated to be useful to be applied in screening.[15][16]

CT scans

A computed tomography (CT) scan can uncover tumors not yet visible on an X-ray. This led to CT scanning being actively evaluated as a screening tool for lung cancer in high-risk patients.

The International Early Lung Cancer Action Project (I-ELCAP) published the results of CT screening on over 31,000 high-risk patients in late 2006 in the New England Journal of Medicine.[17] In this study, 85% of the 484 detected lung cancers were stage I and thus highly treatable. Historically, such stage I patients would have an expected 10-year survival of 88%. Critics of the I-ELCAP study point out that there was no randomization of patients (all received CT scans and there was no comparison group receiving only chest x-rays) and the patients were not actually followed out to 10 years post detection (the median followup was 40 months). Regardless of these shortcomings, it is generally recognized that the prognosis of lung cancer decreases dramatically when the disease is in late stage,[18][19] and that CT screening for lung cancer allows detection of lung cancer during its earliest, most curable stage. CT screening for lung cancer has already been extensively compared to chest x-ray screening in Japan. Among over 6,800 subjects screened in Japan, 67% to 73% of CT-detected lung cancers were missed by chest x-ray, the same test used in the comparison group of some randomized controlled trials of lung cancer screening.[20][21][22]

In contrast, a March 2007 study in the Journal of the American Medical Association (JAMA) found no mortality benefit from CT-based lung cancer screening.[23] 3,200 current or former smokers were screened for 4 years and offered 3 or 4 CT scans. Lung cancer diagnoses were 3 times as high, and surgeries were 10 times as high, as predicted by a model, but there were no significant differences between observed and expected numbers of advanced cancers or deaths.[24] Additional controversy arose after a 2008 New York Times reported that the 2006, pro-CT scan study in the New England Journal of Medicine had been funded indirectly by the parent company of the Liggett Group, a tobacco company.[25]

National Lung Screening Trial

Main article: National Lung Screening Trial

The National Lung Screening Trial was a United States-based clinical trial which recruited research participants between 2002-2004.[26] It was sponsored by the National Cancer Institute and conducted by conducted by the American College of Radiology Imaging Network and the Lung Screening Study Group.[26] The major research in the trial was to compare the efficacy of low-dose helical computed tomography (CT screening) and standard chest X-ray as methods of lung cancer screening.[27]

The trial led to a recommendation in the United States that CT screening be used on people at high risk for developing lung cancer in an effort to detect the cancer earlier and reduce mortality.[4]

Society and culture

Clinical practice guidelines previously issued by the American College of Chest Physicians in 2007 recommended against routine screening for lung cancer because of a lack of evidence that such screening was effective.[28] The newest ACCP guidelines take into account findings from the National Lung Screening Trial and state: "For smokers and former smokers who are age 55 to 74 and who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years, we suggest that annual screening with low-dose CT (LDCT) should be offered over both annual screening with CXR or no screening, but only in settings that can deliver the comprehensive care provided to National Lung Screening Trial participants (Grade 2B)".[29]

In December 2013 the U.S. Preventative Services Task Force (USPSTF) changed its long-standing recommendation that there is insufficient evidence to recommend for or against screening for lung cancer to the following: "The USPSTF recommends 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. 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".[30] The English National Health Service was in 2014 re-examining the evidence for screening.[31]

Following the National Cancer Institute's National Lung Screening Trial, guidelines were released initially in 2012 by the National Comprehensive Cancer Network, an alliance of twenty one cancer centers in the United States. Their consensus guidelines, which are regularly updated, support screening as a process, not a single test, and discuss risks and benefits of screening in high risk individuals within a comprehensive multidisciplinary program. Screening is only recommended for individuals defined as high risk meeting specific criteria. More details can be found in their patient guidelines.[32] While lung cancer screening programs have been supported by the NCCN,[33] International Association for the Study of Lung Cancer (IASLC),[34] American Cancer Society,[35] The American Society of Clinical Oncology (ASCO),[36] and other organizations, the screening CT is not typically covered by most insurers at the present time.[when?][citation needed]

References

  1. ^ a b c d e f g h i American College of Chest Physicians; American Thoracic Society (September 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American College of Chest Physicians and American Thoracic Society, retrieved 6 January 2013
  2. ^ Jaklitsch, MT (July 2012). "The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups". Journal of Thoracic and Cardiovascular Surgery. 144 (1): 33–38. doi:10.1016/j.jtcvs.2012.05.060. PMID 22710039. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  3. ^ Bach, PB (June 2012). "Benefits and harms of CT screening for lung cancer: a systematic review". JAMA: the Journal of the American Medical Association. 307 (22): 2418–2429. doi:10.1001/jama.2012.5521. PMID 22610500. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  4. ^ a b c Aberle, D. R.; Abtin, F.; Brown, K. (2013). "Computed Tomography Screening for Lung Cancer: Has It Finally Arrived? Implications of the National Lung Screening Trial". Journal of Clinical Oncology. 31 (8): 1002–1008. doi:10.1200/JCO.2012.43.3110. ISSN 0732-183X.
  5. ^ Bach PB, Mirkin JN, Oliver TK; et al. (June 2012). "Benefits and harms of CT screening for lung cancer: a systematic review". JAMA. 307 (22): 2418–29. doi:10.1001/jama.2012.5521. PMID 22610500. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  6. ^ a b c d Manser, RL (2004). "Screening for lung cancer". Cochrane Database of Systematic Reviews (1): CD001991. doi:10.1002/14651858.CD001991.pub2. PMID 14973979. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  7. ^ "Lung Cancer Screening". U.S. Preventative Services Task Force. 2013.
  8. ^ Baldwin, DR; Hansell, DM; Duffy, SW; Field, JK (2014 Mar 7). "Lung cancer screening with low dose computed tomography". BMJ (Clinical research ed.). 348: g1970. PMID 24609921. {{cite journal}}: |access-date= requires |url= (help); Check date values in: |date= (help)
  9. ^ Bach PB, Mirkin JN, Oliver TK; et al. (June 2012). "Benefits and harms of CT screening for lung cancer: a systematic review". JAMA. 307 (22): 2418–29. doi:10.1001/jama.2012.5521. PMID 22610500. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  10. ^ Humphrey LL, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, Zakher B, Fu R, Slatore CG (2013). "Screening for Lung Cancer With Low-Dose Computed Tomography: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation". Annals of Internal Medicine. 159 (ePub ahead of print): 411–20. doi:10.7326/0003-4819-159-6-201309170-00690. PMID 23897166.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ "Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening". New England Journal of Medicine. 365 (5): 395–409. 2011. doi:10.1056/NEJMoa1102873. ISSN 0028-4793.
  12. ^ Aberle, D. R.; Abtin, F.; Brown, K. (2013). "Computed Tomography Screening for Lung Cancer: Has It Finally Arrived? Implications of the National Lung Screening Trial". Journal of Clinical Oncology. 31 (8): 1002–1008. doi:10.1200/JCO.2012.43.3110. ISSN 0732-183X.
  13. ^ Manser RL, Irving LB, Stone C, Byrnes G, Abramson M, Campbell D (2004). Manser, Renée (ed.). "Screening for lung cancer". Cochrane database of systematic reviews (Online) (1): CD001991. doi:10.1002/14651858.CD001991.pub2. PMID 14973979.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Sanderson DR. "Lung Cancer Screening: The Mayo Study". Chest. 1986;89(4_Supplement)
  15. ^ Conrad DH, Goyette J, Thomas PS (2008). "Proteomics as a Method for Early Detection of Cancer: A Review of Proteomics, Exhaled Breath Condensate, and Lung Cancer Screening". Journal of General Internal Medicine. 23 (Suppl. 1): 78–84. doi:10.1007/s11606-007-0411-1. PMC 2150625. PMID 18095050.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ Taguchi A, Politi K, Pitteri SJ, Lockwood WW, Faça VM, Kelly-Spratt K, Wong CH, Zhang Q, Chin A, Park KS, Goodman G, Gazdar AF, Sage J, Dinulescu DM, Kucherlapati R, Depinho RA, Kemp CJ, Varmus HE, Hanash SM (Sep 13, 2011). "Lung cancer signatures in plasma based on proteome profiling of mouse tumor models". Cancer Cell. 20 (3): 289–99. doi:10.1016/j.ccr.2011.08.007. PMID 21907921.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Smith JP, Miettinen OS (2006). "Survival of patients with stage I lung cancer detected on CT screening". N. Engl. J. Med. 355 (17): 1763–71. doi:10.1056/NEJMoa060476. PMID 17065637.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  18. ^ Mountain CF (June 1997). "Revisions in the International System for Staging Lung Cancer". Chest. 111 (6): 1710–7. doi:10.1378/chest.111.6.1710. PMID 9187198.
  19. ^ Inoue K; Sato M; Fujimura S; et al. (September 1998). "Prognostic assessment of 1310 patients with non-small-cell lung cancer who underwent complete resection from 1980 to 1993". J. Thorac. Cardiovasc. Surg. 116 (3): 407–11. doi:10.1016/S0022-5223(98)70006-6. PMID 9731782. {{cite journal}}: Unknown parameter |author-separator= ignored (help)
  20. ^ Kaneko M; Eguchi K; Ohmatsu H; et al. (December 1996). "Peripheral lung cancer: screening and detection with low-dose spiral CT versus radiography". Radiology. 201 (3): 798–802. PMID 8939234. {{cite journal}}: Unknown parameter |author-separator= ignored (help)
  21. ^ Sone S; Takashima S; Li F; et al. (April 1998). "Mass screening for lung cancer with mobile spiral computed tomography scanner". Lancet. 351 (9111): 1242–5. doi:10.1016/S0140-6736(97)08229-9. PMID 9643744. {{cite journal}}: Unknown parameter |author-separator= ignored (help)
  22. ^ Sone S; Li F; Yang ZG; et al. (January 2001). "Results of three-year mass screening programme for lung cancer using mobile low-dose spiral computed tomography scanner". Br. J. Cancer. 84 (1): 25–32. doi:10.1054/bjoc.2000.1531. PMC 2363609. PMID 11139308. {{cite journal}}: Unknown parameter |author-separator= ignored (help)
  23. ^ Bach PB, Jett JR, Pastorino U, Tockman MS, Swensen SJ, Begg CB (2007). "Computed tomography screening and lung cancer outcomes". JAMA. 297 (9): 953–61. doi:10.1001/jama.297.9.953. PMID 17341709.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Crestanello JA; Allen MS; Jett J; Cassivi SD; et al. (2004). "Thoracic surgical operations in patients enrolled in a computed tomographic screening trial". Journal of Thoracic and Cardiovascular Surgery. 128 (2): 254–259. doi:10.1016/j.jtcvs.2004.02.017. PMID 15282462. {{cite journal}}: Unknown parameter |author-separator= ignored (help)
  25. ^ Cigarette Company Paid for Lung Cancer Study, by Gardiner Harris. Published in the New York Times on March 26, 2008.
  26. ^ a b National Cancer Institute (2014 [last update]). "National Lung Screening Trial (NLST) Screening - Full Text View - ClinicalTrials.gov". clinicaltrials.gov. Retrieved 23 July 2014. {{cite web}}: Check date values in: |year= (help)CS1 maint: year (link)
  27. ^ National Lung Screening Trial
  28. ^ Alberts WM; American College of Chest Physicians (2007). "Diagnosis and Management of Lung Cancer Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)". Chest. 132 (3_suppl): 1S–19S. doi:10.1378/chest.07-1860. PMID 17873156.
  29. ^ Detterbeck, Frank C.; Lewis SZ; Diekemper R (1 May 2013). "Executive summary: Diagnosis and management of lung cancer, 3rd ed: american college of chest physicians evidence-based clinical practice guidelines". Chest. 143 (5S).
  30. ^ "Lung Cancer Screening". U.S. Preventative Services Task Force. 2013.
  31. ^ Baldwin, DR; Hansell, DM; Duffy, SW; Field, JK (2014 Mar 7). "Lung cancer screening with low dose computed tomography". BMJ (Clinical research ed.). 348: g1970. PMID 24609921. {{cite journal}}: |access-date= requires |url= (help); Check date values in: |date= (help)
  32. ^ http://www.nccn.org/patients/patient_guidelines/lung_screening/index.html
  33. ^ http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#lung_screening
  34. ^ http://iaslc.org/
  35. ^ http://www.cancer.org/cancer/news/news/new-lung-cancer-screening-guidelines-for-heavy-smokers
  36. ^ http://chicago2013.asco.org/asco-releases-clinical-evidence-review-lung-cancer-screening
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