The number of Americans recommended for routine CT scans to spot lung cancer just got a lot bigger.
People between the ages of 50 and 80 who don’t have symptoms of lung cancer, but are at high risk for the disease due to their smoking history should have the annual screen to help detect the disease early, the U.S. Preventive Services Task Force (USPSTF) concluded in new recommendations released Tuesday.
Two key changes nearly double the number of Americans eligible for lung cancer screening, the panelists said. The first major change is that chest CT screening should begin at age 50 instead of 55. The second change reduces the “pack-years” of smoking history that make someone eligible for screening, from 30 pack-years to 20 (one pack-year is the equivalent of smoking an average of 20 cigarettes, or one pack, per day for a year).
The task force’s recommendations are very influential, often forming the guidance for insurance companies’ decisions on coverage for drugs or procedures. The task force is an independent, volunteer panel of national experts in prevention and evidence-based medicine.
The bottom line is that “by screening people who are younger and who have smoked fewer cigarettes, we can save more lives and help people remain healthy longer,” USPSTF member Dr. Michael Barry said in a task force news release. He directs the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital in Boston.
Of course, the best way to reduce the risk of dying of lung cancer is to quit smoking and to continue to stay smoke-free, the panelists stressed. Smoking remains the leading cause of lung cancer, which is diagnosed in more than 200,000 people in the United States each year and is still the No. 1 cancer killer of Americans.
Based on the new guidelines, candidates for lung cancer screening are people aged 50 to 80 who have smoked at least 20 pack-years over their lifetime, and still smoke or have quit smoking only within the last 15 years, the task force said.
People aged 50 to 80 who are current or former smokers should talk to their doctor about whether they are at high risk for lung cancer. If so, they should discuss the benefits and harms of screening.
Risks and benefits
Dr. Daniel Reuland is a member of the Lineberger Comprehensive Cancer Center at the University of North Carolina (UNC), and a co-author of a major data review that helped lead to the new guidelines. The review, published March 9 in the Journal of the American Medical Association, was based on the results of two major trials conducted in the United States and Europe.
These “two large studies have now confirmed that [CT] screening can lower the chance of dying of lung cancer in high-risk people,” Reuland said in a UNC news release. “However, people considering screening should know that a relatively small number of people who are screened benefit, and that screening can also lead to real harms.”
Those potential harms include “false positive” results on a scan, where a spot or nodule appears that might or might not be lung cancer. That can lead to unnecessary biopsies and a long period of worry for patients, Reuland noted.
“We still do not know how often screening should be done or which approach to categorizing lesions is best for reducing the harms, costs and burdens of screening while retaining the benefits,” he said. Reuland believes that research focusing on more accurate diagnoses should become a priority.
Dr. Michael Wert directs the Lung Cancer Screening Program at Ohio State University Comprehensive Cancer Center in Columbus. He isn’t a panel member but applauded the decision to expand the screening population.
“At present, the vast majority of lung cancers are diagnosed once a patient has already become symptomatic, signifying that the cancer is at an advanced stage [stages 3 and 4] and likely no longer curable,” Wert explained.
And while routine screening has greatly reduced the death rate for cancers of the breast, colon and cervix, lung cancer “has historically lagged far behind that for other cancers” because too few people at risk are screened, he said.
With CT scans, “we have a scientifically proven screening tool and protocol for lung cancer screening that can save lives,” Wert said. “Studies have shown that screening increases survival among affected patients by, at minimum, 20%. I urge people who are at increased risk for lung cancer to take advantage of this screening tool, as it could truly save your life through early detection.”
The expansion of lung cancer screening eligibility may be especially helpful to Black Americans and to women, the task force believes. Both of these groups tend to smoke fewer cigarettes than white men, and Blacks have a higher risk of lung cancer than whites. So lowering the pack-year recommendation could be especially helpful.
“The changes to this recommendation mean more Black people and women are now eligible for lung cancer screening, which is a step in the right direction,” task force member Dr. John Wong added in the release. He’s chief of the Division of Clinical Decision Making and a primary care clinician at Tufts Medical Center in Boston.
But cost could remain a barrier, another expert said.
“Medicaid is not required to cover the USPSTF recommended screenings and even when screening is covered, Medicaid programs may use different eligibility criteria,” said Louise Henderson, professor of radiology at UNC School of Medicine. She was co-author of an editorial published in the same issue of JAMA.
“”This is a significant issue, particularly in the nine states where Medicaid does not cover lung cancer screening,” Henderson said in the UNC news release. She noted that people covered by Medicaid are twice as likely to be smokers at high risk for lung cancer, compared to people covered by private insurance.
For his part, Wert called the new guidelines “a welcome update.”
“As a pulmonologist who specializes in lung cancer, I encourage everyone with a significant smoking history between the ages of 50 and 80 to talk to their doctor about lung cancer screening,” he said.
The new recommendations were published online March 9 in the Journal of the American Medical Association.
The U.S. National Cancer Institute has more on lung cancer screening.
SOURCES: Michael Wert, MD, director, lung cancer screening program, Ohio State University Comprehensive Cancer Center–James Cancer Hospital and Solove Research institute, Columbus; University of North Carolina news releases, March 9, 2021; U.S. Preventive Services Task Force, news release, March 9, 2021