Highlights of CHEST's 2018 Updated Lung Cancer Screening Guidelines

By: Dr. Peter Mazzone

January 25, 2018

An update to CHEST’s lung cancer screening guideline, Screening for Lung Cancer: CHEST Guideline and Expert Panel Report has just been published online in the journal CHEST®. This update was made possible by the hard work of my co-authors and the amazing support of the CHEST staff. Our goal was to update the evidence base for the benefit, harms, and implementation of low-radiation dose chest CT screening, then use this evidence base to produce meaningful and usable recommendations. 

The process for developing the guideline followed the rigorous methodological standards of CHEST in which the evidence was gathered from a systematic literature review, and overall quality of the body of evidence was assessed using the GRADE approach. Recommendations were developed and graded based on this assessment.

There are a few aspects of the new guidelines to highlight. First, we have updated some of the core recommendations; second, we have developed new recommendations related to the implementation of high-quality screening; and third, the CHEST approach to guideline development has evolved to allow us to provide recommendations in which the evidence allows and statements based on experience and expert consensus in which it does not. Through this process we developed six graded recommendations and nine ungraded consensus-based statements.

In this update, a few changes to the core recommendations about who should be screened are worthy to note:

• We have recommended an increase to the upper age of the screen-eligible cohort from 74 to 77, in line with CMS coverage and reflecting the oldest age of participants in the National Lung Screening Trial at the end of the screening period.
• We have directly addressed the cohort of individuals who are at high risk for having/developing lung cancer based on clinical risk prediction calculators but do not meet the current eligibility criteria. We recommended that this cohort should not be routinely screened given the greater potential for this cohort to have comorbid conditions that would influence morbidity from the evaluation and treatment of screen-detected findings and death from any cause. We did, however, state that there will be individuals within the cohort deemed to be at high risk for lung cancer from a clinical risk prediction calculator who are healthy enough to benefit from lung cancer screening and that low-radiation dose CT screening could be considered in these individuals.
• We recommended against low-radiation dose CT screening in cohorts at low risk of developing lung cancer and in individuals with comorbidities that adversely influence their ability to tolerate the evaluation of screen-detected findings, tolerate treatment of an early stage screen-detected lung cancer, or that substantially limit their life expectancy.
• We also highlighted that screening is reserved for patients without symptoms that could be caused by the presence of lung cancer, stressing that all symptomatic patients should receive an appropriate diagnostic evaluation.

Our remaining recommendation and statements are focused on aspects of screening implementation that influence the balance of benefit and harms of screening and lend to an approach to screening that respects patient values. An extensive literature review, followed by a recommendation or statement, is provided to guide programs in the following areas:

• the choice of nodule size to define what constitutes a positive test;
• maximizing compliance with annual screening exams;
• developing a comprehensive approach to lung nodule management;
• minimizing overtreatment of potentially indolent lung cancers;
• the provision of evidence-based tobacco cessation treatment;
• providing effective counseling and shared decision-making visits prior to the low-radiation dose CT scan;
• how to perform the low-radiation dose CT scan;
• structured reporting of the exam results, management of non-nodule findings on the low radiation dose CT, and
• the development of data collection and reporting tools that are capable of assisting with quality improvement initiatives.

Throughout the recommendations and statements we have tried to be sensitive to the variety of acceptable approaches to screening program organization, ranging from program structures that are entirely decentralized (test ordering, counseling, and management of the findings by the referring provider) to those that are entirely centralized (test ordering, counseling, and management of the findings by the screening program).

Though we have attempted to comprehensively evaluate the literature and balance available evidence with pragmatism and the needs of our patients, we recognize that well-intentioned and informed experts can have different opinions about aspects of our guidelines. This highlights the need for further research to guide the screening community. Most will agree that it is time to increase access to high- quality lung cancer screening programs across the country. We hope that the updated CHEST lung cancer screening guidelines can help catalyze this.

Peter Mazzone, MD, MPH, FCCP is a staff member at the Respiratory Institute of the Cleveland Clinic where he directs the lung cancer program and the lung cancer screening program. Dr. Mazzone feels fortunate to have led the CHEST lung cancer screening guidelines update.