Mamta Ruparel

Pulmonary nodules and CT screening: the past, present and future

Lung cancer screening has come a long way since the early studies with chest X-ray. Advancing technology and progress in the processing of images have enabled low dose CT to be tried and tested, and evidence suggests its use can result in a significant mortality benefit. There are several issues that need refining in order to successfully implement screening in the UK and elsewhere. Some countries have started patchy implementation of screening and there is increased recognition that the appropriate management of pulmonary nodules is crucial to optimise benefits of early detection, while reducing harm caused by inappropriate medical intervention. This review summarises and differentiates the many recent guidelines on pulmonary nodule management, discusses screening activity in other countries and exposes the present barriers to implementation in the UK.

Lung cancer screening: what we can learn from UKLS?

There has been almost a 1000 ‘lung cancer screening’ papers and abstracts over the past 10 years, with half published in the last two. Avoiding the topic of lung cancer screening at respiratory, radiology and oncology conferences is becoming increasingly challenging. Is it realistic that we are going to screen for lung cancer in the UK? We know, despite our continued efforts, that the UK health system serves its patients with lung cancer poorly. Current UK lung cancer statistics demonstrate a 13% 5-year survival attributed largely to late-stage presentation.1 Approximately 70% of lung cancer is diagnosed at stage III and IV where options for curative treatment are greatly diminished.2 There can be no doubt, therefore, that earlier diagnosis is crucial to improving lung cancer outcomes, and nowhere more so than the UK. However, the data supporting low radiation dose CT screening (LDCT) for lung cancer are from the USA where medicine is practised rather differently and resources not so limited. So, until this issue of Thorax , there has been a paucity of evidence from Britain to support the extrapolation of available data to our patients. The UK Lung Cancer Pilot Screening Trial (UKLS) reports the findings of its Wald single screen design randomised controlled pilot providing data that address many questions, but raise others.3 The first issue is that of determining eligibility for screening. One can reduce patient eligibility by increasing the risk threshold required to screen, thereby enriching the lung …

S14 Lung cancer risk profiles and eligibility of attendees in a lung cancer screening demonstration pilot

Introduction Lung cancer screening by Low-Dose CT (LDCT) has been shown to reduce mortality, and the harm-benefit balance of screening is optimised by screening those at higher risk. The Lung Screen Uptake Trial is a UK based randomised controlled trial of standard versus enhanced invitation methods for LDCT screening in more deprived communities. Methods Patients aged 60 to 75, at higher risk of lung cancer by virtue of their recorded smoking history, were invited to a ‘lung health check appointment’ on behalf of their GP. Attendees at one of two secondary care sites, underwent a nurse consultation that included a lung cancer risk assessment. Participants were eligible for LDCT if they met any of the following three criteria: NLST-like criteria* (≥30 pack-year smoking history and given up ≤15 years ago); PLCOm2012 score ≥1.51%; or LLP score ≥2.5%. This abstract focuses on the performance of the different eligibility criteria. Results At the time of analysis, 1997 individuals had been invited to screening and 936 attended and were enrolled into the study. 854 participants were eligible for LDCT by fulfilling any of the 3 criteria above, and 718 went on to have LDCT. The mean age of participants was 66.0 (SD 4.16), 54.4% were male and the mean smoking pack-year history was 39.7 (SD 24.9). After a median of 9.7 months follow up, 17 lung cancers were confirmed. Ten suspicious pulmonary nodules are undergoing diagnostic work up under the lung cancer multidisciplinary team (MDT) and 80 indeterminate nodules are under CT surveillance. The distribution of these cancers and nodules by eligibility criteria is shown in Table 1. Abstract S14 Table 1 Number of cancers and nodules by eligibility criteria *NLST criteria but with modified age range of 60 to 75 years PLCOm2012 positive LLP positive NLST-like* positive Total in cohort Had CT 576 661 493 718 Indeterminate nodules 64 74 58 80 Suspicious nodule referred to MDT 8 9 7 10 Confirmed cancers 17 16 13 17 Conclusions Using the NLST-like* criteria to determine eligibility would mean the fewest number screened, with 4 fewer cancers detected. The PLCOm2012 score was the most reliable way to detect cancers and resulted in less individuals screened than with use of the LLP score. Further follow up and review of the data is required to fully establish the most effective tool for determining eligibility into LDCT screening though the PLCOm2012 score shows the most promise with the available data.

Reply: Lung Cancer Susceptibility, Ethnicity, and the Benefits of Computed Tomography Screening

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