Lung Cancer Screening by Low-Dose Computed Tomography – Part 1: Expected Benefits, Possible Harms, and Criteria for Eligibility and Population Targeting

Abstract

Background Trials in the USA and Europe have convincingly demonstrated the efficacy of screening by low-dose computed tomography (LDCT) as a means to lower lung cancer mortality, but also document potential harms related to radiation, psychosocial stress, and invasive examinations triggered by false-positive screening tests and overdiagnosis. To ensure that benefits (lung cancer deaths averted; life years gained) outweigh the risk of harm, lung cancer screening should be targeted exclusively to individuals who have an elevated risk of lung cancer, plus sufficient residual life expectancy.

Methods and Conclusions Overall, randomized screening trials show an approximate 20 % reduction in lung cancer mortality by LDCT screening. In view of declining residual life expectancy, especially among continuing long-term smokers, risk of being over-diagnosed is likely to increase rapidly above the age of 75. In contrast, before age 50, the incidence of LC may be generally too low for screening to provide a positive balance of benefits to harms and financial costs. Concise criteria as used in the NLST or NELSON trials may provide a basic guideline for screening eligibility. An alternative would be the use of risk prediction models based on smoking history, sex, and age as a continuous risk factor. Compared to concise criteria, such models have been found to identify a 10 % to 20 % larger number of LC patients for an equivalent number of individuals to be screened, and additionally may help provide security that screening participants will all have a high-enough LC risk to balance out harm potentially caused by radiation or false-positive screening tests.

Key Points: 

• LDCT screening can significantly reduce lung cancer mortality

• Screening until the age of 80 was shown to be efficient in terms of cancer deaths averted; in terms of LYG relative to overdiagnosis, stopping at a younger age (e. g. 75) may have greater efficiency

• Risk models may improve the overall net benefit of lung cancer screening

Citation Format

• Kaaks R, Delorme S. Lung Cancer Screening by Low-Dose Computed Tomography – Part 1: Expected Benefits, Possible Harms, and Criteria for Eligibility and Population Targeting. Fortschr Röntgenstr 2021; 193: 527 – 536

Zusammenfassung

Hintergrund Zahlreiche Studien in den USA und Europa haben zeigen können, dass durch Screening mit Niedrigdosis-Computertomografie (Low-Dose-CT, LDCT) der Lunge die Sterblichkeit an Lungenkrebs gesenkt werden kann, haben aber auch damit verbundene Risiken aufgezeigt, die sich durch ionisierende Strahlung, emotionalen Stress, Eingriffe infolge falsch positiver Befunde oder Überdiagnose ergeben. Um zu gewährleisten, dass die Risiken durch den möglichen Nutzen (abgewendeter Tod durch Lungenkrebs, Gewinn an Lebensjahren) aufgewogen werden, sollte Lungenkrebs-Screening auf Personen zielen, deren Lungenkrebsrisiko erhöht ist und deren verbleibende Lebenserwartung ausreichend hoch ist.

Methoden und Schlussfolgerungen Im Ganzen beträgt die Senkung der Lungenkrebssterblichkeit durch LDCT-Screening ca. 20 %. In Anbetracht der mit dem Alter abnehmenden Lebenserwartung, insbesondere bei langjährigen aktiven Rauchern, nimmt das Risiko der Überdiagnose jenseits des 75. Lebensjahres deutlich zu. Vor dem 50. Lebensjahr ist die Lungenkrebsinzidenz hingegen zu gering, als dass Risiken und auch Kosten ein angemessener Nutzen gegenübersteht. Konzise Kriterien, wie in den NLST- und NELSON-Studien angewendet, stellen einen grundlegenden Anhalt für geeignete Einschlusskriterien dar. Ihnen stehen Modelle zur Risikoprädiktion gegenüber, die neben dem Geschlecht das Alter und die Rauchanamnese als kontinuierliche Variablen verwenden. Verglichen mit konzisen Kriterien konnten mithilfe dieser Modelle 10–20 % mehr Patienten mit Lungenkrebs bei gleicher Gesamtzahl gescreenter Personen identifiziert werden. Zugleich können sie zu einer größeren Sicherheit beitragen, dass die Screening-Teilnehmer ein ausreichend hohes Lungenkrebsrisiko haben, sodass die Risiken aufgrund von Strahlung und den Folgen falsch positiver Screening-Ergebnisse aufgewogen werden.

Kernaussagen: 

• Durch LDCT-Screening kann die Lungenkrebssterblichkeit signifikant gesenkt werden.

• Um Überdiagnose zu beschränken, sollte nach dem 75. Lebensjahr kein LDCT-Screening mehr erfolgen.

• Durch den Einsatz von Risikomodellen kann der Nettonutzen des Lungenkrebs-Screenings verbessert werden.

Key words

lung neoplasms - radiation risks - overdiagnosis - false-positive findings - eligibility criteria - screening

Publication History

Received: 22 July 2020

Accepted: 29 September 2020

Article published online:
19 November 2020

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