Overcoming Perceived Hurdles in Lung Cancer Screening: The Low Risk of Complications of Image-Guided Transthoracic Needle Biopsy

The medical, economic, and social burden imposed by lung cancer, the most lethal cancer worldwide, is a tremendous cost to humans. In the United States alone, lung cancer causes more than 160,000 deaths each year and accounts for nearly one third of all cancer deaths. Until recently, no method of screening had been shown to reduce mortality from lung cancer. In 2010, the National Lung Screening Trial (NLST) proved that screening with low-dose helical computed tomography (CT) of the chest in patients at high risk for lung cancer led to a reduction in lung cancer mortality. Although strides in lung cancer screening have occurred, there has been slow adoption for a myriad of reasons, including concerns over quality, cost, and risk. In this edition of Journal of Oncology Practice, Accordino et al publish their findings regarding the use of image-guided transthoracic needle biopsy in patients with cancer. This study has important implications and will help inform medical care providers and patients in discussion of diagnostic risk, potential harms, and possible benefits of lung cancer screening and cancer diagnosis. The NLST was a multicenter trial conducted at 33 centers across the United States and included over 50,000 individuals. Participants who were eligible for screening were between ages 55 and 74 years; had a history of cigarette smoking of at least 30 pack-years; and, if they were former smokers, must have quit within the past 15 years. Individuals were randomly assigned to screening with either CT or chest x-ray (CXR). Screening was conducted at yearly intervals for 3 years. Any noncalcified nodule identified on CT or CXR that measured at least 4 mm in greatest dimension was considered a positive screen. Thirtynine percent of participants in the CT group and 16% of those in the CXR had at least one positive screening, but the vast majority of these were followed with serial imaging. Only 1.8% of participatns underwent percutaneous cytologic examination or biopsy. The rates of complications after a diagnostic evaluation procedure for a positive screening test were quite low (1.4% in the low-dose CT group). Ultimately, the NLST demonstrated a 20% decrease in lung cancer–specific mortality and a 6.7% reduction in all-cause mortality in the CT group. Despite these dramatic findings, significant debate and caution have ensued regarding implementation and coverage of lung cancer screening, largely due to concerns pertaining to cost and harms of false positives. Unlike colonoscopy, in which an abnormality can be biopsied at the time of the test, lung cancer screening does not result in an immediate pathologic diagnosis. Nodule management, quality reporting, appropriate adherence to guidelines, and the availability of interdisciplinary expertise are important tenets in minimizing the harms of screening and are essential parts of a lung cancer screening strategy. It has been noted that the complication rate in the NLST was quite low, and many have commented that study sites were highvolume academic centers with significant radiologic, pulmonary, and surgical expertise that could not be duplicated in many community settings. In a study of complications after biopsy of a pulmonary nodule in 15,000 CT-guided lung biopsies in four large state databases by Weiner et al, pneumothorax occurred in approximately 15% of patients and 6% of all patients required chest tube insertion. Certainly, this risk is significant for patients who are at lower risk for the development of lung cancer or who are too frail to undergo definitive therapy. In the Accordino et al study, more than 76,000 people with a diagnosis of cancer underwent CT-guided biopsy during the time period from 2006 to 2012. In this large national hospital database, pneumothorax rates were 12.2% of the total outpatient population. More reassuring was that these were most often clinically insignificant, with 2.3% of patients requiring hospitalization and only 0.42% of patients ultimately requiring chest tube placement. This information is timely and will help frame balanced presentations of risks and benefits of lung cancer screening. Continued study of CT screening will further refine the work-up algorithms for all screening programs, leading to fewer false positives and decreasing needless invasive procedures. It is likely that in the future, lung cancer screening will incorporate biomolecular markers to enhance the selection of individuals for screening or to determine how best to monitor those with screen-detected nodules. In the meantime, however, the Centers for Medicare and Medicaid Services (CMS) issued a national coverage determination supporting lung cancer screening for high-risk beneficiaries. Medicare will cover lung CT scans once a year for beneficiaries who are 55 to 77 year old current or former smokers who have quit in the last 15 years, with a smoking history of at least 30 pack-years. In 2013, the United Stated Preventative Task Force recommended annual lung cancer screening using low-dose CT in certain patients, which means most health insurers are legally required to cover screening. It is estimated that 8 million Americans are eligible for CT screening for lung cancer. The widespread implementation of low-dose CT screening for lung cancer will impose significant new challenges for transdisciplinary teams of imagers and clinicians who will offer comprehensive programs of lung cancer surveillance and prevention, primary care physicians who will need to discuss screening with patients, and those who are at high risk for the Health Care Delivery