evekhm/cms_iom_500 huggingface dataset:
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
2. External Technology AssessmentsCMS did not request an external technology assessment (TA) on this issue.3. Internal Technology AssessmentLiterature Search MethodsCMS searched PubMed for publications from the period of August 2014 to July 2021. We chose the starting search date as August 2014 since the literature search for the 2015 National Coverage Determinations internal technology assessment on screening for lung cancer with low dose CT ended in August 2014. General keywords included low dose computed tomography, screening, mortality, and lung cancer. Publications that presented original human clinical data on screening with low dose CT for lung cancer were considered. Keywords for the search included low dose computed tomography, low dose CT, LDCT, screening, survival, mortality, death, and lung cancer. CMS staff searched the bibliographies of relevant publications for other pertinent studies. Abstracts, meeting presentations, reviews, animal studies, publications on emphysema and asbestos, cost analyses, microsimulation modeling studies, mechanistic biomarker studies, and non-English language publications were excluded. Studies with fewer than 10 cases and those not involving human subjects were excluded. The reviewed evidence was gathered from articles submitted by the requester, and from the public comments and the PubMed literature search.Articles were included if they conformed to the following eligibility criteria:Inclusion criteria:Studies using low dose computed tomography (low dose CT) for lung cancer screeningArticles published in scientific journalsTechnology assessments, guidelines, consensus statements, or meta-analysesEnglish languageAdultHumanLiterature from United States, Canada, the United Kingdom, Europe, Australia, China and other Southeast Asian countriesExclusion criteria:
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Non-English language articlesTechnical, nonclinical articles (e.g., animal, biomechanical, cadaver)Conference abstracts, meeting presentationsStudies conducted outside the countries listed aboveStudies published before 2014Studies with less than 10 participantsStudies not related to low dose computed tomographyStudies not related to lung cancerTable 1. Age Eligibility Criteria for Low Dose CT Randomized Controlled TrialsFirst Author (year published), Study Acronym, Study Design, Population: Country, Overall Sample Size (n)Age Inclusion Criteria (years)Age Distribution in Screening Study Population (mean, lowest and highest age groups, frequency; n, years)Race (percent)Women (percent)Timing: Follow Up Duration (mean; years)Outcome: Lung Cancer Mortality: Low Dose CT Arm Compared Control Arm (HR, RR, or OR, 95% CI; p value)Becker (2020) LUSI (RCT) Germany (4,052)50 to 69Median: 5550-54: 46.4% (942/2029)65-69: 11.1% (225/2029)Not shown35.3%8.8  yr (median)HR: 0.74 (0.46 1.19; p = 0.21)HR women: 0.31 (0.10 0.96, p = 0.04)de Koning (2020) NELSON (RCT) Netherlands, Belgium (15,792 total; 13,195 men, 2594 women)50  to 74Median: males: 58 (IQR: 55-63)Range 46-7650-54: 24.6% (1611/6560)  75: 0.6% (40/6560)Not shown16.4%10 yr (actual)RR: 0.76 (0.61 - 0.94; P = 0.01)RR men 50-54: 0.85 (0.48 - 1.50)Doroudi (2018) LSS (RCT) United States (3,318)55 to 74No age data for study population shownNot shownNot shown5.2  yrRR:  1.24 (0.74 - 2.08)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Field (May, 2016) UKLS (RCT) United Kingdom (4,055)50 to 7550-55: 0.7%71-75: 22.4%99% White1% non-white25.1%Not shownNo lung cancer mortality; Only lung cancer incidenceField (February, 2016) UKLS (RCT) United Kingdom (4,055)50 to 75Mean: 67.1  (SD 4.1)Median: 67 Range: 50 to 7599% White1% non-white25.1%1 yrLung cancer mortality not assessed; Confirmed lung cancerInfante (2015) DANTE (RCT) Italy (2,450 men)60 to 74Mean (95% CI): 64.6 (64.364.8)Median: 64.0 (IQR 5)Not shown0%8.35 yr (median)HR: 0.993 (0.691.43)Infante (Pooled, 2017) (pooled analysis DANTE and MILD) Italy (6,549) 49 to 74Median: 61 (IQR 10) 60:  48.5% (1766/3640)>60: 51.5% (1874/3640)Not shown21.5%8.2 yr (median)Pooled  HR: 0.83 (0.611.12)National Lung Screening Trial Research Team (2019) NLST (RCT) United States (53,452)55 to 7455-74: 42.8% (11442 / 26722)70-74: 8.8% (2354/26722)89.6%White4.4%Black1.7% Hispanic2.0%Asian0.3% AmericanIndian /NativeAlaskan0.3%NativeHawaiian/Pacific Islander1.6% Other /unknown41.0%12.3  yr (median)RR dilution-adjusted: 0.89 (0.800.997)Tanner (2016) NLST (secondary analysis of NLST) United States (53,452)55 to 74Not shown89.6% White4.4% Black6.0% Other /  Missing41.0%Not shownHR: 0.62 (0.510.76)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Paci (2017) ITALUNG (RCT) Italy (3,206)55 to 69Mean: 60.9<55: 3% (53/1613)>69: 0.3%  (5/1613)Not  shown35.3%9.3 yrRR:  0.70 (0.47 - 1.03; p = 0.07)Paci (2021) ITALUNG (secondary analysis) Italy (3,206)55 to 69<55: 3% 70: 0%Not shown35%10  yr10 yr survival rates for lung cancer cases: 64% active arm vs 60% control arm (p = 0.69)Pastorino, Silva (Prolonged; July, 2019) MILD (RCT) Italy (4,099)49 to 75Median: 58< 55: 32.5% (773/2376) 70: 3.8% (90/2376)Not shown33.7%10 yrHR: 0.61 (0.39  0.95; p = 0.02)Pastorino, Sverzellati (Ten Year; September, 2019) MILD (secondary analysis of RCT) Italy  (2,376) (subset of screening arm)49 to 75<55: 32.5% (773/2376) 65: 15.5% (368/2376)Not shown31.6%10 yrBiennial (low dose CT every 24 months) arm compared to annual arm: HR: 1.10 (0.59 -2.05)Rampinelli (2017) COSMOS (secondary retrospective analysis of observational screening trial)  Italy (5,203)50 and older50-54: 33.8% (1759/5203) 65: 12% (658/5203)age range not shownNot shown33.9%10 yrNo lung cancer mortality, but lifetime attributable risk of cancer incidence and radiation exposure doseWille (2016) DLCST (RCT) Denmark (4,104)50 to 70Mean 57.9  4.8Not shown44.8%> 5 yrs after last screen, mean follow up duration not shownHR:  1.03 (0.66 1.6; p = 0.89)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Table 2. Age Eligibility Criteria for Low Dose CT Observational Studies and Meta-AnalysesFirst Author, (year published) Study Acronym, Study DesignPopulation: Country Overall Sample Size (n)Age Inclusion Criteria (years)Age Distribution in Screening Study Population (mean; lowest and highest age groups; frequency;  n, years)Timing: Follow up Duration (mean, median; years)Outcome: Lung Cancer Mortality: Low Dose CT Arm Compared Control Arm (HR, RR, or OR, 95% CI; p value)Dement (2020) (prediction modeling)United States (17,069)Not shownNo age dataNot shownModeling resultsHoreweg (2014) NELSON (RCT)Netherlands, Belgium (7,155)50 to 75Median: 58.0 (IQR 54.0-62.0)Not shownNo lung cancer mortality; Results: sensitivity, specificity, positive predictive value; interval cancers, screen-detected lung cancerLeleu (2020) DEP KP80 (single arm prospective study)France (1,307)55 to 74Mean: 61.8Not shownNo lung cancer mortality; Results: prevalence of lung cancer 2.7%.Liang (2019) (cancer registry study)Shanghai and two districts, China (over 9.5 million)Inclusion criteria for age not shown35-3940-4445-4950-5470-7475-7980-8485no sample sizes shownNo follow up period notedLung cancer mortality rate as average annual percent change [APC] = -1.71%, 95% CI: -2.98% 0.04%, P= 0.015)Nawa (2019) (retrospective cohort study)Japan (210) 50Not shown4 to 8 years after introduction of CT screeningReduction (24%) in lung cancer mortalityPatz (2016) NLST (retrospective cohort subgroup analysis)United States (26,231, with negative T0 screen)55 to 74Negative T0 screen60 (55-74)6.4 yrNegative T0 screen vs all T0 screen: 185.8 (95% CI 162.2211.9) per 100,000 person-years vs 277.2 (252.3303.9)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Rulli (2020) (retrospective review)United States (2,924)55 to 79No age specific data shown3 yrLung cancer mortality rate 239 per 100,000 patients.White (2020) (retrospective review)United States (962)Not shownNo age reportedNot shownLung cancer rateWhittaker Brown (2019) NLST (subgroup analysis of interstitial lung abnormalities)United States (50,206)55 to 74Median 61 (IQR 58-66)Not shownHR: 1.51 (1.13-2.03)Wu (2019) (retrospective cohort study)Asian population (2,883)Not shown59.91  8.14Not shownOverall  mortality of 10.75% in screened groupMeta-AnalysesHuang (2019) (9 RCTs)Italy, Denmark, Germany, US, Netherlands, Belgium, China (97,244)45-60 to 69-75Mean 57.9 -61.0  4.8-5.8Median 57.0-64.0 (IQR 5-8)Range 55-74HeterogeneousPooled RR: 0.83 (0.760.90, I2= 1%)Sadate (2020) (7 RCTs)Italy, Denmark, Germany, United States, Belgium, The Netherlands (84,558) 49-60 to 69-74Age data not shown for study population3-10 yrPooled RR: 0.83 (0.76-0.91; I2= 0%)Wang (2018) (4 RCTs)United States, Italy (2), Denmark, (64,129) 49-60 to 70-74Age data not shown for study populationMedian 33.7 months to 6.5 yr; 4.8 person-yearsPooled OR: 1.13 (0.781.64; I2> 75%)Yang (2019) (4 RCTs)United States, Italy (2), Denmark (64,468)>49-60 to 70-74Age data not shown for study populationHeterogeneous: 6 yr 3.5 months to 9.47 yrPooled RR: 0.94 (0.74-1.19; p = 0.62; I2= 43.3%)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Table 3. Smoking History Eligibility Criteria for Low Dose CT Randomized Controlled Trials and Meta-AnalysesFirst Author, (year published) Study Acronym, Study DesignSmoking History Inclusion Criteria (pack-years)Smoking History Study Population Distribution in Intervention Arm (mean  SD; frequency, range, or percent; pack-years)Smoking Cessation Inclusion Criteria (years since quitting smoking)Smoking Cessation Duration Since Quitting: Distribution in Study Population Intervention Arm   (n, years since quitting)Timing: Follow up Duration (mean, median; years)Outcome: Lung Cancer Mortality: Low Dose CT Arm Compared Control Arm (HR, RR, or OR, 95% CI; p value)Becker (2020)  LUSI (RCT)At least 25 years smoking of at least 15 cigarettes per day, or at least 30 years smoking of at least 10 cigarettes per dayNo pack-years shownStopped smoking not more than 10 years before invitation to screeningNone shown8.8  yr (median)HR: 0.74 (0.46  1.19; p = 0.21) HR women: 0.31 (0.10 0.96, p = 0.04)de Koning (2020) NELSON (RCT)>15 cigarettes a day for > 25 years or >10 cigarettes a day for >30 yearsMedian pack-year: 38.0 Interquartile range: 29.7  49.5 Range of pack-years: 0.4 to 159.5Quit  10 years ago1.7% (49/2,908) quit smoking history of > 10 years since cessation of smoking10 yr (actual)RR: 0.76 (0.61 - 0.94; P = 0.01)RR men 50-54: 0.85 (0.48 - 1.50)Doroudi (2018) LSS (RCT)30 pack-year history of cigarette smokingNone shownQuit within the last 10 yearsNone shown5.2 yrRR: 1.24 (0.74 - 2.08)Field (May, 2016) UKLS (RCT)None shown93.4% smoking duration of 20+ years,5.8% smoking duration of 10-19 yearsNone shownNone shownNone shownNo lung cancer mortality Results: only lung cancer incidence
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Infante (2015) DANTE (RCT)20+ pack-yearsMean pack-years: 47.3 (95% CI 45.7 - 49.0), standard error of mean: 0.8Median pack-years: 45.0 (IQR 28.5)Had quit less than 10 years before recruit-mentNone shown8.35 yr (median)HR: 0.993 (0.6881.433)Infante (Pooled, 2017) (pooled analysis DANTE and MILD)None shownNone shownNone shownNone shown8.2 yr (median)Pooled  HR: 0.83 (0.611.12)National Lung Screening Trial Research Team (2019) NLST (RCT)Minimum of 30 pack-years of cigarette smokingMedian pack-years = 48 (25th/75th percentile: 39/66)Had quit within the past 15 yearsNone shown12.3 yr (median)RR dilution-adjusted: 0.89 (0.800.997)Tanner (2016) NLST (secondary analysis of NLST)None shownNone shownNone shownNone shownNone shownHR, 0.62 (0.51  0.76).Paci (2017) ITALUNG (RCT)At least 20 pack-years in last 10 yearsMedian pack-years of smoking: 40 pack-yearsQuit more than 10 years ago excludedNone shown9.3 yrRR: 0.70 (0.47 to 1.03; p = 0.07)Paci (2021) ITALUNG (secondary analysis)None shownNone shownNone shownNone shown10 yr10 yr survival rates for lung cancer cases: 64% active arm vs 60% control arm (p = 0.689)Pastorino, Silva, (Prolonged, July, 2019) MILD (RCT) 20 pack- years< 30 pack-years of cigarette smoking: 21.9% (521/2,376); Median pack-years: 39 pack-years of smokingFormer smoker from < 10 years agoNone shown10 yrHR: 0.61 (0.39  0.95; p =0.02)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Pastorino, Sverzellati (Ten Year, September 2019) MILD (secondary analysis of screening arm in RCT)None shownNone shownNone shownNone shown10 yrBiennial (low dose CT every 24 months) arm compared to annual arm: HR: 1.10 (0.59-2.05)Rampinelli (2017) COSMOS (secondary analysis of an observational screening trial) 20 pack-years of smokingNone shownNone shownNone shown10 yrNo lung cancer mortality, Results: lifetime attributable risk of cancer incidence and radiation exposure doseWille (2016) DLCST (RCT)Minimum of 20 pack-years of smokingMean (SD) pack-years: 36.4  13.4 pack-yearsHave quit after the age of 50 years and within the previous 10 yearsNone shown> 5 yrs after last screen, mean follow up duration not shownHR: 1.03 (0.661.6; p = 0.888)Meta-AnalysesHuang (2019) (9 RCTs)> 20 pack-years to > 30 pack-years, and included > 15 cigarettes a day for > 25 years or > 10 cigarettes per day for > 30 yearsMean  SD: 36.4  13.4,Median (IQR) ranged from 36 (IQR not reported) to 38.0 (19.8) to 45.0 (28.5) to 48 (27) to 54 (IQR not reported)From < 10 years since quitting to < 15 years since quittingNone shownHetero-geneousRR: 0.83 (0.760.90, I2= 1%)Sadate (2020) (7 RCTs)Average smoking history greater than 15 pack-yearsMedian pack-years: 39Mean (95% CI) ranged from 36.4 (95% CI 23  49.8) to 38.0 (95% CI 29.7  49.5) to 47.3 (95% CI 45.7  49) to 56.04 (no 95% CI reported)None shownNone shown3-10 yrRR: 0.83 (0.76 - 0.91; I2= 0%)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Wang (2018) (4 RCTs)Minimum of 20 pack-years to more than 30 pack-yearsNone shownQuitting within 10 years of study enrollment to less than 15 years since quitting to quitting after age 50 years and within 10 years before trial enrollmentNone shownMedian 33.7 months to 6.5 yr; 4.8 person-yearsOR: 1.13 (0.781.64; I2> 75%)Yang (2019) (4 RCTs)None shownNone shownNone shownNone shownHetero-geneous: 6 yr 3.5 months to 9.47 yrPooled RR: 0.94 (0.74-1.19; p = 0.62; I2= 43.3%)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
RCT - randomized controlled trialCOSMOS - Continuous Observation of Smoking SubjectsDANTE - Detection And screening of early lung cancer with Novel imaging Technology and molecular assaysDLCST - Danish Lung Cancer Screening TrialITALUNG - Italian Lung Cancer Screening TrialLSS - Lung Screening StudyLUSI - Lung cancer Screening InterventionMILD - Multicentric Italian Lung DetectionNELSON - NederlandsLeuvens Longkanker Screenings OnderzoekNLST - National Lung Screening TrialUKLS - UK Lung Cancer Screening trialHR - hazard ratio, RR - rate ratio or risk ratio, OR - odds ratio, CI - confidence interval, SD  standard deviation, IQR - interquartile range, T0  baseline screening, yr(s)  year(s)Evidence-based GuidelinesUS Preventive Services Task Force, Krist AH, Davidson KW, Mangione CM, et al. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement.JAMA. 2021 Mar 9;325(10):962-970. doi: 10.1001/jama.2021.1117. PMID: 33687470Jonas DE, Reuland DS, Reddy SM, et al. Screening for Lung Cancer With Low-Dose Computed Tomography: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2021 Mar 9;325(10):971-987. doi: 10.1001/jama.2021.0377. PMID: 33687468Moyer VA; U.S. Preventive Services Task Force (USPSTF). Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Mar 4;160(5):330-8. doi: 10.7326/M13-2771. PMID: 243789172021 USPSTF recommendation statement (USPSTF, Krist; 2021)
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
2021 USPSTF recommendation statement (USPSTF, Krist; 2021)The USPSTF recommends annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. (B recommendation) (USPSTF, Krist; 2021). This recommendation replaces the 2013 USPSTF statement that recommended annual screening for lung cancer with LDCT in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years (USPSTF, Krist; 2021).The USPSTF concludes with moderate certainty that annual screening for lung cancer with LDCT has a moderate net benefit in persons at high risk of lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking. The moderate net benefit of screening depends on limiting screening to persons at high risk, the accuracy of image interpretation being similar to or better than that found in clinical trials, and the resolution of most false-positive results with serial imaging rather than invasive procedures. (USPSTF, Krist; 2021).2013 USPSTF recommendation statement (Moyer, USPSTF; 2014)In 2013, the US Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30pack-year smoking history and currently smoke or have quit within the past 15 years (B recommendation). The USPSTF recommended that screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (Moyer, USPSTF; 2014).The USPSTF concludes with moderate certainty that annual screening for lung cancer with LDCT is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking (Moyer, USPSTF; 2014).
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Donnelly EF, Kazerooni EA, Lee E, et al., and Expert Panel on Thoracic Imaging: ACR Appropriateness Criteria Lung Cancer Screening. J Am Coll Radiol. 2018 Nov;15(11S):S341-S346. doi: 10.1016/j.jacr.2018.09.025. PMID: 30392603In 2018, an expert panel on thoracic imaging assembled by the American College of Radiology reported that the American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment (Donnelly, 2018).In 2018, the American College of Radiology expert panel on thoracic imaging summarized their findings by reporting that for patients between the age of 55 and 80 with 30 or more pack-years smoking history who currently smoke or who have quit within the last 15 years should undergo lung cancer screening with low-dose CT. In patients who do not meet these criteria but who have additional risk factors for lung cancer, lung cancer screening with low-dose CT is controversial but may be appropriate. Imaging is not recommended for lung cancer screening of patient younger than 50 years of age or patients older than 80 years of age or patients of any age with less than 20 packs per year history of smoking and no additional risk factor (i.e., radon exposure, occupational exposure, cancer history, family history of lung cancer, history of [chronic obstructive pulmonary disease] (COPD), or history of pulmonary fibrosis (Donnelly, 2018).Radiation Dosing
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Radiation DosingAs a special imaging consideration, the American College of Radiology Appropriateness Criteria expert panel stated that in general, acceptable low-dose lung cancer screening CT scans should be performed according to the guidelines in the ACRSTR [American College of Radiology (ACR)-Society of Thoracic Radiology (STR)] Practice Parameter for the Performance and Reporting of Lung Cancer Screening Thoracic Computed Tomography (CT) (Donnelly, 2018). Additionally, because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure (Donnelly, 2018).Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report  Executive Summary, CHEST (2021), doi: https://doi.org/10.1016/j.chest.2021.07.003.Mazzone PJ, Silvestri GA, Souter LH, et all. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report, CHEST (2021), doi: https://doi.org/10.1016/j.chest.2021.06.063.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
The purpose of this guideline is to update the evidence base for the benefit, harms, and implementation of low-dose chest CT (LDCT) screening. The American College of Chest Physicians (CHEST)  used the updated evidence base to provide recommendations where the evidence allows, and statements based on experience and expert consensus where it does not. Approved panelists reviewed previously developed key questions using the PICO (population, intervention, comparator, and outcome) format to address the benefit and harms of low-dose CT screening, as well as key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. The systematic literature review identified 75 additional studies that informed the response to the 12 key questions that were developed. . . . Evidence suggests that low-dose CT screening for lung cancer can result in a favorable balance of benefit and harms. The selection of screen-eligible individuals, the quality of imaging and image interpretation, the management of screen detected findings, and the effectiveness of smoking cessation interventions, can impact this balance. (Mazzone, Executive Summary; 2021).RecommendationsThe panel drafted and graded recommendations based on the results of the meta-analyses and evidence profiles. Recommendations were graded according to CHESTs grading system which uses the GRADE approach. (Mazzone, Panel Report 2021). The recommendations were either strong or weak according to this approach. Strong recommendations use the wording we recommend and weak recommendations use the wording we suggest (Mazzone, Panel Report 2021).Excerpt from Recommendations (Mazzone, Panel Report 2021)