Carlijn M. van der Aalst, Ph.D. MPH Department of Public Health Erasmus MC

CT Screening For Lung Cancer Can Reduce Lung Cancer Mortality in a High Risk Population Interview with:

Carlijn M. van der Aalst, Ph.D. MPH Department of Public Health Erasmus MC

Dr. van der Aalst

Carlijn M. van der Aalst, Ph.D. MPH
Department of Public Health
Erasmus MC What is the background for this study?

Response: Lung cancer is the leading cause of cancer-related mortality among both men and women. About 70% of patients with lung cancer are diagnosed with advanced disease, which results in only 15% surviving five years. About 70% of patients with lung cancer are diagnosed with advanced disease, a stage in which cure is problematic. This results in only 15% surviving five years. Although quit smoking is most effective in preventing lung cancer, about half of all lung cancers are currently diagnosed in former smokers, who remain at high risk for decades after quitting smoking.

The National Lung Screening Trial (NLST; U.S.) reported a 20% lung cancer-related mortality reduction and a 6.7% reduction in all-cause mortality for CT screening compared with chest radiography screening for lung cancer in 53,454 enrolled subjects at high risk for lung cancer.1 As a consequence, the United States Preventive Services Task Force (USPSTF) requested an independent review and a modelling study. Based on these NLST data, an efficient strategy with a reasonable harm-benefit ratio could be established, resulting in the recommendation to annually screen persons aged 55-80 with ≥30 pack-years of smoking history, who currently smoke or quit smoking <15 years ago.

However, data of only one trial provides limited evidence and more trial data are needed. NELSON is the second largest lung cancer screening trial that is adequately designed to provide the evidence that is needed to conclude whether CT screening can reduce lung cancer mortality. What are the main findings?

Response: A total of 15,792 volunteers aged 50-74 years were randomized to the screen arm (4 CT screenings) or the control arm (no screening). Of these participants, 13,195 people were men. After a follow-up of 10 years, we found that the lung cancer mortality in male participants who were screened was 24% lower than in male participants. In women, this difference was even 33-59%.

In the NELSON trial, we used volume and growth rate to indicate whether the lung abnormalities found at the CT scan might be malignant. In about 9% an extra CT scan was needed to be able to measure the growth rate. About 2% of the participants were referred to the pulmonologist for further work-up and diagnosis. In 1 out of 2 participants who were referred to the pulmonologist, lung cancer was diagnosed. This relatively new method helps thus to keep the number of referrals to the pulmonologist relatively low.

Furthermore, the lung cancers that were detected with screening were more often in an early, more treatable, stage as compared to the lung cancers found in the control arm: 59% versus 13.5%). What should readers take away from your report?

Response:  With the results of the NELSON trial, the second largest lung cancer screening trial, there is now conclusive evidence that CT screening for lung cancer can reduce lung cancer mortality in a high risk population (long-term smokers and former smokers). What recommendations do you have for future research as a result of this work?

Response:    There are important remaining questions that can further optimize a lung cancer screening programme. For example, one important issue is that more information is needed on how to recruit high-risk participants adequately. Those who are expected to benefit most are relatively less likely to participate in a screening programme. Efforts are needed to adequately inform and invite those people who might benefit most.

Furthermore, annual screening is recommended at the moment, mainly due to the natural history of lung cancer. However, annual screening might not be essential for all people. One CT scan might provide essential information to determine whether annual screening or biennial screening might be most optimal. Thus, more research is needed to investigate whether less intensive screening might be as safe as annual screening in part of screened individuals.

Since smoking cessation is most effective method in reducing the risk for developing lung cancer and other tobacco-related diseases, it is important to investigate how effective smoking cessation services can be integrated in a lung cancer screening programme.

Any disclosures? I have nothing to disclose. 


Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial

Harry J. de Koning, M.D., Ph.D., Carlijn M. van der Aalst, Ph.D., Pim A. de Jong, M.D., Ph.D., Ernst T. Scholten, M.D., Ph.D., Kristiaan Nackaerts, M.D., Ph.D., Marjolein A. Heuvelmans, M.D., Ph.D., Jan-Willem J. Lammers, M.D., Ph.D., Carla Weenink, M.D., Uraujh Yousaf-Khan, M.D., Ph.D., Nanda Horeweg, M.D., Ph.D., Susan van ’t Westeinde, M.D., Ph.D., Mathias Prokop, M.D., Ph.D., et al.

January 29, 2020
DOI: 10.1056/NEJMoa1911793



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Last Updated on February 4, 2020 by Marie Benz MD FAAD