Age Tammemagi
* The hypothetical subjects are white males ages 55‒75, high school graduates with BMI = 25, no COPD, emphysema, chronic bronchitis, and no personal or family history of lung cancer. Each initiated smoking at age 18, and smoked 20 cigarettes per day. CS= current smoker; FS=former smoker (quit ten years from current age, i.e., 55 yrs. old CS has 37 pack-years, FS has 27 pack-years); A = Asbestos exposure;
MSK = Memorial Sloan Kettering model; LLP = Liverpool Lung Project model;
**The MSK model requires smoking duration of 25‒55 years
Table 6: Lung Cancer Screening Recommendations from U.S. Organizations Society* Year Age
ACS33 2013 55‒74 ≥30 ≤ 15 No Adults who are candidates for screening should engage in a process of shared decision making; Screening only should be done in an institution that supports multidisciplinary teams, and has experience with LDCT imag-ing. Recommend against chest radiograph for screening. Strong emphasis on smoking cessation for current smokers.
USPSTF32 2014 55‒80 ≥30 ≤ 15 No Adults who are candidates for screening should engage in a process of shared decision making; Once former smokers have reached >
15 years since smoking cessation, they should stop screening.
ACCP34 2013 55‒74 ≥30 ≤ 15 No Screening only should be done in an institu-tion that supports multidisciplinary teams, and has experience with LDCT imaging.
ASCO12 2013 55‒74 ≥30 ≤ 15 No Screening only should be done in an institu-tion that supports multidisciplinary teams, and has experience with LDCT imaging.
ALA48 2012 55‒74 ≥30 ≤ 15 No No history of lung cancer; Screening only should be done in an institution that supports multidisciplinary teams, and has experience with LDCT imaging. Strong emphasis on smok-ing cessation for current smokers; Recom-mend against chest radiograph for screening;
Screening centers should develop ethical practices for advertising and promotion;
NCCN30 2012 55‒74 ≥30 ≤ 15 Yes Adults with one or more risk factors in addition to smoking history (i.e., asbestos or other occupational hazards, radon exposure, family history, personal cancer history, COPD, pulmonary fibrosis may begin screening if they are age 50 and have a ≥ 20 P-Y history of smoking.
AATS31 2012 55‒74 ≥30 ≤ 15 Yes Adults with one or more risk factors in addition to smoking history (i.e., asbestos or other occupational hazards, radon exposure, family history, COPD with FEVI < 70%, cancer/
thoracic radiation, pulmonary fibrosis, and
> 5% absolute risk of developing lung cancer within the next 5 years may begin screening if they are age 50 and have a ≥ 20 P-Y history of smoking
* ACS=American Cancer Society; USPSTF=United States Preventive Services Task Force; ACCP= American College of Chest Physicians; ASCO=American Society of Clinical Oncology; ALA=American Lung Association; NCCN=
National Comprehensive Cancer Network; AATS=American Association of Thoracic Surgeons.
** Pack-years is a unit for measuring smoking history, and is calculated by multiplying the number of packs of cigarettes smoked per day by years smoked, i.e. 1 pack-year = 1 pack per day for 1 year, or 2 pack years = 2 packs per day for 1 year.
*** All organizations recommend that candidates for screening should be in good health and not have any life-limiting co-morbidity that would preclude curative treatment.
However, according to the LLP model, a 60-year-old man with a ten-pack year history, asbestos exposure, and a family history of either early or late-onset lung cancer exceeds NLST absolute risk thresholds. Thus, there is an urgent need to further study asbestos-exposed adults to determine how to accurately estimate absolute risk of lung cancer based on actual or approximations of asbestos exposure alone or combined with smoking his-tory and other risk factors, and to determine the benefits, adverse effects, and economic issues concerning their inclusion in LDCT screening for lung cancer. Ongoing studies, preferentially RCTs, with sufficient power may still provide an opportunity to identify study subjects with prior asbestos exposure, either in individual trials, or through data pooling projects. Well- designed cohort studies may also be useful, but in either case, it is critically important that there is adherence to a common methodology so that me-ta-analysis is possible going forward.
The optimal screening interval for lung cancer may not be dependent on the underlying risk factors, but more work on estimating risk-based sojourn times will need to be done before this statement can be made with greater confidence. Pastorino et al. (47) detected more cancer with annual vs. bi-ennial screening, but did not observe a survival benefit with either interval compared to the control arm; in contrast, the NLST observed a mortality reduction associated with annual screening (9). Given the high costs associ-ated with lung cancer screening, the question of whether wider screening intervals might be equally effective among all or some subgroups undergo-ing screenundergo-ing will likely be a focus of future investigations.
The responsibility for screening should be nationally or regionally organized so that preferably a single unit/institute would be in charge for the whole process. This includes the organization of screening, quality control, the collection and analysis of all data on benefits, complications and economic issues. The organizer should have sufficient expertise on epidemiology, pulmology, radiology and other relevant sciences. The participating units should be included in the most feasible manner nationally and educated in a sufficient manner.
In conclusion, at this time there is limited evidence to guide risk estimation and LDCT screening in workers at high risk for lung cancer due to asbestos exposure with or without a history of smoking. However, based on the favorable outcome of the lung cancer LDCT screening studies, the dose–re-sponse risk of lung cancer in asbestos-exposed workers, and the well-es-tablished greater than additive contribution to risk in adults exposed to both asbestos and tobacco smoke, it is reasonable to recommend that adults with asbestos exposure be evaluated for eligibility for lung cancer screening. Those adults with prior exposure to asbestos who are in
reason-ably good health and who are at or above the risk threshold set for partic-ipation in the NLST, whether based on smoking history, the combination of asbestos exposure and smoking history, or asbestos exposure alone should be considered for screening for lung cancer.
Much work remains to be done related to risk estimation for lung cancer screening eligibility, especially the interplay between age, smoking history, other exposures to tobacco smoke, and other risk factors such as occupa-tional history or genetic predisposition. Going forward it is imperative that efforts are focused on answering these key questions about lung cancer risk, patient selection, and the benefits and harms of lung cancer screening in asbestos-exposed adults.
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