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Clinical Guidelines |

Lung Cancer Screening: Recommendation Statement FREE

U.S. Preventive Services Task Force*
[+] Article and Author Information

From the U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Rockville, Maryland.


Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Requests for Single Reprints: Reprints are available from the USPSTF Web site (http://www.preventiveservices.ahrq.gov) and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (800-358-9295).


Ann Intern Med. 2004;140(9):738-739. doi:10.7326/0003-4819-140-9-200405040-00014
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This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for lung cancer and the supporting scientific evidence and updates the 1996 recommendations on this topic. In 1996, the USPSTF recommended against screening for lung cancer (a grade D recommendation). The Task Force now uses an explicit process in which the balance of benefits and harms is determined exclusively by the quality and magnitude of the evidence. As a result, current letter grades are based on different criteria than those used in 1996. The complete information on which this statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the systematic evidence review on this topic, available through the USPSTF Web site (www.preventiveservices.ahrq.gov) and the National Guideline Clearinghouse (www.guideline.gov). The complete USPSTF recommendation statement (which includes a brief review of the supporting evidence) and the summary of the evidence are also available in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov).

*For a list of the members of the U.S. Preventive Services Task Force, see the Appendix.

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low-dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests. This is a grade I recommendation . (See Appendix Table 1 for a description of the USPSTF classification of recommendations.)

Table Jump PlaceholderAppendix Table 1.  U.S. Preventive Services Task Force Grades and Recommendations

The USPSTF found fair evidence that screening with LDCT, CXR, or sputum cytology can detect lung cancer at an earlier stage than lung cancer would be detected in an unscreened population; however, the USPSTF found poor evidence that any screening strategy for lung cancer decreases mortality.(See AppendixTable 2 for a description of the USPSTF classification of levels of evidence.) Because of the invasive nature of diagnostic testing and the possibility of a high number of false-positive tests in certain populations, there is potential for significant harms from screening. Therefore, the USPSTF could not determine the balance between the benefits and harms of screening for lung cancer.

Table Jump PlaceholderAppendix Table 2.  U.S. Preventive Services Task Force Strength of Overall Evidence

The benefit of screening for lung cancer has not been established in any group, including asymptomatic high-risk populations such as older smokers. The balance of harms and benefits becomes increasingly unfavorable for persons at lower risk, such as nonsmokers.

The sensitivity of LDCT for detecting lung cancer is 4 times greater than the sensitivity of CXR. However, LDCT is also associated with a greater number of false-positive results, more radiation exposure, and increased costs compared with CXR.

Because of the high rate of false-positive results, many patients will undergo invasive diagnostic procedures as a result of lung cancer screening. Although the morbidity and mortality rates from these procedures in asymptomatic individuals are not available, mortality rates due to complications from surgical interventions in symptomatic patients reportedly range from 1.3% to 11.6%; morbidity rates range from 8.8% to 44%, with higher rates associated with larger resections.

Other potential harms of screening are potential anxiety and concern as a result of false-positive tests, as well as possible false reassurance due to false-negative results. However, these harms have not been adequately studied.

The brief review of the evidence that is normally included in USPSTF recommendations is available in the complete recommendation statement on the USPSTF Web site (http://www.preventiveservices.ahrq.gov).

Lung cancer screening recommendations from the American Cancer Society (1) can be Accessed at http://www.cancer.org/docroot/PUB/content/PUB_3_8X_American_Cancer_Society_Guidelines_for_the_Early_Detection_of_Cancer_update_2001.asp. The policy of the American Academy of Family Physicians (2) can be Accessed at http://www.aafp.org/x24974.xml. Recommendations from the Canadian Task Force on Preventive Health Care can be accessed through its Web site at http://www.ctfphc.org. Relevant guidelines on lung cancer screening from other organizations can be accessed through the National Guideline Clearinghouse at http://www.guideline.gov.

Appendix

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, MD, MPH, Chair, (University of Washington, Seattle, Washington); Janet D. Allan, PhD, RN, CS, Vice-Chair(University of Maryland Baltimore, Baltimore, Maryland); Paul Frame, MD (Tri-County Family Medicine, Cohocton, and University of Rochester, Rochester, New York); Charles J. Homer, MD, MPH (National Initiative for Children's Healthcare Quality, Boston, Massachusetts); Mark S. Johnson, MD, MPH (University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey); Jonathan D. Klein, MD, MPH (University of Rochester School of Medicine, Rochester, New York); Tracy A. Lieu, MD, MPH (Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts); C. Tracy Orleans, PhD (The Robert Wood Johnson Foundation, Princeton, New Jersey); Jeffrey F. Peipert, MD, MPH (Women and Infants' Hospital, Providence, Rhode Island); Nola J. Pender, PhD, RN (University of Michigan, Ann Arbor, Michigan); Albert L. Siu, MD, MSPH (Mount Sinai Medical Center, New York, New York); Steven M. Teutsch, MD, MPH (Merck & Co., Inc., West Point, Pennsylvania); Carolyn Westhoff, MD, MSc (Columbia University, New York, New York); and Steven H. Woolf, MD, MPH (Virginia Commonwealth University, Fairfax, Virginia). This list includes members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.

Smith RA, Mettlin CJ, Davis KJ, Eyre H.  American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin. 2000;50:34-49. [PMID: 10735014] Accessed athttp://www.cancer.org/docroot/PUB/content/PUB_3_8X_American_Cancer_Society_Guidelines_for_the_Early_Detection_of_Cancer_update_2001.aspon 12 March 2004.
 
American Academy of Family Physicians.  Recommendations for Periodic Health Examinations. Accessed athttp://www.aafp.org/x24974.xmlon 15 March 2004.
 

Figures

Tables

Table Jump PlaceholderAppendix Table 1.  U.S. Preventive Services Task Force Grades and Recommendations
Table Jump PlaceholderAppendix Table 2.  U.S. Preventive Services Task Force Strength of Overall Evidence

References

Smith RA, Mettlin CJ, Davis KJ, Eyre H.  American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin. 2000;50:34-49. [PMID: 10735014] Accessed athttp://www.cancer.org/docroot/PUB/content/PUB_3_8X_American_Cancer_Society_Guidelines_for_the_Early_Detection_of_Cancer_update_2001.aspon 12 March 2004.
 
American Academy of Family Physicians.  Recommendations for Periodic Health Examinations. Accessed athttp://www.aafp.org/x24974.xmlon 15 March 2004.
 

Letters

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Comments

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10-minute consultation: Suspected lung cancer
Posted on August 23, 2006
Daniel K C Lee
Department of Thoracic Oncology, Papworth Hospital, Papworth Everard, Cambridge, CB3 8RE, England
Conflict of Interest: None Declared

A 60-year-old ex-smoker presents to your surgery with mild breathlessness and cough. These symptoms have persisted for about 4 weeks despite treatment with a penicillin antibiotic prescribed by one of your colleagues.

What you need to do

  • Organise an urgent chest x-ray (CXR) in view of the smoking history and persisting cough (see box). CXR is widely and rapidly available, inexpensive and results in minimal radiation exposure.
  • Send sputum sample to microbiology for culture and antibiotic sensitivity testing.
  • Consider a further course of antibiotic such as a macrolide antibiotic to treat penicillin-resistant organisms and atypical organisms.

Clinical features requiring an urgent CXR

  • Haemoptysis

Any of the following unexplained symptoms or signs persisting more than three weeks

  • Breathlessness
  • Chest signs
  • Cough that is unexplained or persisting
  • Features suggestive of metastases from lung cancer (bone, brain, liver or skin)
  • Finger clubbing
  • Hoarseness of voice
  • Pain in the chest or shoulder
  • Persistent cervical or supraclavicular lymphadenopathy
  • Weight loss

The CXR shows a solitary mass-like shadow in the lung and is reported by a radiologist as being suspicious of lung cancer.

What issues you should cover

  • Revisit the history paying particular attention to certain pertinent aspects that may point towards either lung cancer or other differential diagnoses (see box).
  • Discuss the benefits of stopping smoking. There is good evidence that smoking cessation improves outcome for patients with lung cancer. It reduces the perioperative risk and improves outcome following chemotherapy as well as long-term survival and quality of life in both small cell and non-small cell lung cancer.

Patients with a solitary lung shadow

Relevant history

  • Respiratory
    • Chest or shoulder pain
    • Cough
    • Haemoptysis
    • Hoarseness of voice
    • Shortness of breath
    • Sputum production
    • Wheezing
  • Constitutional
    • Lethargy
    • Night sweats
    • Poor appetite
    • Weight loss
  • Asbestos exposure
  • Previous malignancy
  • Smoking history
  • Travel history

Differential diagnoses

  • Abscess
  • Adenoma
  • Aspergilloma
  • Carcinoma
  • Hamartoma
  • Metastasis from another organ
  • Pulmonary infarction
  • Round atelectasis
  • Round pneumonia
  • Round pulmonary oedema
  • Tuberculosis

What you should do

  • Examine the patient carefully, observing for finger clubbing and signs indicating locally extensive or metastatic disease, such as peripheral lymphadenopathy, organomegaly, superior vena cava (SVC) obstruction and stridor. Urgent referral for specialist care should be made whilst awaiting the results of CXR in patients who present with stridor or SVC obstruction.
  • Assess the general fitness of the patient taking into account the build of the patient and whether the patient appears well nourished or cachetic while making a note of the height and weight.
  • Discuss the results of the CXR with the patient and convey your concerns to the patient regarding your suspicion of lung cancer if appropriate. Further tests will be required to clarify the diagnosis and extent of the problem. These will usually include a computed tomography (CT) of the thorax, and (depending on fitness) either bronchoscopy or percutaneous biopsy.
  • Refer the patient to a chest physician without delay in keeping with the Department of Health guidelines on the '2-week wait' scheme for referral of patients with suspected lung cancer to secondary care.
  • Address and treat any associated conditions such as concomitant chest infection or airway bronchoconstriction for patient optimisation prior to further investigation and management.

Useful reading


Management of patients with lung cancer: a national clinical guideline. Scottish Intercollegiate Guidelines Network 2005. http://www.sign.ac.uk/pdf/sign80.pdf


Lung cancer: the diagnosis and treatment of lung cancer. National Institute for Clinical Excellence 2005. http://www.nice.org.uk/pdf/CG024niceguideline.pdf


Lung cancer information centre. CancerBACUP 2005. http://www.cancerbacup.org.uk/cancertype/lung


Lung cancer online. Lung Cancer Online Foundation 2005. http://www.lungcanceronline.org


Conflict of Interest:

None declared

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Summary for Patients

Screening for Lung Cancer: Recommendations from the U.S. Preventive Services Task Force

The summary below is from the full reports titled “Lung Cancer Screening: Recommendation Statement” and “Lung Cancer Screening with Sputum Cytologic Examination, Chest Radiography, and Computed Tomography: An Update for the U.S. Preventive Services Task Force.” They are in the 4 May 2004 issue of Annals of Internal Medicine (volume 140, pages 738-739 and pages 740-753). The first report was written by the U.S. Preventive Services Task Force; the second report was written by L.L. Humphrey, S. Teutsch, and M. Johnson.

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