Revised guidelines raise lung cancer screening age
YOUR DOSE OF MEDICINE - Charles C. Chante MD (The Philippine Star) - March 24, 2019 - 12:00am

A proposed change to CHEST’s lung cancer screening guidelines calls for raising the upper age for recent cigaret smokers to 77 years of age from 74 years of age.

This proposal is part of draft guideline that was unveiled during the CHEST annual meeting but is still subject to tweaking by peer review until formal release in early 2018. This draft also offers expanded guidelines on how to implement screening, containing three times as many recommendations as the current lung cancer screening guidelines.

“We want screening to expand in a safe and effective way. We are less restrictive with these guidelines” than in the 2013 version.

Cited were two major changes that will produce modest broadening of the criteria that determine which patients can appropriately get screening. The clearest change was the age range, which expanded from 55-74 years of age set in 2013 to reflect the age criterion for enrollment in the National Lung Screening Trial.

The panel raised the upper age limit to 77 years of age to coincide with what Medicare covers, though it remains short of 80-year-old ceiling recommended by the US Preventive Service Task Force.

The second, subtler change eased back on the outright ban that the 2013 guidelines placed on screening anyone falls outside the target age range and smoking history (at least 30 pack-years and either being a current smoker and having recently quit within the past 15 years) and who is without severe comorbidities.

The guidelines from 2013 said screening people who fell outside these limits “should not be performed.” In contrast, the new draft guidelines simply said that people fall outside of the age and smoking-history criteria but who are still considered high risk for lung cancer based on a risk-prediction calculator should not “routinely” undergo screening. In addition, exceptions could be made for certain patients whose high risk appears to warrant screening.

The revision specified that ahigh-risk person outside of the core criteria might still be a reasonable candidate for screening if this person tallies at least a 1.51 percent risk of developing lung cancer during the next 6 years according to the PLCO risk calculator.

“Some of the evidence allowed us to be a little more flexible,” though not to the point of “opening screening widely” to the people who fall outside the core target population; rather, clinicians gets to have a little more discretion, “We hope this will lead to more patients being screened in a high-quality way,” said in an interview. The panel strove to “look beyond the National Lung Screening Trial and find other groups of patients who could benefit” from screening. “We say the other high-risk people should not, on the whole, be screened” but the clinicians could consider individuals as appropriate for screening on a case-by-case basis.

The revision “fill in the outline” for screening that was established in the 2013 guidelines, the updated guidelines better detailed who benefit the most from screening and who benefit less, as well as the potential complications screening may cause.

“The sweet spot for screening is patients with a medium lung cancer risk without many comorbidities. We are trying to come up with individualized risk profiling,” noted that, in the screening program he runs in Charleston, every person who contact the program and is interested in the screening undergoes risk profiling. Are there people with a risk profile that justifies screening but falls outside the proposed criteria? “Absolutely,”

People considering screening also need to recognize its potential harms. It cited five potential harms: death or complications from a biopsy of a screen-detected nodule, surgery for a screen-detected lesion that turns out to be benign, the psychosocial impact of finding a lung nodule, over diagnosis and the cumulative radiation exposure from a serial low-dose chest CT scans. “all of this dangers are real and may be magnified or mitigated as low-dose CT screening is implemented in real world practice.”

In addition to four evidence-based recommendation that helps define who is and isn’t an appropriate screening candidate, the revised guidelines also included 11 mostly consensus-based “suggestion” about how screening program should ideally operate. This covered issues such as identifying symptomatic patients who require diagnosis rather than screening, having strategies to encourage compliance with annual screening, including smoking cessation treatments in screening program, and having strategies that minimize overtreatment of potentially indolent cancers.

The goal of these suggestions is to help in the design of high-quality program. “It’s not who you screen but also how you screen.”

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