LDCT Lung-cancer Screening: How It Is Done

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Source: biopsy-targets-2.jpg - Lung Cancer Biopsy
Biopsy targets have shrunk dramatically since the early days of CT, when a 6-cm lung nodule (left) was more likely to be targeted for biopsy. In advanced practice today, for example, a 5-mm partly solid nodule (right) with a 2-mm solid component was biopsied to reveal an adenocarcinoma.

On June 24, 2013, in Bethesda, Maryland—at the second joint meeting of the National Cancer Institute (NCI) board of scientific advisors and the National Cancer Advisory Board—William C. Black, MD, a Dartmouth radiologist, copresented “National Lung Screening Trial1 (NLST) Subset Analysis,” a cost-effectiveness analysis of low-dose CT (LDCT) screening for lung cancer. His data showed that LDCT not only was a cost-effective method of screening for lung cancer, but was more cost effective than some other screening exams (such as screening mammography).

“Very shortly thereafter, on July 30, the United States Preventive Services Task Force (USPSTF) posted its revised draft recommendations with a systematic review to update its 2004 guidelines and invited public comment through the end of August,” Ella Kazerooni, MD, related to those gathered at a special session, “Lung Cancer Screening: How I Do It,” on December 1, 2013, at the annual meeting of the RSNA in Chicago, Illinois. “The draft new recommendation was to give lung-cancer screening with LDCT a grade B recommendation for high-risk individuals with a smoking history,” she explains.

During the special session, Kazerooni gave a current-data summary and update. Reginald F. Munden, MD, DMD, MBA, described how to start a screening program; Thomas E. Hartman, MD, provided management strategies for screening-detected nodules; and David F. Yankelevitz, MD, contributed pearls for the biopsy of screening-detected nodules. Caroline Chiles, MD, offered guidance for the management of incidental findings.

The final B grade recommendation from USPSTF, announced later in December, set in motion a series of events that has put lung-cancer screening in the high-risk population on the fast track to reimbursement. While it might appear, to casual observers, to be a sudden development, the ACR®; the NCI; and many other organizations, radiologists, radiology departments, and practices have invested a great deal of time, thought, and energy in determining what an evidence-based program for LDCT lung-cancer screening should look like.

Summary and Update

The USPSTF draft recommendation on lung-cancer screening that Kazerooni flags as a milestone calls for annual LDCT from 55 to 79 years of age for individuals with a history of heavy smoking (if they currently smoke or have stopped within the past 15 years) who have no significant pulmonary disease. As mandated by the Patient Protection and Affordable Care Act (PPACA), a recommendation of B or above from the USPSTF means that private insurers must cover the procedure (with no deductible). While the PPACA does not similarly obligate Medicare, CMS initiated a National Coverage Analysis on February 10, 2014.

Within organized radiology, there has been a great deal of activity aimed at developing standards and resources for lung-cancer screening, Kazerooni (who chairs the ACR Committee on Lung Cancer Screening) says. “The ACR is working on many fronts to provide information to people who seek lung-cancer screening or seek to provide the service,” she reports.

A practice guideline for the performance and interpretation of CT screening for lung cancer is nearing its final review and could be approved at the ACR Annual Meeting and Chapter Leadership Conference (April 26–30, 2014). Appropriateness criteria covering which patients should be screened also are under development.

In progress, as well, is the development of LuRADS, a lung reporting and data system  structured as the successful ACR BI-RADS® is (for mammography reporting). The system will feature a number-based rating method for categorizing screening findings and the management strategies associated with those categories.

The college also is devising a variant of facility accreditation, as well as patient- and radiologist-education materials. “If you are going to screen,” Kazerooni asks, “what are the important things you need to know to interpret, perform, and report?”

Radiologists interested in participating in lung-cancer screening are advised to visit the website ( www.lungcanceralliance.org) of the Lung Cancer Alliance, the only national nonprofit organization that exists solely to provide support and advocacy for people living with lung cancer. “It has really influenced the landscape in moving forward the agenda to get lung-cancer screening reimbursed,” Kazerooni says.

She is optimistic that lung-cancer screening will become public policy in the United States. “With the cost-effectiveness