Lung cancer screening: are we performing it satisfactorily?

“Preventing is better than treating”.

“An ounce of prevention is worth a pound of cure”.

Have we learnt something from these sentences pronounced by Hippocrates and Benjamin Franklin?

Lung cancer represents so far the big killer among cancer patients in 87 countries in men and in 26 countries in women (1). Using the GLOBOCAN statistics, Sung and colleagues estimated approximately 2.2 million new lung cancer patients and 1.8 million lung cancer related deaths occurring worldwide in 2020 (2).

The survival rate of lung cancer patients depends principally on the clinical stage at the time of first diagnosis. Even if recent progresses in surgery with additional adjuvant or neoadjuvant treatments have been improving outcomes, 5-year survival rate remains poor after a delayed diagnosis.

The National Lung Screening Trial demonstrated a decrease in lung-cancer mortality of 20% in former and current heavy smokers who underwent low dose computer tomography (CT), as compared with chest X-ray group (3).

The NELSON trial corroborated in 2020 these results showing a reduction of lung-cancer mortality among male former and current smokers who underwent CT screening when compared with the no screening group (4).

Recently, the United States Preventive Services Task Force (USPSTF) recommended annual low dose CT in current or past smokers (within 15 years) aged 50 to 80 years who have a 20-pack-year smoking history (5).

The benefit of a lung cancer screening was analyzed also from a different perspective, by shifting the focus to the cost effectiveness of the screening program, a crucial point in an era where the resources for the health care systems are often limited (6-9).

However, an unsolved problem seems to be the optimal selection of eligible subjects who can benefit from a lung cancer screening program (10,11). Several controversies have been emerging regarding the representativity in the published trials of the general population. Patients with previous malignancies, ethnic minorities, women or never smokers are usually underrepresented.

For these reason, broadening the eligibility criteria, despite the complexity, is an issue that should to be addressed.

Aiming to find new chances to expand the eligibility, Soto and his group from Stanford tried to assess the improvement of lung cancer screening rate among patients with head and neck cancer (12). One hundred eighty four patients were included in a retrospective analysis and of those, in only a 2-month period, 8 patients out of the 184 were found it be eligible for screening (9 in total considering expanded guidelines).

Given that cancer survivors represent a not negligible part of our population (more than 16.9 million Americans had previous cancer in their life in 2019), is it justified to exclude them a priori from a lung cancer screening program? (13).

Epidemiological studies showed that a growing percentage of patients have already been diagnosed with 1 cancer before lung cancer diagnosis in their lifetime (14,15).

Despite the impossibility, for obvious reasons, to extend the lung cancer screening for all patients with previous malignancies, the careful identification of high risk patients in this subpopulation could improve the rate of early stage lung cancer detection.

Even more interesting seems to be the fact that after a phone survey, more than half of the patients had a poor knowledge of a lung cancer screening existence. Despite some limitations of the paper, such as the retrospective design of the study, the limited number of patients and short interval of the study time, the message suggested by the authors is clear.

Clinical data and guidelines are crucial to improve lung cancer screening rates but could be not sufficient alone.

Broadening the eligibility comes through a better awareness on the issue by health care providers and patients together. The eligibility assessment should be improved by the clinicians who, at the same time, should spread across the message to the population about the importance of smoking cessation and screening strategies.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-411/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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