Lung cancer is the second most common form of cancer and the leading cause of cancer-related fatalities in the United States (US). In the year 2020, an estimated 228,820 individuals received a diagnosis of lung cancer, while 135,720 lost their lives to this disease.
The primary risk factor for developing lung cancer is smoking, accounting for approximately 90% of all cases. Additionally, advancing age is a significant risk factor, with the median age of lung cancer diagnosis being 70 years.
Unfortunately, lung cancer typically carries a grim prognosis, with an overall 5-year survival rate of 20.5%. However, early-stage lung cancer does offer a more optimistic outlook and shows a better response to treatment. This highlights the importance of following lung cancer screening guidelines to ensure early detection and improve outcomes.
In this Guidelines Side-By-Side, we have juxtaposed the latest guidelines (published between 2017-2024) from the American College of Chest Physicians (CHEST), the US Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), and the National Comprehensive Cancer Network (NCCN). By comparing these recommendations, the aim of this article is to furnish healthcare professionals with invaluable insights and optimal strategies for lung cancer screening. This evidence-based methodology is tailored to enhance health outcomes for individuals affected by this disease.
Titles of Comparison:
| Titles | Screening for Lung Cancer | Lung Cancer: Screening | Screening for Lung Cancer | Lung Cancer Screening |
|---|---|---|---|---|
| Society | American College of Chest Physicians (CHEST) | US Preventive Services Task Force (USPSTF) | American Cancer Society (ACS) | National Comprehensive Cancer Network (NCCN) |
| Publication Date | November 2021 | March 2021 | November 2023 | October 2024 |
| Objective | To update the evidence base for the benefit, harms, and implementation of low-dose chest CT screening. | To update its 2013 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on the accuracy of screening for lung cancer with low-dose computed tomography (LDCT) and on the benefits and harms of screening for lung cancer and commissioned a collaborative modeling study to provide information about the optimum age at which to begin and end screening, the optimal screening interval, and the relative benefits and harms of different screening strategies compared with modified versions of multivariate risk prediction models. | The objective was to update the American Cancer Society (ACS) 2013 lung cancer screening (LCS) guideline for adults at high risk for lung cancer. | To annually update the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)for Lung Cancer Screening which were originally developed in 2011. |
| Target Population | For asymptomatic persons who are at high risk of lung cancer based on cumulative exposure to tobacco by smoking. | This recommendation statement applies to adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. | The guideline is intended to provide guidance for screening to health care providers and their patients who are at high risk for lung cancer due to a history of smoking. | The guideline is intended to provide guidance for screening to health care providers and their patients who are at high risk for lung cancer. |
| Methodology | Approved panelists reviewed previously developed key questions using the Population, Intervention, Comparator, Outcome format to address the benefit and harms of low-dose CT screening, and key areas of program implementation. A systematic literature review was conducted using MEDLINE via PubMed, Embase, and the Cochrane Library on a quarterly basis since the time of the previous guideline publication. | To update its 2013 recommendation, the USPSTF commissioned a systematic review on the accuracy of screening for lung cancer with LDCT and the benefits and harms of screening for lung cancer. | The ACS Guideline Development Group (GDG) utilized a systematic review of the LCS literature commissioned for the USPSTF 2021 LCS recommendation update; a second systematic review of lung cancer risk associated with years since quitting smoking (YSQ); literature published since 2021; two Cancer Intervention and Surveillance Modeling Network-validated lung cancer models to assess the benefits and harms of screening; an epidemiologic and modeling analysis examining the effect of YSQ and aging on lung cancer risk; and an updated analysis of benefit-to-radiation-risk ratios from LCS and follow-up examinations. | The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. |
| Graded Strength of Recommendations | Yes | Yes | Yes | Yes |
| Graded Level of Evidence | Yes | Yes | Yes | Yes |
| Systematic Review Conducted | Yes | Yes | Yes | Yes |
| Literature Review Conducted | Yes | Yes | Yes | Yes |
| COIs & Funding Source(s) Disclosed | Yes | Yes | Yes | Yes |
| Full-Text | Screening for Lung Cancer | Lung Cancer: Screening | Screening for Lung Cancer | Lung Cancer Screening |
| Summary | Screening for Lung Cancer Summary | Lung Cancer: Screening Summary | Screening for Lung Cancer Summary of the Update | N/A |
Comparison of Key Points
Overall Comparison:
| Criteria | CHEST (2021) | USPSTF (2021) | ACS (2023) | NCCN (2024) |
|---|---|---|---|---|
| Age Range | 50-80 years | 50-80 years | 50-80 years | ≥50 years |
| Smoking History | 20+ pack-years | 20+ pack-years | 20+ pack-years | 20+ pack-years |
| Screening Method | Low-dose CT (LDCT) | LDCT | LDCT | LDCT |
| Frequency of Screening | Annually | Annually | Annually | Annually |
| Initiation of Screening | Age 50 with ≥ 20 pack-year history have quit within the past 15 years | Age 50 with ≥ 20 pack-year history or who have quit in the last 15 years | Age 50 with ≥ 20 pack-year history and currently smoked or previously smoked | Age 50 with ≥ 20 pack-year history or ≥20 year history of smoking cigarettes |
| Discontinuation of Screening | Age 80, no longer meet smoking criteria or have comorbidities that substantially limit their life expectancy | Age 80 or screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery | Age 80 or no longer meets smoking criteria or Comorbid conditions that limit life expectancy <5 years; not willing to accept treatment for screen-detected cancer | There is uncertainty about the appropriate duration of screening and the age at which screening is no longer appropriate |
| Additional Rsk Factors | Radon or occupational exposures, history of cancer, COPD or pulmonary fibrosis, family history of lung cancer | Environmental exposures, prior radiation therapy, other (noncancer) lung diseases, and family history | N/A | Radon exposure, history of cancer, history of COPD or pulmonary fibrosis, family history of lung cancer, occupational exposure |
Key decision variables include:
- Patient’s age
- Patient’s smoking history, including “pack-year” data*
- Patient’s current smoking status
*A one pack-year is the equivalent of smoking an average of one pack of cigarettes per day for a year. So one pack per day for 20 years or two packs per day for 10 years are each equivalent to a 20 pack-year smoking history.
The major differences between the guidelines include:
- Age - NCCN does not provide a cut-off of 80 years like the other guidelines do. Instead, they suggest screening be halted once the patient is unable to undergo curative treatments.
- Current smoking status - While NCCN and ACS recommendations focus on the pack-year data, the USPSTF and CHEST recommendations say that any individuals who meet pack-year requirements, but who quit smoking 15 or more years prior, would not fall into the annual screening group under normal circumstances.
- Special Inclusions - CHEST offers a comment that some individuals not meeting the age or smoking criteria for annual screening may still be screened annually if there is a likely net-benefit. Specific details on who may fit into this group are not provided.
- Exclusions - The exclusions do not match exactly across all four guidelines, though ACS and CHEST provide similar exclusions. USPSTF only provides the exclusion for individuals who have comorbid conditions that harm or hinder treatment.
Exclusions overview - patients NOT eligible for lung cancer screening, include:
- Individuals exhibiting symptoms of lung cancer (NCCN)
- Individuals with previously confirmed lung cancer (NCCN)
- Individuals who have comorbid conditions that would prohibit curative treatment of lung cancer (NCCN)
- Comorbid conditions that would increase harm or hinder treatment (ACS + CHEST + USPSTF)
- Comorbid conditions that limit life expectancy to less than 5 years (ACS + CHEST)
Similarities:
- All four organizations agree that screening should be performed annually, and that the preferred screening method is a low-dose CT examination.
In conclusion, these guidelines are mostly consistent in terms of eligibility criteria, with some minor variations. Overall, they all suggest with moderate certainty that annual screening for lung cancer using LDCT is beneficial.
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