On January 8, 2020, the American Cancer Society announced the largest one year drop in cancer mortality, driven by improvements in lung cancer. On January 29, 2020, the NELSON Trial results were published in The New England Journal of Medicine, “Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial.” The NELSON Trial—a long-awaited report of a randomized lung cancer screening trial in Europe—demonstrated a large lung cancer mortality reduction in patients undergoing low-dose computed tomography (LDCT) screening, affirming the results from the National Lung Screening Trial (NLST) published nearly 9 years ago.
Dr. Douglas E. Wood describes the findings from the European trial and what they mean for policy and program development for lung cancer early detection through CT screening.
The implications for lung cancer screening guidelines and policy are enormous.
The Dutch–Belgian lung-cancer screening trial (Nederlands–Leuvens Longkanker Screenings Onderzoek [NELSON]) is a critically important addition to the evidence supporting early detection for patients at risk of lung cancer.7 First, it is another large trial that shows a substantial mortality benefit from CT screening; in fact, an even larger benefit than seen in the NLST. Screened NELSON patients benefited from a 24% mortality reduction (33% reduction for women). Second, the eligibility for screening was broader than that for the NLST, supporting broader inclusion for lung cancer screening in existing guidelines and policy. Third, the NELSON trial demonstrated a very low rate of referrals for “false positive” exams (2.1%)—one of the major concerns raised by those skeptical of screening benefits. Fourth, both the NLST and NELSON are believed to actually underestimate the true benefit of screening as they each only performed a baseline and two follow up scans, then ceasing further screening. After the final screen, one would expect the study group to revert back toward the control group as new cancers will subsequently develop at a similar rate in both populations.
The implications for lung cancer screening guidelines and policy are enormous. The USPSTF is reevaluating their recommendations and one could reasonably expect that the additional evidence from the NELSON trial would result in a Grade A recommendation, stronger than the current Grade B recommendation from 2013. Also, it is likely that the AAFP also will upgrade their recommendation to support lung cancer screening. Finally, existing guidelines should be willing to broaden inclusion criteria to assure access to screening for the true population at high risk of lung cancer, not just those studied in the NLST.
Lung cancer screening is having a favorable impact on lung cancer mortality, and improvements in lung cancer mortality are driving overall reductions in cancer mortality in the United States. The impetus must now be to help eligible patients gain access to high quality screening programs, because LUNG CANCER SCREENING SAVES LIVES!
American Cancer Society Facts and Figures 2020. https://www.cancer.org/latest-news/facts-and-figures-2020.html Accessed February 1, 2020.
National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, et al: Reduced lung-cancer screening mortality with low-dose computed tomographic screening. N Engl J Med 365:395-409, 2011.
Wood DE, Eapen GA, Ettinger DS, Hou L, Jackman D, Kazerooni E, Klippenstein D, Lackner RP, Leard L, Leung AN, Massion PP, Meyers BF, Munden RF, Otterson GA, Peairs K, Pipavath S, Pratt-Pozo C, Reddy C, Reid ME, Rotter AJ, Schabath MB, Sequist LV, Tong BC, Travis WD, Unger M, Yang SC. Lung cancer screening. J Natl Compr Canc Netw 2012; 10:24-65.
Lung Cancer Screening version 2020.1. NCCN Clinical Practice Guidelines in Oncology. https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf Accessed February 4, 2020.
Wood DE. Lung cancer screening should be expanded to high-risk individuals not currently meeting eligibility criteria in the ACCP Guidelines on lung cancer. Chest 2018; 153:1299-1302.
Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl): e78S-e92S.
de Koning HJ, van der Aalst CM, de Jong PA, et.al. Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial. N Engl J Med January 29, 2020. DOI: 10.1056/NEJMoa1911793.
Douglas E. Wood, MD, is the Henry N. Harkins Professor and Chair of the Department of Surgery at the University of Washington in Seattle. Dr. Wood serves as Chair of the National Comprehensive Cancer Network (NCCN) Lung Cancer Screening Panel and Vice-Chair of the NCCN Non-Small Cell Lung Cancer Panel. He also is an STS Past President and has represented the Society on the Lung Cancer Guidelines panel of the American College of Chest Physicians.