VA lung cancer screening program finds high rate of incidental findings, low cancer detection rate

An estimated 900,000 veterans of a population of 6.7 million VHA patients met the criteria for LCS.
An estimated 900,000 veterans of a population of 6.7 million VHA patients met the criteria for LCS.

Implementation of a comprehensive lung cancer screening program in the Veterans Health Association (VHA) will require significant clinical effort with uncertain patient benefit, according to a study published in JAMA Internal Medicine.

The US Preventive Services Task Force recommends annual lung cancer screening with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years, although little published data exist regarding implementing this in clinical practice, according to Linda S Kinsinger, MD, MPH, from the VHA National Center for Health Promotion and Disease Prevention in Durham, NC, and colleagues.

Dr Kinsinger's group implemented a 3-year Lung Cancer Screening Demonstration Project (LCSDP) in 8 geographically diverse hospitals. The objective was to analyze the clinical experience of patients who underwent LCS in terms of positive test results, lung cancers detected, and incidental findings. Also, the researchers wanted to estimate the size of the VHA population that potentially meets eligibility criteria for LCS.

Patient criteria included those aged 55 to 80 years without a diagnosis of esophageal, liver, pancreatic, or lung cancer and without a documented estimated life expectancy of fewer than 6 months. Patients were then reviewed for smoking histories to identify current or former (quit less than 15 years ago) cigarette smokers who had smoked a minimum of 30 pack-years.

Patient-level outcomes included percentage of candidates eligible for LCS who agreed to undergo screening, percentage of low-dose computed tomography (LDCT) results that led to positive test results (nodules needing to be tracked or suspicious findings requiring further evaluation), percentage of screened patients found to have lung cancer and descriptions of cancers, percentage of LDCT results with incidental findings, and estimated number of VHA patients who may be candidates for LCS.

Overall, 2106 patients had completed an LDCT scan by June 30, 2015, and were included in the analyses. Of the 2106 patients, 1257 (59.7%) screened had a positive test result, including 1184 patients (56.2%) who had 1 or more nodules needing to be tracked. A total of 73 patients (3.5%) of all patients screened had possible lung cancer findings; of these, 31 patients (1.5%) were confirmed. A total of 857 patients (40.7%) had 1 or more incidental findings reported. The most common were emphysema, other pulmonary abnormalities, and coronary artery calcification.

The researchers calculated that 2,780,933 primary care VHA patients potentially met the eligibility criteria for visits, age, and medical history. “If the eligibility percentage found in our 8-site project is representative of the VHA population as a whole, we estimate that nearly 900,000 veterans in the VHA health care system would meet the initial screening criteria for age, smoking history, and medical history.”

In an accompanying editorial, Rita F Redberg, MD, MSc and Patrick G O'Malley, MD, MPH, stated, “We commend Kinsinger et al for their careful analysis of the VA LCS program. We urge other programs to conduct the same careful analysis of risks and benefits and outcomes of lung cancer screening to continue to inform the process and allow patients and their physicians as well as health care systems to make the best choices.”

References

  1. Kinsinger LS, Anderson C, Kim J, et al. Implementation of lung cancer screening in the Veterans Health Administration. JAMA Intern Med. 30 January 2017. doi: 10.1001/jamainternmed.2016.9022.
  2. Redberg RF, O'Malley PG. Important Questions About Lung Cancer Screening Programs When Incidental Findings Exceed Lung Cancer Nodules by 40 to 1. JAMA Intern Med. 30 January 2017.  doi: 10.1001/jamainternmed.2016.9446.
  3. Huo J, Shen C, Volk RJ, Shih YT. Use of CT and chest radiography for lung cancer screening before and after publication of screening guidelines: Intended and unintended uptake. JAMA Intern Med. 30 January 2017. doi: 10.1001/jamainternmed.2016.9016.
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