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The USPSTF has updated its previous guideline (NEJM JW Gen Med Feb 15 2014 and Ann Intern Med 2014; 160:330) for lung cancer screening with low-dose computed tomography (LDCT) by expanding the age criterion and lowering the smoking-history threshold. The new recommendation is based on both a large European randomized trial (NEJM JW Gen Med Feb 15 2020 and N Engl J Med 2020; 382:503) and recent sophisticated risk-modeling studies.
The USTSPF concludes annual LDCT confers moderate net benefit for lung cancer screening in older adults (age range, 50–80) with ≥20 pack-year smoking history who continue to smoke or have quit within the past 15 years. The recommendation applies until a person develops other health conditions that would preclude long-term benefit or unless a person is unwilling or unable to undergo curative surgical therapy (B recommendation).
US Preventive Services Task Force.Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA 2021 Mar 9; 325:962. (https://doi.org/10.1001/jama.2021.1117)
Colson YL et al. New USPSTF guidelines for lung cancer screening: Better but not enough. JAMA Surg 2021 Mar 9; [e-pub]. (https://doi.org/10.1001/jamasurg.2021.0242)
Fukunaga MI et al. The 2021 US Preventive Services Task Force recommendation on lung cancer screening: The more things stay the same…. JAMA Oncol 2021 Mar 9; [e-pub]. (https://doi.org/10.1001/jamaoncol.2020.8376)
Henderson LM et al. Broadened eligibility for lung cancer screening: Challenges and uncertainty for implementation and equity. JAMA 2021 Mar 9; 325:939. (https://doi.org/10.1001/jama.2020.26422)
Comment
The expanded recommendation is based on the assumption that LDCT readings are at least as accurate as those in the major trials and that patients with low-risk findings are followed by serial imaging. Note, however, that this recommendation remains a “B” — not the strongest USPSTF endorsement about the balance of benefits and harms.
The new guideline expands the U.S. population eligible for screening by about 80%, but several editorialists note that the problem with lung cancer screening is not eligibility, but adherence and access. Only about 5% to 10% of patients eligible under the prior recommendation have been screened, with substantial racial and socioeconomic disparities. The Centers for Medicare & Medicaid Services requires documentation of a shared decision-making counseling visit before LDCT can be ordered, which might be optimal but might also limit access. Moreover, some Medicaid and private insurance plans do not cover LDCT screening. The recommendations of most professional associations mimic the prior USPSTF recommendation and seem likely to be updated eventually.