2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

LUNG CANCER SCREENING
Fig. 1. Guidelines published by the National Comprehensive Cancer Network for the diagnostic evaluation of positive screens in which solid
or part-solid nodules are detected. Abbreviations: LDCT, low-dose helical computed tomography; PET/CT, positron emission tomography/
computed tomography. Reproduced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines for Lung Cancer
Screening V.1.2012). © 2012 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines and illustrations herein
may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete
version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK ® , NCCN ® , NCCN GUIDELINES ® , and all
other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.
corporation of lung cancer screening adds additional complexity
to a busy out-patient clinic, erodes already limited
clinical time and resources, and disrupts workflow. The
intent of screening and its importance must be communicated
unambiguously to patients, screening exams must be
scheduled, patients with significant findings on screens
must be referred for additional testing, and patients counseled
about likely outcomes and their implications. Finally,
screening implementation will compete for attention with
other validated and less costly health care measures like
breast cancer or colon cancer screening, smoking cessation,
weight loss, and exercise. 25,26
There are formidable challenges to the implementation of
lung cancer screening from the community perspective.
Successful implementation will require the diffusion of
screening across all socioeconomic strata. Community engagement
will be an important element of implementation
in many cultural settings and requires trust and a successful
dialogue in which community members can be informed
about the health consequences of smoking, lung-cancer risk,
and the balance of benefits versus risks of early detection,
while also educating the medical profession regarding community
priorities. The diffusion of screening and preventive
services is particularly important in underserved and minority
populations because these communities are disproportionately
adversely affected by lung cancer; they are
commonly diagnosed at advanced stages, less commonly
undergo surgical resections, and, in particular, black men
have a lower overall survival from lung cancer. If lungcancer
screening is to be equitably administered to all
individuals at risk, the following barriers must be addressed:
lack of awareness and low prioritization of lungcancer
prevention and early detection; cultural concerns of
trust, fatalism, and stigmatization; financial constraints;
and geographical barriers to access. 27,28
The NLST enrolled only patients at high risk of lung
cancer. Although it would be naïve and narrow-minded to
not recognize that additional patients, outside of the NLST
criteria, may have substantial risk of lung cancer that
warrants screening, one must be very cautious in extrapo-
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