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Lung Cancer Screening 240 NCCN Arnold J. Rotter, MD; Matthew B. Schabath, PhD; Lecia V. Sequist, MD, MPH; Betty C. Tong, MD, MHS; William D. Travis, MD; Michael Unger, MD, FCCP; and Lung Cancer Stephen C. Yang, MD Screening Lung cancer is the leading cause of cancer-related mor- Clinical Practice Guidelines in Oncology tality in the United States and worldwide.1–4 In 2011, it Douglas E. Wood, MD; George A. Eapen, MD; is estimated that 156,900 deaths (85,600 in men, 71,300 David S. Ettinger, MD; Lifang Hou, MD, PhD; in women) from lung cancer will occur in the United David Jackman, MD; Ella Kazerooni, MD; States.4 Five-year survival rates for lung cancer are only Donald Klippenstein, MD; Rudy P. Lackner, MD; approximately 15.6%, partly because most patients have Lorriana Leard, MD; Ann N. C. Leung, MD; Pierre P. Massion, MD; Bryan F. Meyers, MD, MPH; advanced-stage lung cancer at initial diagnosis (http:// Reginald F. Munden, MD, DMD, MBA; seer.cancer.gov/statfacts/html/lungb.html).5 Gregory A. Otterson, MD; Kimberly Peairs, MD; These facts, combined with the success of screen- Sudhakar Pipavath, MD; Christie Pratt-Pozo, MA, DHSc; ing in improving outcomes in cervical, colon, and breast Chakravarthy Reddy, MD; Mary E. Reid, PhD; cancers, have been the impetus for studies to develop an NCCN Clinical Practice Guidelines in Please Note Oncology for Lung Cancer Screening The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of consensus of the authors regarding their views of currently accepted ap- Key Words proaches to treatment. Any clinician seeking to apply or NCCN Clinical Practice Guidelines, NCCN Guidelines, lung consult the NCCN Guidelines® is expected to use indepen- cancer, screening, LDCT, smoking, carcinogen, tobacco (JNCCN dent medical judgment in the context of individual clinical 2012;10:240–265) circumstances to determine any patient’s care or treatment. NCCN Categories of Evidence and Consensus The National Comprehensive Cancer Network® (NCCN®) Category 1: Based upon high-level evidence, there is uniform makes no representation or warranties of any kind regarding NCCN consensus that the intervention is appropriate. their content, use, or application and disclaims any respon- Category 2A: Based upon lower-level evidence, there sibility for their applications or use in any way. is uniform NCCN consensus that the intervention is © National Comprehensive Cancer Network, Inc. appropriate. 2012, All rights reserved. The NCCN Guidelines and the Category 2B: Based upon lower-level evidence, there is illustrations herein may not be reproduced in any form NCCN consensus that the intervention is appropriate. without the express written permission of NCCN. Category 3: Based upon any level of evidence, there Disclosures for the NCCN Guidelines is major NCCN disagreement that the intervention is Panel for Lung Cancer Screening appropriate. At the beginning of each NCCN Guidelines panel meeting, panel All recommendations are category 2A unless otherwise members disclosed any financial support they have received from noted. industry. Through 2008, this information was published in an Clinical trials: NCCN believes that the best management for aggregate statement in JNCCN and online. Furthering NCCN’s any cancer patient is in a clinical trial. Participation in clinical commitment to public transparency, this disclosure process has trials is especially encouraged. now been expanded by listing all potential conflicts of interest respective to each individual expert panel member. Individual disclosures for the NCCN Lung Cancer Screening Panel members can be found on page 265. (The most recent version of these guidelines and accompanying disclosures, including levels of compensation, are available on the NCCN Web site at www.NCCN.org.) These guidelines are also available on the Internet. For the latest update, visit www.NCCN.org. © JNCCN–Journal of the National Comprehensive Cancer Network | Volume 10 Number 2 | February 2012 241 NCCN Guidelines® Journal of the National Comprehensive Cancer Network Lung Cancer Screening effective lung cancer screening test.6,7 Ideally, effective The NCCN Lung Cancer Screening Panel devel- screening will lead to earlier detection of lung cancer oped this new screening guideline in 2011 based on the (before patients have symptoms and when treatment current body of evidence.8 These guidelines 1) describe is more likely to be effective) and will decrease mortal- risk factors for lung cancer; 2) recommend criteria for ity.8 Currently, most lung cancer is diagnosed clinically selecting high-risk individuals for screening; 3) provide when patients present with symptoms (such as cough, recommendations for evaluation and follow-up of nod- chest pain, weight loss); unfortunately, patients with ules found during screening; 4) discuss the accuracy of these symptoms usually have advanced lung cancer. LDCT screening protocols and imaging modalities; Early detection of lung cancer is an important op- and 5) discuss the benefits and risks of screening. portunity for decreasing mortality. Considerable in- terest has been shown in developing screening tools to detect early-stage lung cancer. Recent data support Screening for Non–Small using spiral (helical) low-dose computed tomography Cell Lung Cancer (LDCT) of the chest to screen select patients who are Most lung cancers (85%) are classified as non–small at high risk for lung cancer (http://www.cancer.gov/ cell lung cancer (NSCLC); small cell lung cancer clinicaltrials/noteworthy-trials/nlst).8 occurs in 13% to 15% of patients (see the NCCN Text continues on p. 247 NCCN Lung Cancer Screening Panel Members Kimberly Peairs, MDÞ The Sidney Kimmel Comprehensive Cancer Center at Douglas E. Wood, MD/Chair¶ Johns Hopkins University of Washington/ Sudhakar Pipavath, MDϕ Seattle Cancer Care Alliance University of Washington/ George A. Eapen, MDΞ Seattle Cancer Care Alliance The University of Texas MD Anderson Cancer Center Christie Pratt-Pozo, MA, DHSc¥ David S. Ettinger, MD† H. Lee Moffitt Cancer Center & Research Institute The Sidney Kimmel Comprehensive Cancer Center at Chakravarthy Reddy, MDΞÞ Johns Hopkins Huntsman Cancer Institute at the University of Utah Lifang Hou, MD, PhD& Mary E. Reid, PhD& Robert H. Lurie Comprehensive Cancer Center of Roswell Park Cancer Institute Northwestern University Arnold J. Rotter, MDϕ David M. Jackman, MD† City of Hope Comprehensive Cancer Center Dana-Farber/Brigham and Women’s Cancer Center Matthew B. Schabath, PhD& Ella Kazerooni, MDϕ H. Lee Moffitt Cancer Center & Research Institute University of Michigan Comprehensive Cancer Center Lecia V. Sequist, MD, MPH† Donald Klippenstein, MDϕ Massachusetts General Hospital Cancer Center H. Lee Moffitt Cancer Center & Research Institute Betty C. Tong, MD, MHS¶ Rudy P. Lackner, MD¶ Duke Cancer Institute UNMC Eppley Cancer Center at William D. Travis, MD≠ The Nebraska Medical Center Memorial Sloan-Kettering Cancer Center Lorriana Leard, MDΞ Michael Unger, MDΞ UCSF Helen Diller Family Comprehensive Cancer Center Fox Chase Cancer Center Ann N. C. Leung, MDϕ Stephen C. Yang, MD¶ Stanford Comprehensive Cancer Center The Sidney Kimmel Comprehensive Cancer Center at Pierre P. Massion, MDΞ Johns Hopkins Vanderbilt-Ingram Cancer Center Bryan F. Meyers, MD, MPH¶ NCCN Staff: Kristina Gregory, RN, MSN, OCN, and Siteman Cancer Center at Barnes-Jewish Hospital and Miranda Hughes, PhD Washington University School of Medicine Reginald F. Munden, MD, DMD, MBAϕ KEY: The University of Texas MD Anderson Cancer Center Gregory A. Otterson, MD† Specialties: ¶Surgical Oncology; ΞPulmonary Medicine; The Ohio State University Comprehensive Cancer Center – †Medical Oncology; &Epidemiology; ϕDiagnostic Radiology; James Cancer Hospital and Solove Research Institute ÞInternal Medicine; ¥Patient Advocacy;≠Pathology © JNCCN–Journal of the National Comprehensive Cancer Network | Volume 10 Number 2 | February 2012 242 Lung Cancer Screening Version 1.2012 RISK ASSESSMENT RISK STATUS SCREENING SCREENING EVALUATION OF FOLLOW-UP OF SCREENING FINDINGS MODALITY FINDINGS SCREENING FINDINGS See Evaluation Annual LDCT If no increasek,l in size, Solid or part of Screening screening for annual LDCT screening solid noduleg 4 mmj High risk: Findings (next page) 3 y and until for at least 2 y and until f,h,i f,h,i Age 55-74 y and Lung age 74 y age 74 y 30 pack-year history nodule(s) Ground glass opacity of smoking and on LDCT (GGO)g/ Smoking cessation See Evaluation of Ground glass nodule < 15 y Baseline g Screening (category 1) (GGN) / If no increaseik,l n low-dose Findings (page 244) > 4-6 mmj LDCT in 6 mof,h or Nonsolid nodule size, LDCT in 12 mof,h computed (NS)g Smoking historya Age 50 y and tomography ➤ 20 pack-year history Present or past (LDCT)f Radon exposureb of smoking and Annual LDCT If Occupational One additional risk k,l Recommend No lung j f,h If no increasein increase c factor (other than screening for > 6-8 mm LDCT in 3 mo surgical excision exposure nodule(s) size, LDCT in 6 mof,h in sizek,l d secondhand smokee) 3 y and until age Solid or Cancer history on LDCT (category 2B) 74 yf,h,i part-solid Family history of lung noduleg cancer Disease history (COPD Low suspicion LDCT in 3 mof,h or pulmonary fibrosis) of lung cancer e Smoking exposure Moderate risk: (secondhand smoke) Age 50 y and Absence of symptoms j 20 pack-year history of Routine lung cancer > 8 mm Consider PET/CT Annual LDCT or signs of lung cancer smoking or secondhand screening not recommended screening for at (if symptoms, see No cancer smoke exposuree least 2 y and until appropriate guideline Biopsy No additional risk factors age 74 yf,h,i at www.NCCN.org) Suspicion of or lung cancerg Surgical See NCCN Clinical Low risk: excision Cancer Age < 50 y and/or Routine lung cancer Practice Guidelines f,h confirmed < 20 pack-year screening not recommended Solid LDCT in 1 mo in Oncology (NCCN history of smoking endobronchial (immediately after If no resolution Bronchoscopy Guidelines) for Non- nodule vigorous coughing) Small Cell Lung Cancer* *To view the most recent version of these guidelines, visit the NCCN Web site at www.NCCN.org.
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