A 54-year-old patient, former smoker (25 pack-year history, quit 10 years ago) states, “Doc, I know it is outside the guidelines. But I am worrying all the time that the residual scar from my pneumonia last year might be a lung cancer. And I am willing to pay cash for the study.” Should a chest CT scan be ordered with the diagnosis of abnormal chest radiograph?
This patient indeed has valid concerns. Lung cancer is the leading cause of cancer death in the United States, and smoking is associated with 85% of all lung cancer cases.1 In addition, lung cancer mortality is related to its stage at diagnosis, but only 15% of cases are diagnosed at early stages.2 Although lung cancer screening has been researched for many years, no screening test showed significant mortality benefit until the National Lung Screening Trial (NLST) published its results in 2011.3 The NLST concluded that annual screening with low-dose CT (LDCT) scanning in current and former smokers (cessation within prior 15 years), aged 55 to 74 years, with 30 pack-years leads to a reduction in lung cancer mortality of 16% and a reduction in all-cause mortality of 6.7%.4 Many professional organizations, including the American College of Chest Physicians (CHEST), the American Thoracic Society, the American Cancer Society, and the American Association for Thoracic Surgery, have since begun recommending annual LDCT scan screening.5 In addition, the US Preventive Services Task Force (USPSTF) recently published its final recommendation in favor of screening.5 However, all are in agreement that prevention of lung cancer through smoking cessation continues to be the best and most cost-effective strategy to decrease lung cancer mortality.5 Despite these recommendations for screening patients for lung cancer using LDCT scanning, most experts agree there are also concerns regarding the implementation of such programs.