The American Cancer Society (ACS) widened the pool of past and current smokers eligible for lung cancer screening in its new guideline recommendations, potentially opening the door to 5 million more U.S. adults.
Annual lung cancer screening with low‐dose CT is strongly recommended for asymptomatic patients ages 50 to 80 years who either currently smoke, or who have a 20 pack‐year or greater smoking history, wrote Robert Smith, PhD, of the ACS in Atlanta, and co-authors of the ACS Guideline Development Group in CA: A Cancer Journal for Clinicians.
Notably gone are years since quitting smoking (YSQ) criteria to determine screening eligibility for former smokers — a departure from existing guidelines and insurance coverage criteria that say screening should not begin if someone quit 15 years ago or should cease screening once they reach that point.
“The rationale for this change is explained as follows: the individual risk of lung cancer does indeed decrease over time once someone quits smoking, but this reduction is relatively lower only if compared with a similar person who continues to smoke,” wrote Don Dizon, MD, and Arif Kamal, MD, MBA, MHS, both of Brown University in Providence, Rhode Island, in an accompanying editorial.
“Compared with a person who never smoked, the risk for lung cancer appears to remain three times greater, even at 20 and 30 YSQ. This introduces an entirely new cohort of people now eligible for lung cancer screening, some of whom we may not visualize when imagining the patient who should be contacted for annual screening,” the duo wrote.
While lung cancer rates have been declining since 1992, it remains the leading source of mortality and lost person-years as the result of cancer for both U.S. men and women. This year alone, the ACS estimates approximately 238,340 new diagnoses of lung cancer and 127,070 deaths from lung cancer will be reported.
“This updated guideline continues a trend of expanding eligibility for lung cancer screening in a way that will result in many more deaths prevented by expanding the eligibility criteria for screening to detect lung cancer early,” said Smith in a press release. “Recent studies have shown extending the screening age for persons who smoke and formerly smoked, eliminating the ‘years since quitting’ requirement and lowering the pack per year recommendation could make a real difference in saving lives.”
Precluding referrals for screening may be factors such as existing comorbid conditions, limited life expectancy, or unwillingness to undergo treatment for a positive screen finding, the guideline authors acknowledged.
Previously, the 2013 ACS guidelines had endorsed annual lung cancer screening with low‐dose CT for patients ages 55 to 74 who were current smokers or who had a 30 pack-year history or more. Lung cancer screening was also previously recommended by the ACS for patients who had quit within the past 15 years.
Sara Ghandehari, MD, of Cedars-Sinai Medical Center in Los Angeles, told MedPage Today that the update eliminating the years-since-quitting consideration sets the ACS guidelines apart from Medicare and the U.S. Preventive Services Task Force (USPSTF) guidelines, and is “a great step towards increasing eligibility for lung cancer screening as well as eliminating some of the steps required for providers to identify eligible patients.”
“By eliminating one of these steps, the quit-date in particular, it kind of simplifies and reduces the complexity of determining eligibility,” she said in an interview.
But the bigger aspect, said Ghandehari, is the larger eligible population: “I have a number of patients who have been diagnosed with lung cancer beyond the 15-year follow-up.”
Therese Bevers, MD, of MD Anderson Cancer Center in Houston, predicted that there may be some issues regarding insurance coverage with the updates made to the ACS guidelines, but the greater potential for early detection is worth it.
“Hopefully this will affect reimbursement and make it more open. Because I think these recommendations are good, it’s going to allow more people to get screened and thus the potential to catch lung cancers earlier when they’re more treatable — and we would see fewer people dying,” she told MedPage Today.
Bevers also stressed the importance of keeping up-to-date on various guidelines, which may help clear confusion between various institutional guidelines and patients who wonder if they are eligible.
Medicare, for example, currently covers lung cancer screening with referral from a provider for patients ages 50 to 77 who are asymptomatic, have a smoking history of at least 20 pack-years, and either currently smoke or have quit smoking the previous 15 years.
Ghandehari expressed hope that lung cancer screening guidelines will become more streamlined and similar between organizations over time, which may ease payment issues.
“I think the key factor is we are so behind in screening for lung cancer. And any effort that is taken to simplify cancer screening — increase its acceptance, so that we’re catching this cancer earlier — is key,” she said.
In order to develop the new guideline update, the ACS writing group relied largely on a systematic review from 2021 that had been commissioned for the USPSTF lung cancer screening recommendation update that year.
The ACS continues to recommend that patients who currently smoke are encouraged to quit, and are provided with evidence-based smoking‐cessation tools in order to do so.
These guidelines were supported by funding from the American Cancer Society Guideline Development Group and the National Comprehensive Cancer Network.
Smith reported relationships with ACS. Coauthors reported relationships with the ACS, the National Cancer Institute, Sanofi, Seno Medical Instruments, Genentech Foundation, CRISPR Therapeutics, BEAM Therapeutics, Intellia Therapeutics, Editas Medicine, Freenome, and Guardant Health.
Bevers, Dizon, Ghandehari, and Kamal reported no relevant disclosures.
CA: A Cancer Journal for Clinicians
Source Reference: Wolf A M D, et al “Screening for lung cancer: 2023 guideline update from the American Cancer Society” CA Cancer J Clin 2023; DOI: 10.3322/caac.21814.
CA: A Cancer Journal for Clinicians
Source Reference: Dizon DS, Kamal AH “Lung cancer screening guidelines: Smoking matters, not quitting” CA Cancer J Clin 2023; DOI: 10.3322/caac.21811.