WJR-Lung Cancer Screening Computed Tomography or Chest Radiographs

7/23/2019 WJR-Lung Cancer Screening Computed Tomography or Chest Radiographs

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ung cancer screening: Computed tomograph

y or chest radiographs?

Edwin JR van Beek, Saeed Mirsadraee, John Murchison

C!"!#$ van Beek EJR, Mirsadraee S, Murchison J% Lung cancer screening: Compute

d tomography or chest radiographs? &or'd J Radio'()*+ -./0: */12*13

URL http://www.wjgnet.com/1949-8470/full/v7/i8/189.htm

DOI http://dx.doi.org/10.4329/wjr.v7.i8.189

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C#RE !4 he use o5 'ow dose computed tomography .C0 5or 'ung cancer screening

is superior to the use o5 standard chest radiograph .C6R0, and there5ore st

andard C6R shou'd not 7e used 5or this purpose% 8owever, the app'ication

o5 nove' computer assisted diagnosis so5tware may in5'uence the uti'ity o5

C6R and may u'timate'y 7e a cost2e55icient method in those countries whe

re de'ivery o5 'ow2dose C is not 5easi7'e due to in5rastructure or costs con

straints%

9E R;S Lung cancer Chest radiograph Computed tomography Screening 8ea'th ec

onomics

COPYRIGHT The Author(s) 2015u$li!hed $% +#i!hideng u$li!hing

roup &nc. (ll right! re!erved.

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rder reprint! or re5ue!t permi!!ion!: !"#o$%e&'#et%o*

NA+E O,

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World Journal of Radiology

ISSN 1949-8470 *online

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3/21

ESPS +3us%r"t NO4 1677

Co/u*s4 EDITORIAL

ung cancer screening: Computed tomography or chest radiographs?

Edwin JR van Beek, Saeed Mirsadraee, John Murchison

;dwin ueen?! =edic#l e!e#rch &n!titute niver!it% of ;din$urgh

;din$urgh ;@16 4


4/21

;dwin


5/21

Eir!t deci!ion: (pril 27 201

evi!ed: (pril 29 201

(ccepted: =#% 27 201

(rticle in pre!!: =#% 28 201

u$li!hed online: (ugu!t 28 201

A!str3%t

Iorldwide lung c#ncer i! the le#ding c#u!e of mort#lit% due to

m#lign#nc%. he v#!t m#jorit% of c#!e! of lung c#ncer #re !moing

rel#ted #nd the mo!t eective w#% of reducing lung c#ncer incidence

#nd mort#lit% i! $% !moing ce!!#tion. &n the Ie!tern world !moing

ce!!#tion policie! h#ve met with limited !ucce!!. he other m#jor

me#n! of reducing lung c#ncer de#th! i! to di#gno!e c#!e! #t #n

e#rlier more tre#t#$le !t#ge emplo%ing !creening progr#mme! u!ing

che!t r#diogr#ph! or low do!e computed tomogr#ph%. &n m#n%

countrie! !moing i! !till on the incre#!e #nd the !heer !c#le of the

pro$lem limit! the #ord#$ilit% of !uch !creening progr#mme!. hi!

!hort review #rticle will ev#lu#te the current evidence #nd potenti#l

#re#! of re!e#rch which m#% $eneBt polic% m#ing #cro!! the world.

8e 'ors4Fung c#ncerC 'he!t r#diogr#phC 'omputed tomogr#ph%C

creeningC @e#lth economic!

The Author(s) 2015 u$li!hed $% +#i!hideng u$li!hing roup

&nc. (ll right! re!erved.

Core t"4 he u!e of low do!e computed tomogr#ph% *' for lung

c#ncer !creening i! !uperior to the u!e of !t#nd#rd che!t r#diogr#ph

*'J #nd therefore !t#nd#rd 'J !hould not $e u!ed for thi!


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purpo!e. @owever the #pplic#tion of novel computer #!!i!ted

di#gno!i! !oftw#re m#% inDuence the utilit% of 'J #nd m#%

ultim#tel% $e # co!t-eKcient method in tho!e countrie! where

deliver% of low-do!e ' i! not fe#!i$le due to infr#!tructure or co!t!

con!tr#int!.

v#n +ee ;


7/21

$een explored. he!e h#ve m#inl% $een $#!ed #round im#ging u!ing

the che!t r#diogr#ph *'J #nd computed tomogr#ph% *'.

C9R

&n the e#rl% 1980! # lung !creening progr#mme u!ing 4-monthl%

'J! in high ri! p#tient! w#! developed #t the =#%o 'linicNO.

u$ject! !elected were over 4 %e#r! old m#le he#v% !moer!

deBned #! one p#c/d#%. he% were r#ndoml% #!!igned to # control

group *493 p#tient! or repe#ted 'J follow up #t 4 mo interv#l

*4618 p#tient! #fter the% h#d undergone #n initi#l 'J #nd !putumc%tolog% ex#min#tion th#t were $oth norm#l. he follow up !ucce!!

w#! 7M #t 4 mo #nd 92 lung c#ncer! were detected $% 'J *of

which 7 #l!o h#d !putum c%tolog% po!itive Bnding! while 1

p#tient! h#d norm#l 'J with #$norm#l !putum c%tolog% for #n

over#ll incidence of 109 *2.4M. ( !igniBc#nt num$er of the!e lung

c#ncer! were vi!i$le in retro!pect. Eurthermore 2 of the lung

c#ncer were cl#!!iBed #! !t#ge


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improve mort#lit% #dv#nt#ge over p#tient! who were oered #nnu#l

te!tingN7O.

( more recent #ttempt #t u!ing 'J !creening w#! c#rried out in the

ro!t#te Fung 'olorect#l #nd v#ri#n c#ncer !creening tri#lN8O. hi! !tud%

r#ndomi!ed 14901 men #nd women #ged -74 %e#r! to either !t#nd#rd

c#re *7746 or #nnu#l !creening *7744 for four %e#r! during the period

1993-2001. he num$er of lung c#ncer de#th! w#! e5u#l in $oth group!

*1213 vs 1230 with !imil#r !t#ge #nd hi!tolog% of lung c#ncer!.

herefore it w#! concluded th#t #nnu#l 'J !creening doe! not $eneBt

outcome of lung c#ncer mort#lit%.

Erom the!e l#rge !c#le !tudie! #! well #! from the )#tion#l Fung

creening ri#l *)F *!ee $elow it i! concluded th#t the

#pplic#tion of routine #nnu#l che!t r#diogr#ph% for !creening of high-

ri! p#tient! for lung c#ncer #lthough detecting # !igniBc#nt num$er

of lung c#ncer c#!e! i! not $eneBci#l in term! of improvement of

mort#lit%.

CT

he )F comp#red 'J! with computed tomogr#ph% for the

!creening of p#tient! #t high ri! for developing lung c#ncerN9O. =en

#nd women were !elected in the #ge group -74 %e#r! with #

hi!tor% of cig#rette !moing of #t le#!t 30 p#c %e#r! or h#d the!e

expo!ure r#te! $ut h#d 5uit !moing within 1 %e#r!. he !u$ject!

were r#ndomi!ed to either three #nnu#l !creening po!terior-#nterior

'J! *26732 or low-do!e ' *26722. (lmo!t 4-fold higher po!itive

!creening te!t! were o$t#ined with ' *24.2M vs 6.9M with the

f#l!e po!itive r#te !lightl% lower in the 'J! group *94.M vs

96.4M. he incidence of proven lung c#ncer w#! higher in the '

group comp#red to the 'J group *rel#tive ri! 1.13C 9M'&: 1.03-


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1.23. =ore import#ntl% mort#lit% due to lung c#ncer decre#!ed

from 309 de#th! per 100000 per!on-%e#r! in the r#diogr#ph% group

to 247 de#th! from lung c#ncer per 100000 per!on-%e#r! in the low-

do!e ' group # decre#!e of 20M. &n #ddition the ' group

$eneBtted from other di#gno!e! th#t po!itivel% #ected mort#lit%

r#te! with 6.7M fewer p#tient! d%ing in the low-do!e ' group.

&n ;urope !ever#l !tudie! were !t#rted to ev#lu#te the potenti#l

role of low-do!e che!t ' for lung c#ncer !creening. hree !tudie!

did not demon!tr#te # $eneBt of lung c#ncer !creening with ' in

term! of mort#lit% $ut the!e were in!uKcientl% powered to reli#$l%

dr#w !uch conclu!ionN10-12O. here #re # further Bve ongoing !tudie!

th#t #re %et to report on the Bn#l re!ult! $ut !ome will $e #$le to

give #n!wer! to the 5ue!tion whether ' !creening improve!

outcome of lung c#ncer p#tient!N13-17O.

he )ederl#nd!-Feuven! Fong#ner creening nderQoe

*);F) !tud% i! # utch/+elgi#n project which recruited 20000 high-

ri! !u$ject! #nd r#ndomi!ed h#lf of them for low-do!e ' #nd the

other h#lf for 'J !creeningN13O. &t i! the l#rge!t ;urope#n !tud% #nd

h#! !uKcient power to en#$le # !t#tement whether low-do!e '

!creening h#! $eneBt over che!t r#diogr#ph% !creening.

(nother !tud% from '#n#d# h#! reported the Br!t !creening round

re!ult! #nd i! focu!ed on inclu!ion of c%tolog% u!ing

#utoDuore!cence $roncho!cop% #! well #! modelling #ppro#che!

tow#rd! optimi!#tion of predictive v#lue for lung nodule!N18O.

( potenti#l ri! #!!oci#ted with !creening i! the f#l!e po!itive

re!ult! th#t c#n le#d to further inve!tig#tion! #nd #ddition#l co!t!. (

r#ndomiQed controlled tri#l of low-do!e ' vsche!t r#diogr#ph% * n

R 3318 in $oth #rm! #! p#rt of the )F demon!tr#ted # f#l!e-

po!itive r#te of 21M #nd 9M for !ingle low-do!e ' #nd che!t


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r#diogr#ph% !creening re!pectivel%N19O. ( tot#l of 7M of p#rticip#nt!

with # f#l!e-po!itive low-do!e ' ex#min#tion #nd 4M with # f#l!e-

po!itive che!t r#diogr#ph% !u$!e5uentl% underwent #n inv#!ive

procedure.

(nother potenti#l ri! #!!oci#te with lung c#ncer !creening i! the

potenti#l incre#!ed ri! of lifetime c#ncer! #! # re!ult of ioni!ing

r#di#tion. he e!tim#ted ri! of c#ncer from expo!ure to ' ioni!ing

r#di#tion i! reported to $e more when the !creening i! !t#rted e#rlier

in life or on #nnu#l $#!i! #nd in fem#le!. ( !tud% reported #n

e!tim#ted .M incre#!e in lung c#ncer ri! #ttri$ut#$le to #nnu#l

'-rel#ted r#di#tion expo!ure #nd concluded th#t # mort#lit% $eneBt

of con!ider#$l% more th#n M m#% $e nece!!#r% to outweigh the

potenti#l r#di#tion ri!!N20O.

creening progr#m! #re #!!oci#ted with #ddition#l co!t! $oth

from the !creening procedure #nd the follow up intervention!.

reviou! !tudie! reported th#t !creening for lung c#ncer #ppe#red to

$e co!t-eective in high ri! more elderl% popul#tion!N2122O. ther

!tudie! 5ue!tioned the potenti#l co!t eectivene!! of lung c#ncer

!creening. @owever their re!ult! were $#!ed on lower e!tim#ted

eectivene!! of !creening th#n wh#t w#! demon!tr#ted $% the

)FN2324O.

( more recent co!t-utilit% #n#l%!i! of lung c#ncer !creening $% low

do!e ' reported th#t repe#t #nnu#l lung c#ncer !creening in high

ri! #dult! #ged 0-64 w#! highl% co!t-eectiveN2O. he !tud% #l!o

indic#ted th#t oering !moing ce!!#tion intervention! with the

!creening progr#m improved the co!t-eectivene!! of lung c#ncer

!creening $etween 20M-4M.

( contr#r% report w#! pu$li!hed #! p#rt of # he#lth technolog%

#!!e!!ment which !ugge!ted th#t lung c#ncer !creening would not $e


11/21

co!t-eectiveN26O. @owever it !hould $e con!idered th#t thi! report w#!

i!!ued prior to the re!ult! of mo!t of the recent l#rge lung c#ncer !creening

tri#l!.

he l#rge!t #nd mo!t recent !tud% the )F #l!o h#d #n economic

#n#l%!i! #nd co!t-eectivene!! #n#l%!i! performedN27O. hi! !tud%

demon!tr#ted th#t the #ddition#l he#lthc#re co!t! of performing low-

do!e ' !creening would co!t S1631 per per!on with the

increment#l co!t! per life-%e#r g#ined #nd the co!t! per 5u#lit%

#dju!ted life %e#r g#ined coming in #t S2000 #nd S81000

re!pectivel%. &mport#ntl% there w#! 5uite # wide r#nge of life %e#r

g#in! depending on #ge *optim#l #ge r#nge 60-69 %e#r! ri! for

developing lung c#ncer *highe!t ri! group! $eneBtting mo!t #nd

gender *with women $eneBtting le#!t. hi! c#u!ed # r#nge of co!t!

for 5u#lit% #dju!ted life %e#r g#ined #n%where $etween S32000-

S61000. he !tud% did not !how # co!t-eective $eneBt for che!t

r#diogr#ph% !creening.

DISCUSSION

'le#rl% $#!ed on the #$ove !tudie! ' i! !uperior to 'J! for !creening in

lung c#ncer. (lthough the )F #ppe#r! to h#ve #n!wered the 5ue!tion

conclu!ivel% there #re !till ongoing !tudie! th#t m#% inDuence the

m#nner in which !creening will $e #ppro#ched in the future.

igniBc#nt de$#te i! !till ongoing #! to how often we !hould $e

!creening the optim#l popul#tion th#t could $eneBt interpret#tion

of nodule! #void#nce of f#l!e po!itive re!ult! #nd #ppro#che!

including po!itron emi!!ion tomogr#ph%-computed tomogr#ph%

m#gnetic re!on#nce im#ging #nd #utoDuore!cence $roncho!cop%

for in!t#nceN28-34O. =#n% of the!e point! #re !till undergoing

ev#lu#tion #nd future !tud% re!ult! #re e#gerl% #w#ited.


12/21

here #re !ome #ddition#l point! to $e t#en into con!ider#tion

which m#% !till give 'J! # potenti#l role for !creening of lung

c#ncer.

Eir!t 'J! h#ve m#tured from # technic#l per!pective #nd the wide

introduction of digit#l 'J! oer! # new #ppro#ch to #pplic#tion of

computer #!!i!ted di#gno!i! *'(. hu! !ever#l !tudie! h#ve !hown

gre#ter !en!itivit% for lung nodule detection u!ing '( methodologie!

#nd thi! m#% $e of $eneBt when u!ing the te!t #! # !creening te!t N336O.

@owever # conclu!ive !tud% !howing the $eneBt of !creening with che!t

r#diogr#ph% #nd #dded '( h#! not $een performed #nd could $e

import#nt in thi! re!pect.

econd 'J! #re $% f#r the che#per of the two im#ging mod#litie! #nd

more commonl% #v#il#$le. hi! i! #n import#nt i!!ue p#rticul#rl% in

countrie! th#t #re le!! well developed #nd where !moing continue! to $e

on the incre#!e #nd the lung c#ncer epidemic i! on the ri!e. here i! #

high f#l!e neg#tive r#te u!ing the 'J. 'J !creening progr#mme! !hould

$e $#ced up with cro!!-!ection#l im#ging with # low thre!hold in pl#ce for

inve!tig#ting even !m#ll #$norm#litie! detected on the 'J with ' !c#n.

&t m#% not $e fe#!i$le to #rr#nge for l#rge-!c#le !creening u!ing ' #nd in

the!e circum!t#nce! one could con!ider u!ing the 'J.

Ihil!t )F demon!tr#ted th#t $eneBt! from e#rl% detection of

lung c#ncer outweigh! the ri! of ioniQing r#di#tion the potenti#l ri!

i! !u$!t#nti#l. &n )F p#rticip#nt! received #n #ver#ge expo!ure of

8 mv over 3 %e#r! of !creening/di#gno!tic ex#min#tion! which c#n

potenti#ll% c#u!e 1 c#ncer in ever% 200 !creenedN37O. ecentl%

multiple !tudie! h#ve $een inve!tig#ting the fe#!i$ilit% of r#di#tion

do!e reduction to !u$-mv level whil!t the di#gno!tic #ccur#c% i!

m#int#inedN3839O. ince there i! # high contr#!t re!olution $etween #ir

#nd lung nodule! !igniBc#nt r#di#tion do!e reduction c#n $e


13/21

#chieved while m#int#ining good di#gno!tic 5u#lit%. T#riou!

!tr#tegie! !uch #! reduced tu$e volt#ge tu$e current or $oth i!

$eing u!ed. he #pplic#tion of iter#tive recon!truction would

m#int#in !p#ti#l re!olution in low do!e !tudie! whil!t m#int#in

di#gno!tic #ccur#c%N40O.

ver#ll it i! highl% liel% th#t low-do!e ' !creening for p#tient! #t

high ri! for developing lung c#ncer i! # co!t-eective #ppro#ch

which will le#d to improved outcome due to e#rlier detection #nd

tre#tment of thi! highl% leth#l m#lign#nc%. &n countrie! th#t h#ve the

re!ource! #v#il#$le it m#e! !en!e therefore to u!e low-do!e ' #!

# !creening methodolog%. Eor countrie! where Bn#nce! or logi!tic!

render low-do!e ' !creening impo!!i$le to deliver 'J! on #n

#nnu#l $#!i! !hould $e con!idered #nd #ddition#l u!e of '( m#%

improve !en!itivit% for e#rlier le!ion!.

RE,ERENCES

1 C3%er Rese3r%h U8. Fung c#ncer mort#lit% !t#ti!tic!. N#cce!!ed

2013 =#% 11O. (v#il#$le from: F:

http://www.c#ncerre!e#rchu.org/c#ncer-

info/c#ncer!t#t!/t%pe!/lung/mort#lit%/u-lung-c#ncer-mort#lit%-

!t#ti!tic!

2 ISD S%ot/3. &nform#tion #nd t#ti!tic!. Fung c#ncer #nd

me!otheliom#. N#cce!!ed 2013 (ugu!t 7O. (v#il#$le from: F:

http://www.i!d!cotl#nd.org/@e#lth-opic!/'#ncer/'#ncer-

t#ti!tic!/Fung-'#ncer-#nd-=e!otheliom#/

3 Se#e/ R )#i!h#dh#m


14/21

=iettinen . urviv#l of p#tient! with !t#ge & lung c#ncer

detected on ' !creening. N Engl J Med 2006C 755: 1763-1771

N=&: 1706637 &: 10.106/);


15/21

ichter A 'lement!en eer!holm ). he #ni!h r#ndomiQed

lung c#ncer ' !creening tri#l--over#ll de!ign #nd re!ult! of the

prev#lence round. J Thorac Oncol 2009C


16/21

re!ult! of the epi!c#n !tud%: # Erench r#ndomiQed pilot tri#l of

lung c#ncer !creening comp#ring low do!e ' !c#n *F' #nd

che!t J-r#% *'J. !ung Cancer 2007C 5=: 0-8 N=&:

1762447O

1 Lo"es Pe#3 A icoQQi =#!c#lchi = =#ri# '#roQQi E '#rroQQi

F 'omin ' pinelli ' E#l#!chi E r#QQini = &nnocenti E onchi '

#ci ;. e!ign recruitment #nd $#!eline re!ult! of the &(F)

tri#l for lung c#ncer !creening with low-do!e '. !ung Cancer

2009C :


17/21

10.106/);


18/21

#n#l%!i! of lung c#ncer !creening #nd the #ddition#l $eneBt! of

incorpor#ting !moing ce!!#tion intervention!. P!o# One2013C =:

e71379 N=&: 23940744O

26 ./3%; C +#gu!t ( +ol#nd ( I#ler =cFeod ' e Terteuil

(%re!


19/21

v#n oijen = reuter =


20/21

+%er! 'olditQ ( ould =A


21/21

Documents

WJR-Lung Cancer Screening Computed Tomography or Chest Radiographs