An analysis of the US National Lung Screening Trial (NLST) has found that the presence of certain types of abnormalities in regions outside of the lungs on low-dose computed tomography (LDCT) images may be associated with a significantly increased risk for extrapulmonary cancer.
The abnormalities, termed significant incidental findings (SIFs), could help clinicians decide when follow-up care is likely to catch extrapulmonary cancer early and when it may not be necessary.
“In this paper, we provide an evidence base for making decisions on abnormalities outside of the lungs that might be seen at lung screening,” said study author Ilana Gareen, PhD, a professor of epidemiology at Brown University School of Public Health. “The goal is to give physicians and patients better data so that they can make more informed choices about those abnormalities that should be considered for follow-up and those that most likely can be ignored.”
Writing in JAMA Network Open, Gareen and co-authors explain that LDCT lung cancer screening frequently detects SIFs unrelated to lung cancer; in the NLST, 34% of 26,455 patients screened with LDCT had SIFs reported but the nature of the SIFs varied.
And although there are recommendations for reporting and addressing SIFs, there is limited evidence for an association between SIFs detected at LDCT lung cancer screening and extrapulmonary cancer diagnoses.
To address this, Gareen and team analyzed data from 75,104 LDCT screening rounds performed in 26,445 individuals (mean age, 61 years; 59.0% men) who were randomly assigned to receive LDCT during the NSLT. The participants had a history of heavy smoking (≥30 pack–years), meaning they are also at high risk for several extrapulmonary cancers, including pancreatic, bladder, and kidney cancer.
The researchers focused on SIFs that were labelled as potentially indicative of extrapulmonary cancer (cancer SIF), rather than those that possibly indicated emphysema or cardiovascular disease.
They report that cancer SIFs were recorded for 2265 (3.0%) screening rounds in 1807 (6.8%) participants across the three screening rounds they received.
Participants with cancer SIFs were significantly older than those with no cancer SIF (mean 62.1 vs. 61.4 years) and significantly more likely to have a history of a smoking-related disease (68.6 vs. 65.7%).
Within one year of a screening round, 1025 participants were diagnosed with an extrapulmonary cancer. Of these, 67 (6.5%) had a SIF on LDCT. This corresponds to 3.0% of participants with a cancer SIF.
Overall, the risk for extrapulmonary cancer among the people with a cancer SIF was 29.6 per 1000 screening rounds compared with 13.3 per 1000 screening rounds in those without a cancer SIF. After adjustment for potential confounders, the marginal risk difference between the two groups was 13.9 per 1000 participants, suggesting that for every 1000 people screened, the presence of a cancer SIF is associated with 13.9 additional cases of extrapulmonary cancer.
When the researchers looked at specific cancer types, they found that the marginal risk difference was substantially higher for urinary cancers, at 17.0 per 1000 participants. It was 5.0 for digestive cancer, 12.3 for breast cancer, and 13.8 for other cancers including lymphoma and leukemia.
“In general, if an abnormality is found that might indicate cancer, the patient receives additional imaging to evaluate that abnormality,” Gareen told Inside Precision Medicine. “Our paper provides additional information as to those abnormalities that should be considered to increase the risk of a cancer diagnosis.”
Importantly, mortality from extrapulmonary cancer accounted for 22.3% of the certified deaths in the LDCT arm of the NLST. Therefore “early detection of these cancers may facilitate early treatment and potentially reduce associated morbidity and mortality,” the authors write. “Identification of cancer SIFs associated with extrapulmonary cancers in NLST participants could be used to plan appropriate diagnostic evaluations for patients undergoing lung cancer screening.”
Gareen said the next step will be to determine if the findings are replicated in lung screening in the community, or if the rate in community screening is higher or lower.
In accompanying comment, Patrick Senior and Andrew Creamer, both from Gloucestershire Hospitals NHS Foundation Trust, in Gloucester, United Kingdom, point out that the false positive rate for a cancer SIF was 97% but say “it is hard to imagine a scenario in which an incidental finding with even a possibility of representing cancer would be disregarded.”
However, they note that “when considered in the context of the numbers of people eligible for lung cancer screening programs around the world, acting on such findings poses a considerable additional burden on the health systems that must investigate them.”
Senior and Creamer say that the results “underscore the importance of both a robust health economics analysis of how screening programs manage such incidental findings and patient-centered research to understand the impact that such unexpected results may have on the individual. Further research is needed to ensure that screening programs are confident when faced with information they did not ask for.”
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