[China National Lung Cancer Screening Guideline with Low-dose Computed Tomography (2023 Version)]

Risk assessment of persistent incidental pulmonary subsolid nodules to guide appropriate surveillance interval and endpoints

Guidelines for the follow-up of pulmonary subsolid nodule (SSN) vary in terms of frequency and criteria for discontinuation. We aimed to evaluate the growth risk of SSNs and define appropriate follow-up intervals and endpoints. The immediate risk (IR) and cumulative risk (CR) of SSN growth were assessed using the Kaplan-Meier method according to nodule consistency and size. Follow-up plans were proposed based on optimal growth risk threshold of 5%. 892 SSNs, comprising 833 pure ground-glass nodules (pGGNs) and 59 part-solid nodules (PSNs) were included. For pGGNs ≤ 6.6 mm, the CR exceeded 5% at every 3-year interval in the first 9 years. For pGGNs measuring 6.6-8.8 mm and >8.8 mm, the IR remained above 5% for the first 2-7 years, and the 2-year CR for pGGNs measuring 6.6-8.8 mm in the 8th and 9th years achieved 6.66%. For PSNs, the IR peaked in the 4th year (44%) and then declined. Therefore, triennial follow-up for 9 years is recommended for pGGNs ≤ 6.6 mm, annual follow-up for 7 years followed by biennial follow-up for 2 years for pGGNs measuring 6.6-8.8 mm, annual follow-up for 7 years for pGGNs > 8.8 mm, and continuous annual follow-up until nodule growth for PSNs.

Cost-effectiveness of risk model-based lung cancer screening in smokers and nonsmokers in China

BACKGROUND

China bears the largest global burden of lung cancer, with a striking 40% of cases occurring in individuals who have never smoked. While the mortality-reducing benefits of low-dose computed tomography (LDCT) for lung cancer screening are established, the quest for an optimal screening strategy continues, considering the potential adverse effects of LDCT. The Chinese NCC-LCm2021 model was developed based on a nationwide population to identify at-risk individuals among smokers and nonsmokers. However, the cost-effectiveness of this model has yet to be determined.

METHODS

The cost-effectiveness analysis simulates a Chinese birth cohort using a calibrated Markov model based on individual data from a prospective cohort of the Guangzhou Lung Cancer Screening Program. Health utility was extracted from the literature. Cost parameters were obtained from the price of basic medical services in public medical institutions. Our analysis evaluated 236 distinct screening strategies, varying by screening initiation age, risk thresholds, and smoking status. The primary outcomes were quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs).

RESULTS

For smokers, four strategies on the efficiency frontier yielded incremental QALYs ranging from 0.011 to 0.039 compared to no screening, with ICERs ranging from $21,874 to $55,038 when compared to the previous efficient strategies. The optimal strategy was annual screening of smokers aged 45 years and older with a 3-year risk of lung cancer incidence of 0.55%, offering the largest gain in QALYs at a willingness-to-pay (WTP) threshold of $38,224 (three times GDP per capita). This optimal strategy dominated the 2023 Chinese guideline-recommended strategy. For nonsmokers, the strategies on the efficiency frontier yielded incremental QALYs ranging from 0.006 to 0.041 compared to no screening, with ICERs ranging from $26,517 to $37,994 when compared to the previous efficient strategies. Correspondingly, the optimal strategy is annual screening of nonsmokers aged 45 years and older with a 3-year risk of lung cancer incidence of 0.20%.

CONCLUSIONS

This economic evaluation found that lung cancer screening strategies based on the Chinese NCC-LCm2021 model were cost-effective for both smokers and non-smokers in China. Furthermore, tailoring risk thresholds to smokers and nonsmokers can enhance the cost-effectiveness of lung cancer screening.

"I Saw it Incidentally but Frequently": Exploring the Effects of Online Health Information Scanning on Lung Cancer Screening Behaviors Among Chinese Smokers

In China, lung cancer is the most common cancer with high mortality. While prior research suggests that health information scanning influences cancer screening within the general population, a deeper exploration of the underlying mechanisms is imperative. This study specifically targets smokers, aiming to investigate whether online health information scanning can effectively encourage lung cancer screening and elucidate the mechanisms driving this association. Data were extracted from a Chinese national survey conducted between January and September 2023, exclusively involving current smokers (N = 992). A moderated mediation model was employed to examine a cognitive-affective sequential chain of mediation through risk perceptions and cancer worry. Results showed that 99.1% of Chinese smokers reported online health information scanning, which possessed significant influence. Online health information scanning was positively associated with effective lung cancer screening among smokers directly (OR = 1.927, p < .01) and indirectly (OR = .065, p < .001). The perceived threat of smoking and cancer worry served as the cognitive and affective mediating mechanisms. Furthermore, a moderating effect of eHealth literacy was observed (OR = 6.292, p < .05). Smokers with higher eHealth literacy are more inclined to undergo effective lung cancer screening. Based on these findings, public health sectors should leverage online platforms to disseminate tailored cancer screening education and implement initiatives to enhance public eHealth literacy.

Three-dimensional reconstruction for determining positional indications of pulmonary segmentectomy/subsegmentectomy for ground glass opacity-dominant clinical T1a-bN0 non-small cell lung cancer

Background

The precision of segmentectomy/subsegmentectomy for ground glass opacity (GGO)-dominant cT1a-bN0 non-small cell lung cancer (NSCLC), including mono-segmentectomy, mono-subsegmentectomy, combined subsegmentectomies, and single segmentectomy with adjacent subsegmentectomy, has improved. The aim of this study is to investigate their positional indications by focusing on the three-dimensional location of lesions, utilizing three-dimensional computed tomography bronchography and angiography (3D-CTBA).

Methods

We retrospectively analyzed 195 patients with GGO-dominant cT1a-bN0 NSCLC who underwent segmentectomy/subsegmentectomy between August 2015 and November 2020. We included 173 patients: mono-segmentectomy (71, 41.04%), mono-subsegmentectomy (37, 21.39%), combined subsegmentectomies (42, 24.28%), and single segmentectomy with adjacent subsegmentectomy (23,13.29%). Patient demographics and perioperative outcomes were compared among groups to identify positional indications.

Results

Significant differences were observed among the four groups in terms of lobe location of the lesions and their relationships with adjacent intersegmental veins (P<0.001), but not in their diameter and depth (P=0.33; P=0.79). All groups showed similar surgical margins (P=0.77) despite differences in the number of subsegments resected (P<0.001). No perioperative deaths or postoperative recurrences were reported. For lesions located in the middle region, located inter-segmentally, or with a diameter >1 cm, a greater number of subsegments were resected (P=0.02; P<0.001; P=0.003), while the surgical margins were not inferior to those located in the outer region, located intra-segmentally, or with a diameter ≤1 cm (P=0.29; P=0.77; P=0.46).

Conclusions

It is the specific lobe in which lesions are located and their relationship with adjacent intersegmental veins that determine the specific surgical procedure of segmentectomy/subsegmentectomy for GGO-dominant cT1a-bN0 NSCLC, rather than their diameter and depth.

Construction of a risk prediction model for isolated pulmonary nodules 5-15 mm in diameter

Background

Based on current technology, the accuracy of detecting malignancy in solitary pulmonary nodules (SPNs) is limited. This study aimed to establish a malignant risk prediction model for SPNs 5-15 mm in diameter.

Methods

We collected clinical characteristics and imaging features from 317 patients with SPNs 5-15 mm in diameter from the 900th Hospital of the Joint Logistic Support Force as a training cohort and 100 patients with SPNs 5-15 mm in diameter as a validation cohort. Univariate logistic regression analysis, least absolute shrinkage and selection operator (LASSO), and binary logistic regression analysis were used to screen for the independent influencing factors of benign and malignant SPN and to establish a prediction model for benign and malignant SPN with a diameter of 5-15 mm. The model in this study was compared with the Mayo model, Veterans Affairs (VA) model, Brock model, and Peking University People's Hospital (PKUPH) model. Finally, the clinical application value of this model was assessed.

Results

Univariate logistic regression analysis showed that smoking history, nodule diameter, nodule location, nodule density, margin, calcification, lobulation sign, spiculation sign, and vascular cluster sign were statistically significant factors. The results of LASSO and binary logistic regression analysis showed that smoking history, nodule diameter, nodule density, margin, lobulation sign, and vascular cluster sign were independent influencing factors of SPNs. The prediction model was successfully constructed and demonstrated a good predictive performance, with an area under the curve (AUC) value of 0.814 [95% confidence interval (CI): 0.768-0.861; P<0.001] in the training cohort and 0.864 (95% CI: 0.794-0.934; P<0.001) in the validation cohort. This model was shown to be highly accurate in predicting malignant SPNs and thus has a high clinical application value. Compared with previously described prediction models, including the Mayo model, VA model, Brock model, and PKUPH model, the proposed model demonstrated a significantly superior predictive ability.

Conclusions

The prediction model developed in this study can be used as an early screening method for SPNs 5-15 mm in diameter.

Plasma nicotine and its metabolite as biomarkers of tobacco exposure and their relevance to pulmonary nodule

Aim: Explore the optimal cut-off values for plasma nicotine and its metabolites in assessing smoking status and quantify the association between individual tobacco exposure and pulmonary nodules (PNs).Materials & methods: A total of 2245 plasma samples were included for the determination of nicotine (Nic), cotinine (Cot) and trans-3'-hydroxycotinine (OHCot) concentrations. The receiver operating characteristic curve was used to determine the optimal biomarkers reflecting smoking status. Binary logistic regression, restricted cubic spline and generalized linear model were used to analyze the association of nicotine and its metabolites with PNs. Quantile g-computation was used to investigate the mixed effects between them.Results: Cot was found to be the best biomarker of self-reported active-passive smoking, with optimal thresholds of 9.06 and 1.26 ng/ml, respectively. Except for OHCot, increased concentrations of Cot, Nic, total nicotine equivalent (TNE2) and TNE3 were significantly positively associated with the risk of PNs, whereas nicotine metabolite ratio presented a negative association. The mixed effects of OHCot, Cot and Nic were associated with PNs, with an odds ratio of 1.17 and a 95% CI of 1.05-1.30.Conclusion: Nicotine and its metabolites as potential biomarkers of tobacco exposure were significantly associated with PNs.

Early cancer screening surveillance in one medical center of China

Objectives

Cancer screening aims to detect and treat malignant lesions at an early stage and to prolong patients' lifetime. There is still a lack of effective cancer screening programs in China. We initiated a screening project in 2018 and this study presented the cancer screening status in China.

Methods

We conducted a cross-sectional study in one cancer-care medical center of China. The screening program included routine blood tests, plasma tumor markers, gastric endoscopy, colonoscopy, ultrasound, and computed tomography (CT) scans. Screening results were presented as sensitivity, specificity and positive predictive values (PPVs).

Results

Twenty-three (1.46%) out of 1,576 participants were eventually diagnosed with malignant tumors or high-grade intraepithelial neoplasia (HGIN). A family history of malignancy (78.26% in diagnosed cancer and HGIN vs. 46.36% in the others) was the only statistically significant parameter associated with cancer detection (p = 0.002). None of the common tumor markers were associated with the cancers screened. Except for colonoscopy (50.00%) and ultrasound for renal cancer (66.67%), the sensitivities of most screening methods were 100%. The specificities of all the screening means were above 96%. Most PPVs ranged from 30-60%.

Conclusion

We emphasized risk stratification for early cancer screening, such as a family history of cancer. The survey illustrated that gastric endoscopy, colonoscopy, ultrasound, and lung CT for early cancer screening had high specificity, reasonable sensitivity, and PPV. We anticipated this report would motivate larger-sample studies to estimate the risk-to-benefit ratio of cancer screening and urge the establishment of a native Chinese screening project and even guidelines.

Smoking, mortality, access to diagnosis, and treatment of lung cancer in Brazil

INTRODUCTION

Lung cancer (LC) is a relevant public health problem in Brazil and worldwide, given its high incidence and mortality. Thus, the objective of this study is to analyze the distribution of smoking and smoking status according to sociodemographic characteristics and disparities in access, treatment, and mortality due to LC in Brazil in 2013 and 2019.

METHOD

Retrospective study of triangulation of national data sources: a) analysis of the distribution of smoking, based on the National Survey of Health (PNS); b) investigation of LC records via Hospital-based Cancer Registry (HCR); and c) distribution of mortality due to LC in the Mortality Information System (SIM).

RESULTS

There was a decrease in the percentage of people who had never smoked from 2013 (68.5%) to 2019 (60.2%) and in smoking history (pack-years). This was observed to be greater in men, people of older age groups, and those with less education. Concerning patients registered in the HCR, entry into the healthcare service occurs at the age of 50, and only 19% have never smoked. While smokers in the population are mainly Mixed-race, patients in the HCR are primarily White. As for the initial stage (I and II), it is more common in White people and people who have never smoked. The mortality rate varied from 1.00 for people with higher education to 3.36 for people without education. Furthermore, White people have a mortality rate three times higher than that of Black and mixed-race people.

CONCLUSION

This article highlighted relevant sociodemographic disparities in access to LC diagnosis, treatment, and mortality. Therefore, the recommendation is to strengthen the Population-Based Cancer Registry and develop and implement a nationwide LC screening strategy in Brazil since combined prevention and early diagnosis strategies work better in controlling mortality from the disease and continued investment in tobacco prevention and control policies.

LDCT screening results among eligible and ineligible screening candidates in preventive health check-ups population: a real world study in West China

To compare the LDCT screening results between eligible and ineligible screening candidates in preventive health check-ups population. Using a real-world LDCT screening results among people who took yearly health check-up in health management center of West China Hospital between 2006 and 2017. Objects were classified according to the China National Lung Cancer Screening Guideline with Low-dose Computed Tomography (2018 version) eligibility criteria. Descriptive analysis were performed between eligible and ineligible screening candidates. The proportion of ineligible screening candidates was 64.13% (10,259), and among them there were 4005 (39.04%) subjects with positive screenings, 80 cases had a surgical lung biopsy. Pathology results from lung biopsy revealed 154 cancers (true-positive) and 26 benign results (false-positive), the surgical false-positive biopsy rate was 4.17%, and ineligible group (7.69%) was higher than eligible group (2.47%), P < 0.05. Further, in ineligible screening candidates, the proportion of current smokers was higher among males compared to females (53.85% vs. 4.88%, P < 0.05). Of the 69 lung cancer patients detected in ineligible screening candidates, lung adenocarcinoma accounts for a high proportion of lung cancers both in male (75.00%) and female (85.00%). The proportion of ineligible screening candidates and the surgical false-positive biopsy rate in ineligible candidates were both high in health check-ups population.

[Effectiveness Evaluation of Low-dose Spiral Computed Tomography for Lung Cancer Screening in Minhang District of Shanghai]

BACKGROUND

Low-dose spiral computed tomography (LDCT) has been recommended for lung cancer screening in high-risk populations. However, evidence from Chinese populations was limited due to the different criteria for high-risk populations and the short-term follow-up period. This study aimed to evaluate the effectiveness in Chinese adults based on the Lung Cancer Screening Program in Minhang District of Shanghai initiated in 2013.

METHODS

A total of 26,124 subjects aged 40 years or above were enrolled in the Lung Cancer Screening Program during the period of 2013 and 2017. Results of LDCT examination, and screen-detected cancer cases in all participants were obtained from the Reporting System of the Lung Cancer Screening Program. The newly-diagnosed cases and their vital status up to December 31, 2020 were identified through a record linkage with the Shanghai Cancer Registry and the Shanghai Vital Statistics. Standardized incidence ratio (SIR) and 95%CI were calculated using the local population at ages of 40 or above as the reference. Proportions of early-stage cancer (stage 0-I), pathological types, and 5-year observed survival rates of lung cancer cases were estimated and compared between the cases derived from the screened and non-screened populations. Cox regression models were applied to evaluate the hazard ratio (HR) and 95%CI of LDCT screening with all-cause death of the lung cancer cases.

RESULTS

The crude and age-standardized incidence of lung cancer in screened population were 373.3 (95%CI: 343.1-406.1) and 70.3 per 100,000 person-years, respectively, with an SIR of 1.8 (95%CI: 1.6-1.9), which was observed to decrease with following-up time. The early-stage cancer accounted for 49.4% of all lung cancer cases derived from the screened population, significantly higher than 38.4% in cases from the non-screened population during the same period (P<0.05). The proportion of lung adenocarcinoma (40.7% vs 35.9%) and 5-year survival rate (53.7% vs 41.5%) were also significantly higher in the cases from the screened population (all P<0.05). LDCT screening was associated with 30% (HR=0.7, 95%CI: 0.6-0.8) reduced all-cause deaths of the cases.

CONCLUSIONS

The participants of the screening program are at high-risk of lung cancer. LDCT favors the early-detection of lung cancer and improves 5-year survival of the screened cases, indicating a great potential of LDCT in reducing the disease burden of lung cancer in Chinese populations.