By Jeff Elton, PhD, CEO, ConcertAI

While lung cancer treatment options have expanded substantially over the last 10 to 15 years with the advent of immunotherapies and targeted agents, the earlier a cancer is detected, the more likely there will be a positive outcome from treatment. Unfortunately, more than two thirds of patients with lung cancer are diagnosed with symptoms when the disease is advanced, and even with improved treatment options, patients diagnosed with metastatic disease still have poor overall survival. For cancers of the breast, cervix, and colon/rectum, screening of asymptomatic individuals through mammography, Pap smear, and colonoscopy (and other modalities), respectively, has been standard practice and part of guidelines for many years, to improve early detection and decrease mortality. Likewise, lung cancer screening with low-dose CT scanning in high-risk individuals (ex- and current smokers) was shown to decrease lung cancer mortality in the landmark NLST trial published in 2011 and in a more recent European study and has been incorporated into guideline recommendations from several organizations. Therefore, optimizing lung cancer screening is essential to improve survival rates from this disease. Today, lung cancer screening is available and reimbursed for an ever-larger proportion of the at-risk population, including eligible Medicare beneficiaries since 2015. However, adherence rates to screening recommendations in the at-risk US population are much lower than those reported in the randomized trials, and consequently far fewer individuals who might benefit from screening using low-dose CT scanning actually undergo the procedure.

Recently, a research letter in JAMA Network Open by Henderson et al provides a timely update on the current status of CT screening for lung cancer. The authors identified the prevalence of lung cancer screening in the United States in 2022 using CDC survey data measured against 2 sets of U.S. Preventive Services Task Force (USPSTF) recommendations for screening eligibility, the original 2013 recommendations and the more stringent revisions from 2021. The USPSTF 2013 guidelines recommended annual lung cancer CT screening for individuals aged 55 to 80 years who currently smoke and have a 30 pack-year smoking history or have quit within the past 15 years. The 2021 guidelines recommended annual screening beginning at age 50 years with a 20 pack-year history, therefore increasing the population of eligible individuals. The changes were made for a number of reasons, but especially to equalize access to screening based on differential risks by race/ethnicity and sex. What is of note for the study is that it was highly representative of populations in all 50 states and for those eligible for screening according to the current and previous guidelines. The authors found that in 2022, the lung cancer screening-eligible population was 13,526,348 individuals based on 2021 criteria and 8,154,440 using 2013 criteria, an increase of 66% in the eligible population. Positively, the change in eligibility criteria led to the greatest increases in eligibility among Asian, Black, and Hispanic individuals. Also, the number of eligible females increased by 78%, compared with 57% for males. In 2022, per 2021 criteria, 16.4% of eligible individuals were screened. In 2022, per 2013 criteria, 19.6% were screened. So, while approximately 619,054 newly eligible individuals were screened under expanded recommendations, it is still only a small proportion of the total population that is eligible and a smaller proportion of the population for the 2021 criteria vs. the 2013 criteria. In other words, we are not screening to the level of established risk, and there remain inequalities in who gets access to screening. For example, the highest proportion of individuals being screened lived in the Northeast and Mid-Atlantic regions, areas with a higher density of healthcare resources and access to CT screening centers, whereas screening was much less likely to occur in states such as New Mexico or Wyoming.

Screening is important, and it simply saves lives. Screening has also gotten safer. Low-dose CT screening has been demonstrated to identify the more frequent adenocarcinomas and squamous cell carcinomas at early stages. Moreover, the potential impact of screening on lung cancer mortality should be compared to notable recent advances in lung cancer management, including the following:

• Recent clinical trials have shown that for certain people with early-stage non-small cell lung cancer (NSCLC), removing a piece of the affected lobe is as effective as surgery to remove the whole lobe, an approach termed lung-sparing surgery. 
• Target therapeutics, such as osimertinib (Tagrisso),  given as an adjuvant therapy to people with early-stage NSCLC that has certain mutations in the EGFR gene can provide very positive outcomes.
• The immunotherapy drugs, atezolizumab (Tecentriq)and pembrolizumab (Keytruda) are also approved as adjuvant treatments after surgery and chemotherapy, for specific patient populations with early-stage NSCLC. 
• The immunotherapy therapeutic nivolumab (Opdivo) together with chemotherapy, can be used to treat early-stage lung cancer before surgery as a neoadjuvant. The CheckMate 816 trial showed that patients receiving neoadjuvant nivolumab plus chemotherapy were more likely to have a pathological complete response (no viable tumor in resected lung and lymph nodes) than those receiving chemotherapy alone. 
• In the trial KEYNOTE-671, patients with early-stage NSCLC receiving pembrolizumab plus chemotherapy before surgery and pembrolizumab after surgery had improved outcomes versus neoadjuvant or adjuvant treatments alone.  

All of this is to say that, while these advances in lung cancer treatment are important and certainly improve outcomes, an earlier diagnosis achieved through screening can also save lives and likely improves the quality of life after surgery and treatment.

What can be done to further improve the success of lung cancer screening and enable more individuals at risk to undergo screening? ConcertAI’s TeraRecon is a mainstay of cancer screening programs, used by thousands of radiologists around the world for CT interpretation and measurement. ConcertAI is dedicated to advancing high throughput and highly accessible screening approaches. Working with companies such as Riverrain (to detect lung nodules found in radiology scans, and quantify temporal changes in nodule size), and Optellum (which helps guide clinicians in the context of their nodule clinics through an FDA-approved radiomics-based AI algorithm), ConcertAI’s TeraRecon makes AI screening and intervention accessible at 1,000s of location. The combined solution is unique and assists clinicians in detecting at-risk patients across a health system and prioritization of those at highest risk for follow-up interventions. The integration of Virtual Nodule Clinic with the TeraRecon platform supports thoracic oncology care teams to identify and track more patients, with accelerated time to a confirmatory cancer diagnosis while reducing invasive procedures.

This is but one example of how we can assure that the U.S. Preventive Services Task Force guidelines are put into practice. It is ethical, responsible, and economic to do so.