The U.S. Preventive Services Task Force (USPSTF) guidelines for lung cancer screening (released in December 2013) recommend that adults aged 55-80 years who smoke 30 packs per year and who are current smokers or have quit for less than 15 years receive annual low-dose CT screening. More than 8 million U.S. adults meet this criterion. However, the benefits of a once-per-year screening strategy must be weighed against the risks, which include potential overdiagnosis, a high incidence of false-positive results, and increased radiation exposure. Some investigators have also questioned the feasibility of guidelines based on clinical trial results in clinical practice. In this article, HemOnc Today outlines the USPSTF guidelines, the benefit/harm of annual screening for lung cancer, further optimization and the need for consensus on various treatment guidelines. 1, Following the American Cancer Society, the National Comprehensive Cancer Network, the American Lung Association and several other organizations, the USPSTF has introduced updated recommendations for lung cancer screening with some form of low-dose CT. 2, The USPSTF guidelines are based on the results of the U.S. National Lung Cancer Screening Trial, which involved 53,454 adults aged 55-74 years at high risk for lung cancer, with subjects divided into an annual low-dose CT screening group or a chest X-ray group. The results showed that there were 247 lung cancer deaths/100,000 person-years in the CT group and 309 lung cancer deaths/100,000 person-years in the X-ray screening group. The study was calculated to obtain the information that low-dose CT screening can reduce lung cancer mortality by 20%. 3, A 2013 paper published in the journal Cancer showed that if a similar screening method were implemented in screening-eligible U.S. adults (estimated at 8.6 million people), the number of lung cancer deaths potentially saved would be about 12,250 per year. 4. USPSTF’s recommendation would allow payable third-party payer insurance coverage under the Affordable Care Act (ACA) as a required insurance coverage benefit, which in turn would be reviewed by the Medicare Evidence Development & Coverage Advisory Committee as a CMS insurance coverage decision. 5. The National Comprehensive Cancer Network guidelines recommend screening for people who are younger (50 years old) and have risk factors other than smoking (mainly from statistical modeling studies, such as radon exposure, occupational exposure, and family history of lung cancer). Because of the potential harms of CT, the American Academy of Family Physicians has determined that “there is insufficient evidence to recommend or oppose lung cancer screening. However, a study involving 962 primary care physicians and general internists between 2006 and 2007 showed that primary care physicians “frequently prescribe lung cancer screening tests to asymptomatic patients.” The results showed that 55% of physicians prescribed chest X-rays, 22% prescribed low-dose spiral CT, and less than 5% prescribed sputum cytology. 7. As part of the USPSTF review, a modeling study evaluated the results showing an overdiagnosis rate of 10-12%, suggesting that the screened nodules posed absolutely no threat. However, an analysis of data from the National Lung Cancer Screening Trial showed a higher incidence of overdiagnosis calculated from estimates derived from approximately 7 years of follow-up. The results showed that 18.5% of any lung cancer cases detected by low-dose CT were overdiagnosed, with an overdiagnosis risk of 22.5% for non-small cell lung cancer and 78.9% for bronchoalveolar cell carcinoma. 8. The most widely used guideline in the field of radiology is the Fleischner guideline, which determines that patients at high risk for lung nodules should undergo repeat CT if the nodule diameter is >4 mm (threshold). This threshold is also used by investigators of the National Lung Cancer Screening Trial for nodules initially classified as positive “suspected” lung cancer. However, a radiology guideline being developed by the American College of Radiology and expected to be released in 2014 increases this threshold to 6 mm. The guideline, named LungRADS, includes a structured reporting and management tool for radiologists (similar to the BI-RADS for mammography). 9. The USPSTF guidelines recommend that the decision to initiate screening should be based on a full discussion of the possible benefits, limitations, and results of known and uncertain harms. The ACS guidelines for lung cancer screening emphasize the need for patient-physician communication more than the USPSTF guideline recommendations. The guidelines state that clinicians and treatment centers that are in a position to perform a large number of high-quality lung cancer screenings should discuss screening strategies with eligible patients, rather than recommending screening strategies unilaterally for all patients who meet high-risk criteria. The American Lung Association’s guidelines also emphasize informed decision-making, recommending that “the choice of lung cancer screening should be individualized and that the American Lung Association should ensure that each patient has adequate information to make a decision.