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New lung cancer guidelines oppose general CT screening

September 11, 2007

New evidenced-based guidelines from the American College of Chest Physicians (ACCP) recommend against the use of low-dose computed tomography (LDCT) for the general screening of lung cancer. Published as a supplement to the September issue of CHEST, the peer-reviewed journal of the ACCP, the guidelines cite there is little evidence to show lung cancer screening impacts mortality in patients, including those who are considered at high risk for the disease. The guidelines also recommend against the use of vitamin or mineral supplements for the prevention of lung cancer, for these do little to decrease the risk of lung cancer, while beta-carotene has been associated with increased risk of lung cancer.

"Even in high risk populations, currently available research data do not show that lung cancer screening alters mortality outcomes," said W. Michael Alberts, MD, FCCP, chair of the ACCP lung cancer guidelines and Chief Medical Officer, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL. "We hope that one day, we can find a useful and accurate tool for general lung cancer screening, but, at this time, the evidence does not support the use of LDCT screening."

In its second edition, Diagnosis and Management of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) provides 260 of the most comprehensive recommendations related to lung cancer prevention, screening, diagnosis, staging, and medical and surgical treatments. The guidelines also review complementary and integrative therapy for the prevention and treatment of lung cancer.

SCREENING

Due to the lack of supporting evidence, the guidelines recommend against the use of LDCT, chest radiographs, or single or serial sputum cytologic evaluation for lung cancer screening in the general population, including smokers or others at high risk, except in the context of a well-designed clinical trial.

"Population screening for lung cancer is not recommended and may, ultimately, put the patient at risk for further complications," said Gene L. Colice, MD, FCCP, vice chair of the ACCP lung cancer guidelines and Director, Pulmonary, Critical Care, and Respiratory Services, Washington Hospital Center, Washington, DC. "Nodules are commonly found during screening; however, to determine whether they are cancerous requires additional testing, which is fairly invasive and extensive. This may cause the patient needless risk, both physically and psychologically."

PREVENTION

The guidelines also recommend against the preventive use of several of the following common supplements and medications in at-risk patients or those with a history of lung cancer: Beta-carotene - The guidelines strongly recommend against the use of beta-carotene supplements for primary, secondary, or tertiary prevention, citing the higher incidence of lung cancer among those who use the supplement.

Vitamin A - The guidelines strongly recommend against the use of retinoids (vitamin A), including isotretinoin, for they have not been shown to decrease the incidence of second tumors and could increase mortality among current smokers.

Vitamin E - Vitamin E is not recommended for lung cancer prevention, as studies show no difference in the incidence of lung cancer among those taking vitamin E compared with those not taking it.

Aspirin - Although some literature suggests that aspirin may play a protective role regarding cancer, the guidelines do not recommend aspirin for the prevention of lung cancer, as studies show that aspirin does not decrease the risk of lung cancer or death due to lung cancer.

INTEGRATIVE THERAPY

For the first time, the ACCP lung cancer guidelines have included recommendations on mind-body modalities as part of a multimodality approach to reduce the anxiety, mood disturbances, and chronic pain associated with lung cancer. Massage therapy is recommended for patients who are experiencing anxiety or pain, while acupuncture is recommended for patients experiencing fatigue, dyspnea, chemo-induced neuropathy, or in cases where pain or nausea/vomiting is poorly controlled. Electrostimulation wristbands are not recommended for managing chemo-induced nausea/vomiting, as studies show that they do little to delay nausea/vomiting compared with placebo.

The recommendations were rigorously developed and reviewed by 100 multidisciplinary panel members, including pulmonologists, medical oncologists, radiation oncologists, thoracic surgeons, integrative medicine specialists, oncology nurses, pathologists, health-care researchers, and epidemiologists. The guidelines were further reviewed and approved by the ACCP Thoracic Oncology NetWork, the Health and Science Policy Committee, the Board of Regents, and external reviewers from the journal CHEST. The guidelines have been endorsed by the American Association for Bronchology, American Association for Thoracic Surgery, American College of Surgeons Oncology Group, American Society for Therapeutic Radiology and Oncology, Asian Pacific Society of Respirology, Oncology Nurses Society, Society of Thoracic Surgeons, and the World Association of Bronchology.

Lung cancer continues to be the leading cause of cancer deaths in men and women in the United States, causing more deaths than the next four most common cancers combined, including colon, breast, pancreas, and prostate. Thirty-one percent of cancer deaths in men are attributable to lung cancer, while the number is slightly lower at 26% in women. However, if current trends continue, the incidence of lung cancer will be identical for men and women during the next decade.

"Each year, great strides are made in the diagnosis and treatment of lung cancer, allowing patients with the disease to live longer and increase the quality of their lives. However, the real culprit behind lung cancer is tobacco," said Mark J. Rosen, MD, FCCP, President of the American College of Chest Physicians. "Avoiding tobacco is the key to preventing most forms of lung cancer. Until we eliminate tobacco use completely, we will continue to deal with its devastating health consequences."

American College of Chest Physicians

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