Significant Rate of Patients Experience Complications Post-Lung Cancer Screening

Rates of downstream procedures and complications as a result of lung cancer screening occur significantly more often in real-world practice than previously observed in the National Lung Screening Trial (NLST), according to new findings.¹

New data from a retrospective cohort analysis showed the rate of major complications among patients undergoing invasive procedures after abnormal lung cancer screenings was more than 2-fold among patients from any of 5 health care systems compared to NLST. The findings elucidate a heightened need to address the benefit-risk profile of lung cancer screening—a practice that which has previously encountered slow uptake among Americans despite the prevalence of lung cancer.

The NLST enrolled more than 53,000 current or former heavy smokers aged 55 – 74 years old to assess outcomes of low-dose helical computed tomography (CT) versus standard chest X-rays for the detection of lung cancer. Initially published in 2011, the results showed CT scanning was associated with a 20% reduction in mortality from lung cancer compared to standard radiography.²

A team of investigators led by Katharine A. Rendle, PhD, MSW, MPH, of the department of family medicine & community health at Perelman School of Medicine, sought to identify the rates of downstream procedures and complications linked to lung cancer screening using available data from NLST and health network records.¹

“Lung cancer screening using low dose computed tomography reduces lung cancer mortality but can lead to downstream procedures, complications, and other potential harms,” Rendle and colleagues wrote. “Estimates of these events outside NLST have been variable and lacked evaluation by screening result, which allows more direct comparison with trials.”

The team conducted their analysis using individuals who previously completed a baseline low-dose CT scan for lung cancer between 2014 – 2018. They sought outcomes including downstream imaging, invasive diagnostic procedures, and complications from said procedures. Investigators calculated overall and outcome-stratified absolute rates, as well as positive and negative predictive values.

The final analysis included 9266 screened patients; among them, 1472 (15.9%) reported an abnormality based on their low dose CT scan. Of that population, 140 were diagnosed with lung cancer in ≤12 months—indicating a positive predictive value of 9.5% (95% CI, 8.0 – 11.0) and negative predictive value of 99.8% (95% CI, 99.7 – 99.9). Diagnostic sensitivity was 92.7% (95% CI, 88.6 – 96.9) and specificity was 84.4% (95% CI, 83.7 – 85.2).

Rendle and colleagues observed an absolute downstream imaging rate of 31.9%, as well an invasive procedure rate of 2.8%. Among patients who underwent invasive procedures following abnormal low dose CT scans, 30.6% experienced a complication, compared to 17.7% of patients in NLST. The disparity was similarly significant with regard to major complications—20.6% versus 9.4%.

Though the team noted their findings were limited by the retrospective design and reliance on procedural coding, they concluded results suggest a need to re-evaluate the follow-up care among patients undergoing lung cancer screening.

“The results indicate substantially higher rates of downstream procedures and complications associated with lung cancer screening in practice than observed in NLST,” they wrote. “Diagnostic management likely needs to be assessed and improved to ensure that screening benefits outweigh potential harms.”

References

1. ^{Rendle KA, Saia CA, Vachani A, et al. Rates of Downstream Procedures and Complications Associated With Lung Cancer Screening in Routine Clinical Practice : A Retrospective Cohort Study. Ann Intern Med. Published online January 2, 2024. doi:10.7326/M23-0653}
2. ^{National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi:10.1056/NEJMoa1102873}