School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.
Respirology. 2020 Nov;25 Suppl 2:5-23. doi: 10.1111/resp.13963.
Lung cancer is the number one cause of cancer death worldwide. The benefits of lung cancer screening to reduce mortality and detect early-stage disease are no longer in any doubt based on the results of two landmark trials using LDCT. Lung cancer screening has been implemented in the US and South Korea and is under consideration by other communities. Successful translation of demonstrated research outcomes into the routine clinical setting requires careful implementation and co-ordinated input from multiple stakeholders. Implementation aspects may be specific to different healthcare settings. Important knowledge gaps remain, which must be addressed in order to optimize screening benefits and minimize screening harms. Lung cancer screening differs from all other cancer screening programmes as lung cancer risk is driven by smoking, a highly stigmatized behaviour. Stigma, along with other factors, can impact smokers' engagement with screening, meaning that smokers are generally 'hard to reach'. This review considers critical points along the patient journey. The first steps include selecting a risk threshold at which to screen, successfully engaging the target population and maximizing screening uptake. We review barriers to smoker engagement in lung and other cancer screening programmes. Recruitment strategies used in trials and real-world (clinical) programmes and associated screening uptake are reviewed. To aid cross-study comparisons, we propose a standardized nomenclature for recording and calculating recruitment outcomes. Once participants have engaged with the screening programme, we discuss programme components that are critical to maximize net benefit. A whole-of-programme approach is required including a standardized and multidisciplinary approach to pulmonary nodule management, incorporating probabilistic nodule risk assessment and longitudinal volumetric analysis, to reduce unnecessary downstream investigations and surgery; the integration of smoking cessation; and identification and intervention for other tobacco related diseases, such as coronary artery calcification and chronic obstructive pulmonary disease. National support, integrated with tobacco control programmes, and with appropriate funding, accreditation, data collection, quality assurance and reporting mechanisms will enhance lung cancer screening programme success and reduce the risks associated with opportunistic, ad hoc screening. Finally, implementation research must play a greater role in informing policy change about targeted LDCT screening programmes.
肺癌是全球癌症死亡的首要原因。基于两项使用低剂量计算机断层扫描（LDCT）的标志性试验结果，肺癌筛查可降低死亡率并早期发现疾病，其益处已毋庸置疑。肺癌筛查已在美国和韩国实施，并正在被其他社区考虑。成功地将已证实的研究成果转化为常规临床实践需要来自多个利益相关者的精心实施和协调投入。实施方面可能因不同的医疗保健环境而异。为了优化筛查效益并最小化筛查危害，仍存在重要的知识空白需要解决。肺癌筛查与所有其他癌症筛查计划不同，因为肺癌风险由吸烟这一高度污名化的行为驱动。污名化以及其他因素可能会影响吸烟者对筛查的参与度，这意味着吸烟者通常“难以接触”。本综述考虑了患者旅程中的关键要点。第一步包括选择筛查的风险阈值，成功吸引目标人群并最大限度地提高筛查参与率。我们回顾了吸烟者参与肺癌和其他癌症筛查计划的障碍。综述了试验和真实世界（临床）计划中使用的招募策略以及相关的筛查参与率。为了便于跨研究比较，我们提出了一种用于记录和计算招募结果的标准化命名法。一旦参与者参与了筛查计划，我们将讨论对最大限度地提高净效益至关重要的计划组成部分。需要采用全计划方法，包括对肺结节管理进行标准化和多学科方法，结合概率性结节风险评估和纵向体积分析，以减少不必要的下游检查和手术；纳入戒烟；以及识别和干预其他与烟草相关的疾病，如冠状动脉钙化和慢性阻塞性肺疾病。国家支持与烟草控制计划相结合，并提供适当的资金、认证、数据收集、质量保证和报告机制，将增强肺癌筛查计划的成功，并降低机会性、临时筛查相关的风险。最后，实施研究必须在为有针对性的 LDCT 筛查计划的政策变化提供信息方面发挥更大的作用。
