• Palda VA, Van Spall HGC. Screening for lung cancer: updated recommendations from the Canadian Task Force on Preventive Health Care. London (ON): Canadian Task Force on Preventive Health Care (CTFPHC); 2003 Aug. 22 p. [28 references]

Lung cancer

Prevention
Screening

Family Practice
Internal Medicine
Oncology
Preventive Medicine
Pulmonary Medicine
Radiology

Advanced Practice Nurses
Allied Health Personnel
Physician Assistants
Physicians

• To update the 1994 recommendations of the Canadian Task Force of Preventive Health care for lung cancer screening
• To make recommendations on the effectiveness of chest radiographic examination and spiral computed tomography (CT) for lung cancer screening in asymptomatic patients

Asymptomatic adults with a history of smoking with no previous history of lung cancer

Screening for Lung Cancer

1. Chest x-ray
2. Spiral computed tomography (CT) scan

• Mortality from lung cancer (primary outcome)
• Rate of lung cancer detection
• Rate of false positive and false negative screening results

Searches of Electronic Databases

The MEDLINE and Cochrane databases were searched for articles indexed under the Medical Subject Headings "lung neoplasms", "mass screening", "case-control studies", "tomography, x-ray computed", and/or "diagnosis". The text words "helical CT", "low-dose CT", or "spiral CT" were also used as to identify relevant publications. The search was limited to controlled trials or diagnostic studies involving adult human subjects and published in the English language between the years 1990 and July 2002.

The two principal authors independently reviewed all articles. Publications that were not relevant to lung cancer screening or diagnosis were excluded from further consideration. Also excluded were review articles, case-cohort studies, retrospective autopsy-based studies, and cost-effective analyses. Radiologic studies that were done for purposes other than screening for or diagnosing lung cancer were excluded. Finally, studies that investigated the technical aspects of computed tomography as they relate to lung cancer screening were excluded.

The Cochrane database search generated one relevant article for review. The MEDLINE search identified 2 updates of randomized controlled trials not captured by the Cochrane review as well as 5 case-control studies of lung cancer screening, all from Japan. Lastly, 3 studies of computed tomography scanning as a screening test were identified. Some of these were serial publications of the same subjects. All studies retrieved are summarized in Table 1 of the original guideline document.

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Research Design Rating

I: Evidence from randomized controlled trials (RCT)

II-1: Evidence from controlled trials without randomization

II-2: Evidence from cohort or case-control analytic studies, preferably from more than 1 centre or research group

II-3: Evidence from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments could also be included here

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Quality (Internal Validity) Rating

Good: A study that meets all design-specific criteria* well

Fair: A study that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw"

Poor: A study that has at least one design-specific* "fatal flaw," or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations

*General design-specific criteria are outlined in Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D. Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. Am J Prev Med 2001;20(suppl 3):21-35.

Systematic Review with Evidence Tables

Not stated

Expert Consensus

Critical Appraisal

Members of the Canadian Task Force reviewed 1) the initial analytic framework and key questions for the proposed review; 2) the subsequent draft(s) of the complete manuscript providing critical appraisal of the evidence prepared by the lead author(s), including identification and critical appraisal of key studies, and ratings of the quality of this evidence using the task force's established methodological hierarchy, and 3) a summary of the evidence and proposed recommendations.

Consensus Development

Evidence for this topic was presented by the lead author(s) and deliberated upon during a task force meeting in October 2002. Expert panelists addressed critical issues, clarified ambiguous concepts, and analyzed the synthesis of the evidence. At the end of this process, the specific clinical recommendations proposed by the lead author were discussed, as were issues related to clarification of the recommendations for clinical application and any gaps in evidence. The results of this process are reflected in the description of the decision criteria presented with the specific recommendations. The group and lead author(s) arrived at final decisions on recommendations unanimously.

Procedures to achieve adequate documentation, consistency, comprehensiveness, objectivity, and adherence to the task force methodology were maintained at all stages during review development, the consensus process, and beyond to ensure uniformity and impartiality throughout.

Recommendations Grades for Specific Clinical Preventive Actions

A: The Canadian Task Force (CTF) concludes that there is good evidence to recommend the clinical preventive action.

B: The CTF concludes that there is fair evidence to recommend the clinical preventive action.

C: The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D: The CTF concludes that there is fair evidence to recommend against the clinical preventive action.

E: The CTF concludes that there is good evidence to recommend against the clinical preventive action.

I: The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation; however, other factors may influence decision-making.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review

Comparison with Guidelines from Other Groups

Recommendations from the following organizations regarding lung cancer screening in asymptomatic people were reviewed:

• The US Preventive Services Task Force (USPSTF)
• The American College of Chest Physicians
• The American Cancer Society

External Peer Review

After final revision, the manuscript was sent by the Task Force to 2 experts in the field (identified by Task Force members at the meeting). Feedback from these experts was incorporated into a subsequent draft of the manuscript.

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III, good, fair, poor] are indicated after each recommendation. Definitions for these grades and levels are repeated following the recommendations.

The Canadian Task Force on Preventive Health Care (CTFPHC) concludes that there is fair evidence to recommend against screening asymptomatic people for lung cancer using chest radiographic examination. (D recommendation) (Manser et al., 2002 [I, fair]; Kubik, Parkin, & Zatloukal, 2000 [I, fair]; Marcus et al., 2000 [I, fair]; Nishii et al., 2001 [II-2, fair]; Okamoto et al., 1999 [II-2, fair]; Sagawa et al., 2001 [II-2, fair]; Sobue, 2000 [II-2, fair]; Tsukada et al., 2001 [II-2, fair]).

The CTFPHC concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation as to whether spiral computed tomography (CT) scanning should be used for screening asymptomatic people for lung cancer. However, other factors may influence decision-making. (I recommendation). (Henschke et al., 1999; Henschke et al., 2001; Sone et al., 1998; Sone et al., 2001; Diederich et al., 2000 [II-2, III]).

Despite the insufficient evidence to date regarding lung cancer screening, smoking cessation should be emphasized to the patient as the preferred modality for reducing lung cancer mortality.

Definitions:

Levels of Evidence - Research Design Rating

Research Design Rating

I: Evidence from randomized controlled trials (RCT)

II-1: Evidence from controlled trials without randomization

II-2: Evidence from cohort or case-control analytic studies, preferably from more than 1 centre or research group

II-3: Evidence from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments could also be included here

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Quality (Internal Validity) Rating

Good: A study that meets all design-specific criteria* well

Fair: A study that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw"

Poor: A study that has at least one design-specific* "fatal flaw," or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations

*General design-specific criteria are outlined in Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D. Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. Am J Prev Med 2001;20(suppl 3):21-35.

Recommendations Grades for Specific Clinical Preventive Actions

A: The Canadian Task Force (CTF) concludes that there is good evidence to recommend the clinical preventive action.

B: The CTF concludes that there is fair evidence to recommend the clinical preventive action.

C: The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D: The CTF concludes that there is fair evidence to recommend against the clinical preventive action.

E: The CTF concludes that there is good evidence to recommend against the clinical preventive action.

I: The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a recommendation; however, other factors may influence decision-making.

None provided

Maneuver: Annual chest radiographic examination (CXR) of asymptomatic people

Level of Evidence:
I, fair (One systematic review of randomized controlled trials and two randomized trial updates); II-2, fair (five case-control studies)

Maneuver: Spiral computed tomography (CT) scanning (CT scan versus CXR) of asymptomatic people

Level of Evidence:
II, III (five diagnostic studies)

Refer to the "Major Recommendations" field.

• Appropriate use of lung cancer screening in asymptomatic people
• Decreased number of false-positives associated with screening tests
• Decreased risk of invasive diagnostic procedures to confirm suspicious or false-positive findings
• Prevention of exposure of the patient to unnecessary radiation
• Prevention of decreased motivation to stop smoking if a false-negative result is obtained

May miss detection of early stage lung cancer

The Canadian Task Force on Preventive Health Care (CTFPHC) recognizes that in many cases, patient-specific factors need to be considered and discussed, such as the value the patient places on the clinical preventive action; its possible positive and negative outcomes; and the context and/or personal circumstances of the patient (medical and other). In certain circumstances where the evidence is complex, conflicting, or insufficient, a more detailed discussion may be required.

An implementation strategy was not provided.

Staying Healthy

Effectiveness
Patient-centeredness

• Palda VA, Van Spall HGC. Screening for lung cancer: updated recommendations from the Canadian Task Force on Preventive Health Care. London (ON): Canadian Task Force on Preventive Health Care (CTFPHC); 2003 Aug. 22 p. [28 references]

Not applicable: The guideline was not adapted from another source.

2003 Aug

Canadian Task Force on Preventive Health Care - National Government Agency [Non-U.S.]

The Canadian Task Force on Preventive Health Care (CTFPHC) is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

Canadian Task Force on Preventive Health Care (CTFPHC)

Primary Authors: Valerie A. Palda, MD, MSc; Harriette G.C. Van Spall, MD, BSc

Canadian Task Force on Preventive Health Care (CTFPHC) Chairman: Dr. John W. Feightner, Professor, Department of Family Medicine, The University of Western Ontario, London, Ont.; Members: Drs. Paul Bessette, Professeur titulaire, Département d'obstétrique-gynécologie, Université de Sherbrooke, Sherbrooke, Que.; R. Wayne Elford, Professor and Chair of Research, Department of Family Medicine, University of Calgary, Calgary, Alta.; Denice Feig, Assistant Professor, Department of Endocrinology, University of Toronto, Toronto, Ont.; Harriet MacMillan, Departments of Psychiatry & Behavioural Neurosciences, & Pediatrics, Canadian Centre for Studies of Children at Risk, McMaster University, Hamilton, Ont.; Jean-Marie Moutquin, Professeur titulaire et directeur, Département d'obstétriquegynécologie, Université de Sherbrooke, Sherbrooke, Que.; Valerie Palda, Assistant Professor, Department of General Internal Medicine, University of Toronto, Toronto, Ont.; Christopher Patterson, Professor and Head, Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ont.; Bruce A. Reeder, Professor, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Sask; Elaine E.L. Wang, Associate Professor, Departments of Pediatrics and of Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, Ont.

Resource People: Nadine Wathen, Coordinator; Ruth Walton, Research Associate; and Jana Fear, Research Assistant, Canadian Task Force on Preventive Health Care, Department of Family Medicine, The University of Western Ontario, London, Ont.

Not stated

None available

This NGC summary was completed by ECRI on October 18, 2004. The information was verified by the guideline developer on November 2, 2004.