Thoracic: Lung Cancer
Overestimation of screening-related complications in the National Lung Screening Trial

Read at the 102nd Annual Meeting of The American Association for Thoracic Surgery, Boston, Massachusetts, May 14-17, 2022.
https://doi.org/10.1016/j.jtcvs.2022.10.051Get rights and content

Abstract

Background

Lung cancer screening-associated complications are often quoted as one of the major barriers for wider screening adoption. A detailed analysis of the National Lung Screening Trial dataset was performed to extrapolate the safety of lung cancer screening.

Methods

Lung cancer screening-associated invasive procedures and their related complications were analyzed using the National Lung Screening Trial dataset. Factors associated with 90-day postprocedure complications per patient were analyzed with logistic-regression multivariable analysis.

Results

Major complications rate in patients undergoing low-dose computed tomography screening who were diagnosed with lung cancer was 10.2% compared with only 0.04% for patients without lung cancer. Low-dose computed tomography screening, compared with chest radiography, led to major complications in an excess of only 3.5 per 10,000 patients without lung cancer. Among 25,633 patients without lung cancer who underwent low-dose computed tomography screening, 45 developed 90-day postprocedure complications (71 total complications). The most common were pneumothorax (n = 29; 41%), postprocedure hospitalization (n = 6; 8.5%), and infection/fever requiring antibiotics (n = 5; 7%). Cardiac/respiratory arrest occurred in less than 1 in 10,000 low-dose computed tomography–screened patients without lung cancer. On multivariable analysis, pulmonary comorbidity (confidence interval, 1.00-3.37) and procedure type (thoracoscopy [confidence interval, 2.04-10.64] or thoracotomy [confidence interval, 2.38-8.93]) were associated with postprocedure complications in patients without lung cancer. Randomization arm (low-dose computed tomography vs chest x-ray) was not a significant factor (confidence interval, 0.89-1.37).

Conclusions

It is more informative to report procedural complications in patients not found to have cancer as the true screening-associated risk. Only 4 in 10,000 of patients undergoing low-dose computed tomography screening but not found to have lung cancer will have major complications. Permanent or debilitating complications are exceedingly rare.

Section snippets

National Lung Screening Trial

The randomized controlled National Lung Screening Trial (NLST) enrolled 53,454 individuals from 33 US medical centers who were deemed high risk for developing lung cancer in the period from August 2002 to April 2004. Enrolled individuals were 55 to 74 years of age and were current or former smokers who quit within the prior 15 years with at least 30 pack/year history of cigarette smoking at the time of randomization. Individuals who had symptoms of lung cancer, a history of lung cancer, or

Results

The NLST dataset used in this study included 53,452 individuals who underwent lung cancer screening with LDCT (n = 26,722) or CXR (n = 26,730). Of those, 2058 patients were diagnosed with lung cancer (LDCT arm [n = 1089]; CXR arm [n = 969]) (Table 1).

Discussion

This study is an in-depth analysis of the invasive procedures performed and the rate of related adverse effects in patients enrolled in the NLST who underwent lung cancer screening. Although the potential risk of complications related to invasive procedures is often listed as a harm of LDCT lung cancer screening, the actual nature and extent of those complications and their relationship to the final diagnosis of screened individuals have not been fully described.

In this study, the rates of

Conclusions

We provide a detailed analysis of the risk of complications in patients who underwent screening in the NLST and demonstrate that the rates of intermediate and major complications among patients who do not have lung cancer are remarkably low. Permanent or debilitating complications are exceedingly rare. Standardized approaches to nodule investigation and expanded use of minimally invasive surgical techniques will likely decrease screening-related morbidity even further. We hope that these

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