History of Lung Cancer Screening

The US Department of Veterans Affairs (VA) has a long track record of committing resources to improve outcomes for Veterans at risk for lung cancer. Examples of this commitment include a landmark study conducted with the American Cancer Society between 1958-1961 to complete one of the first prospective cohort studies assessing the feasibility of routine chest X-rays for lung cancer screening (LCS). 1,2 Another early landmark effort was the VA-Armed Forces Cooperative Study,3  also initiated in 1958, that enrolled over 1,000 Veterans with asymptomatic solitary pulmonary nodules; after 10 years of follow-up, its findings revealed a 10% survival advantage at 5-years when patients underwent surgical resection of radiographically visible lung nodules before the development of symptoms (38.5% vs 26.3%).

With the advent of advanced imaging techniques in the 1990s, the next generation of landmark LCS studies sought to evaluate the viability of using higher resolution low dose computed tomography (LDCT) for early detection in lieu of chest X-rays. 4,5 Led by the I-ELCAP group, the next landmark study published in 1999 confirmed the expectation that, compared with chest X-rays, LDCT increased the likelihood of detecting small non-calcified nodules at an earlier and more curable stage.4 The results of the non-randomized trial found that non-calcified lung nodules were detected three times as commonly as on chest X-ray, malignant tumors four times as commonly, and stage I tumors six times as commonly.

Yet concerns about the potential futility of earlier detection and harms of biopsying patients without lung cancer led to demands for a randomized clinical trial of LDCT vs chest X-rays. Once again, the VA was positioned to contribute to the unmet needs for advancing the science of lung screening. To assess the feasibility of conducting, investigators at the VA Medical Center (VAMC) in Denver demonstrated that a randomized controlled trial for LCS would be feasible by reporting 79% of Veterans invited to screen agreed to be randomized between LDCT and a nutrition pamphlet.6 This supported the conduct of the National Lung Screening Trial (NLST) which eventually reported the benefits of lung screening in 2011, setting the stage for implementation projects to increase access to the life-saving benefits of screening LDCT scans.7

In 2012, at the request of Under Secretary of Health Robert Petzel, the VA initiated the Lung Cancer Screening Demonstration Project (LCSDP), a 3-year feasibility evaluation of LDCT implementation at 8 VAMCs.8 The final results of the LCSDP, published in January 2017, concluded that the VA was not yet ready to implement a wide-scale lung cancer screening (LCS) program at that time, citing challenges that included the need for a robust tracking system and registry as well as variation in LDCT scan quality and radiographic interpretation of results.8 Meanwhile, over a dozen VAMCs continued to offer their own local LCS programs, independently of the LCSDP. 9

Launched in July 2017, the VA-Partnership to Increase Access to Lung Screening (VA-PALS) opted to build upon earlier experiences from the LCSDP to accelerate the availability of high-quality early detection programs across the VA. The VA-PALS program successfully obtained funding to hire LCS nurse navigators at its participating sites given the LCSDP identified this position as a critical role.10 Efforts were successful to adapt the evidence-based lung screening management system developed by I-ELCAP for distribution across the VA through a collaboration with Paraxial Technologies and the VistA Expertise Network. Termed the VAPALS-ELCAP lung screening management system, it is currently running at the Phoenix VA Medical Center and is authorized for use by any VA medical center through the VA Enterprise Cloud.

In 2021, additional resources for lung screening were authorized by Congress to further boost access through the VA Lung Precision Oncology Program. VA’s commitment to lung screening is currently focused on ensuring access to equitable high-quality programs and is centrally managed by the Veterans Health Administration National Center for Lung Cancer Screening. The VAPALS-ELCAP program team continues to develop tools to enhance radiology interpretation and further advance the quality and efficiency of LCS for Veterans at risk for lung cancer as more VAMCs are now offering LCS than ever before.

REFERENCES

  1. Lilienfeld A, Archer PG, Burnett CH, et al. An evaluation of radiologic and cytologic screening for the early detection of lung cancer: a cooperative pilot study of the American Cancer Society and the Veterans Administration. Cancer Res. 1966;26(10):2083-2121. http://www.ncbi.nlm.nih.gov/pubmed/5922259.
  2. National Research Council, Institute of Medicine, National Cancer Policy Board. Fulfilling the Potential of Cancer Prevention and Early Detection. National Academies Press (US); 2003.
  3. Higgins GA, Shields TW, Keehn RJ. The Solitary Pulmonary Nodule. Arch Surg. 1975;110(5):570. doi:10.1001/archsurg.1975.01360110116019.
  4. Henschke C, McCauley D, Yankelevitz D, Naidich D, McGuinness G, Miettinen O, et al. Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet. 1999;354(9173):99-105.
  5. International Early Lung Cancer Action Program Investigators, Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Smith JP, et al. Survival of patients with stage I lung cancer detected on CT screening. The New England journal of medicine. 2006;355(17):1763-71.
  6. Garg K, Keith RL, Byers T, et al. Randomized Controlled Trial with Low-Dose Spiral CT for Lung Cancer Screening: Feasibility Study and Preliminary Results. Radiology. 2002;225(2):506-510. doi:10.1148/radiol.2252011851.
  7. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011 Aug 4;365(5):395-409. doi: 10.1056/NEJMoa1102873. Epub 2011 Jun 29. PMID: 21714641; PMCID: PMC4356534.
  8. Kinsinger LS, Anderson C, Kim J, et al. Implementation of Lung Cancer Screening in the Veterans Health Administration. JAMA Intern Med. 2017;177(3):399. doi:10.1001/jamainternmed.2016.9022.
  9. Okereke IC, Bates MF, Jankowich MD, Rounds SI, Kimble BA, Baptiste JV, Ng TT, Nici LL. Effects of Implementation of Lung Cancer Screening at One Veterans Affairs Medical Center. Chest. 2016 Nov;150(5):1023-1029. doi: 10.1016/j.chest.2016.08.1431. Epub 2016 Aug 25. PMID: 27568228.
  10. Jackson GL, King HA, McNeil RB, et al. Evaluation of the VA Lung Cancer Screening Clinical Demonstration Project.; 2016.