Moving Beyond the National Lung Screening Trial: Discussing Strategies for Implementation of Lung Cancer Screening Programs

The National Lung Screening Trial (NLST) has sparked new interest in the adoption of lung cancer screening using low-dose computed tomography (LDCT). If adopted at a national level, LDCT screening may prevent approximately 18,000 lung cancer deaths per year, potentially constituting a high-value public health intervention. Before incorporating LDCT screening into practice, health care institutions need to consider the risks associated with LDCT screening and the impact of LDCT screening on health care costs, as well as other remaining areas of uncertainty, including the unknown cost-effectiveness of LDCT screening. This article will review the benefits and risks of LDCT screening in light of the results of the NLST and other randomized trials, it will discuss the additional health care costs associated with LDCT screening from the perspective of health care payers, and it will examine the published cost-effectiveness analyses of LDCT screening. A subsequent discussion highlights guideline recommendations for implementation strategies, the goals of which are to ensure that those eligible for LDCT screening derive the benefits while minimizing the risks of screening and avoiding an unnecessary escalation in screening-related costs. The article concludes by endorsing the use of LDCT screening in institutions capable of responsible implementation of screening in both medical and economic terms. The key elements of responsible implementation include the development of standardized screening practices, careful selection of screening candidates, and the creation of prospective registries that will mitigate current areas of uncertainty regarding LDCT screening.