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ESR/ERS statement paper on lung cancer screening


In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe’s health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.

Key Points

Pulmonologists and radiologists both have key roles in the set up of multidisciplinary LCS teams with experts from many other fields.

Pulmonologists identify people eligible for LCS, reach out to family doctors, share the decision-making process and promote tobacco cessation.

Radiologists ensure appropriate image quality, minimum dose and a standardised reading/reporting algorithm, together with a clear definition of a “positive screen”.

Strict algorithms define the exact management of screen-detected nodules and incidental findings.

• For LCS to be (cost-)effective, it has to target a population defined by risk prediction models.

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  1. 1.

    Ferlay J, Colombet M, Soerjomataram I et al (2018) Cancer incidence and mortality patterns in Europe: estimates for 40 countries and 25 major cancers in 2018. Eur J Cancer 103:356–387

  2. 2.

    Malvezzi M, Carioli G, Bertuccio P et al (2017) European cancer mortality predictions for the year 2017, with focus on lung cancer. Ann Oncol 28:1117–1123

  3. 3.

    World Bank (1999) Curbing the epidemic: governments and the economics of tobacco control (English). World Bank, Washington, DC

  4. 4.

    Kauczor HU, Bonomo L, Gaga M et al (2015) ESR/ERS white paper on lung cancer screening. Eur Respir J 46:28–39

  5. 5.

    Quaife SL, Vrinten C, Ruparel M et al (2018) Smokers’ interest in a lung cancer screening programme: a national survey in England. BMC Cancer 18:497

  6. 6.

    Broekhuizen H, Groothuis-Oudshoorn CGM, Vliegenthart R et al (2017) Public preferences for lung cancer screening policies. Value Health 20:961–968

  7. 7.

    Stone E, Vachani A (2016) Tobacco control and tobacco cessation in lung cancer-too little, too late? Semin Respir Crit Care Med 37:649–658

  8. 8.

    Macmillan Cancer Support. Manchester’s Lung Health Check Pilot (2017). http://www.macmillan.org.uk. Accessed Aug 2019

  9. 9.

    Brain K, Lifford KJ, Carter B et al (2016) Long-term psychosocial outcomes of low-dose CT screening: results of the UK Lung Cancer screening randomised controlled trial. Thorax 71:996–1005

  10. 10.

    Mazzone PJ, Silvestri GA, Patel S et al (2018) Screening for lung cancer: CHEST guideline and expert panel report. Chest 153:954–985

  11. 11.

    Tanner NT, Silvestri GA (2019) Shared decision-making and lung cancer screening: let’s get the conversation started. Chest 155:21–24

  12. 12.

    Politi MC, Studts JL, Hayslip JW (2012) Shared decision making in oncology practice: what do oncologists need to know? Oncologist 17:91–100

  13. 13.

    Lowenstein LM, Deyter GMR, Nishi S et al (2018) Shared decision-making conversations and smoking cessation interventions: critical components of low-dose CT lung cancer screening programs. Transl Lung Cancer Res 7:254–271

  14. 14.

    Aberle DR, Adams AM, Berg CD et al (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365:395–409

  15. 15.

    de Koning H, van der Aalst C, ten Haaf K et al (2018) PLO2.05 Effects of volume CT lung cancer screening: mortality results of the NELSON randomised-controlled population based trial. J Thorac Oncol; 13: Suppl., S185

  16. 16.

    Pinsky PF (2018) Lung cancer screening with low-dose CT: a world-wide view. Transl Lung Cancer Res 7:234–242

  17. 17.

    Moyer VA (2014) Screening for lung cancer: U.S. preventive services task force recommendation statement. Ann Intern Med 160:330–338

  18. 18.

    Wood DE, Kazerooni EA, Baum SL et al (2018) Lung cancer screening, version 3.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw 16:412–441

  19. 19.

    van Klaveren RJ, Oudkerk M, Prokop M et al (2009) Management of lung nodules detected by volume CT scanning. N Engl J Med 361:2221–2229

  20. 20.

    Crosbie PA, Balata H, Evison M et al (2019) Implementing lung cancer screening: baseline results from a community-based ‘Lung health check’ pilot in deprived areas of Manchester. Thorax 74:405–409

  21. 21.

    Rzyman W, Szurowska E, Adamek M (2019) Implementation of lung cancer screening at the national level: polish example. Transl Lung Cancer Res 8(Suppl. 1):S95–S105

  22. 22.

    Kovalchik SA, Tammemagi M, Berg CD et al (2013) Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med 369:245–254

  23. 23.

    Black WC, Gareen IF, Soneji SS et al (2014) Cost-effectiveness of CT screening in the National Lung Screening Trial. N Engl J Med 371:1793–1802

  24. 24.

    Hazelton WD, Clements MS, Moolgavkar SH (2005) Multistage carcinogenesis and lung cancer mortality in three cohorts. Cancer Epidemiol Biomark Prev 14:1171–1181

  25. 25.

    Raji OY, Duffy SW, Agbaje OF et al (2012) Predictive accuracy of the Liverpool Lung project risk model for stratifying patients for computed tomography screening for lung cancer: a case-control and cohort validation study. Ann Intern Med 157:242–250

  26. 26.

    Knoke JD, Burns DM, Thun MJ (2008) The change in excess risk of lung cancer attributable to smoking following smoking cessation: an examination of different analytic approaches using CPS-I data. Cancer Causes Control 19:207–219

  27. 27.

    Bach PB, Kattan MW, Thornquist MD et al (2003) Variations in lung cancer risk among smokers. J Natl Cancer Inst 95:470–478

  28. 28.

    Tammemagi MC, Katki HA, Hocking WG et al (2013) Selection criteria for lung-cancer screening. N Engl J Med 368:728–736

  29. 29.

    Meza R, Hazelton WD, Colditz GA et al (2008) Analysis of lung cancer incidence in the nurses’ health and the health professionals’ follow-up studies using a multistage carcinogenesis model. Cancer Causes Control 19:317–328

  30. 30.

    Ten Haaf K, Jeon J, Tammemagi MC et al (2017) Risk prediction models for selection of lung cancer screening candidates: a retrospective validation study. PLoS Med 14:e1002277

  31. 31.

    Baldwin DR, Duffy SW, Wald NJ et al (2011) UK Lung screen (UKLS) nodule management protocol: modelling of a single screen randomised controlled trial of low-dose CT screening for lung cancer. Thorax 66:308–313

  32. 32.

    Tammemagi MC (2018) Selecting lung cancer screenees using risk prediction models—where do we go from here. Transl Lung Cancer Res 7:243–253

  33. 33.

    Criss SD, Sheehan DF, Palazzo L et al (2018) Population impact of lung cancer screening in the United States: projections from a microsimulation model. PLoS Med 15:e1002506

  34. 34.

    Patz EFJ, Greco E, Gatsonis C et al (2016) Lung cancer incidence and mortality in National Lung Screening Trial participants who underwent low-dose CT prevalence screening: a retrospective cohort analysis of a randomised, multicentre, diagnostic screening trial. Lancet Oncol 17:590–599

  35. 35.

    Pastorino U, Silva M, Sestini S et al (2019) Prolonged lung cancer screening reduced 10-year mortality in the MILD trial. Ann Oncol 30:1162–1169

  36. 36.

    Yousaf-Khan U, van der Aalst C, de Jong PA et al (2017) Final screening round of the NELSON lung cancer screening trial: the effect of a 2.5-year screening interval. Thorax 72:48–56

  37. 37.

    Mazzone PJ, Sears CR, Arenberg DA et al (2017) Evaluating molecular biomarkers for the early detection of lung cancer: when is a biomarker ready for clinical use? An official American Thoracic Society policy statement. Am J Respir Crit Care Med 196:e15–e29

  38. 38.

    de Koning HJ, Meza R, Plevritis SK et al (2014) Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. preventive services task force. Ann Intern Med 160:311–320

  39. 39.

    Jaklitsch MT, Jacobson FL, Austin JH et al (2012) The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg 144:33–38

  40. 40.

    National Comprehensive Cancer Network (2019) NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening. Version 2. Plymouth Meeting, PA, NCCN

  41. 41.

    Canadian Task Force on Preventive Health Care (2016) Recommendations on screening for lung cancer. CMAJ 188:425–432

  42. 42.

    Rota M, Pizzato M, La Vecchia C et al (2019) Efficacy of lung cancer screening appears to increase with prolonged intervention: results from the MILD trial and a meta-analysis. Ann Oncol 30:1040–1043

  43. 43.

    World Health Organization (2019) European Tobacco Use: Trends Report 2019. Geneva, WHO

  44. 44.

    Lopez AD, Collishaw NE, Piha T (1994) A descriptive model of the cigarette epidemic in developed countries. Tob Control 3:242–247

  45. 45.

    Hiscock R, Bauld L, Amos A et al (2012) Smoking and socioeconomic status in England: the rise of the never smoker and the disadvantaged smoker. J Public Health (Oxf) 34:390–396

  46. 46.

    National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health (2014) The Health Consequences of Smoking–50 Years of Progress: a Report of the Surgeon General. Atlanta, GA, Centers for Disease Control and Prevention (US)

  47. 47.

    Peretti-Watel P, Seror V, Verger P et al (2014) Smokers’ risk perception, socioeconomic status and source of information on cancer. Addict Behav 39:1304–1310

  48. 48.

    Parsons A, Daley A, Begh R et al (2010) Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ 340:b5569

  49. 49.

    Jimenez-Ruiz CA, Andreas S, Lewis KE et al (2015) Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit. Eur Respir J 46:61–79

  50. 50.

    Fucito LM, Czabafy S, Hendricks PS et al (2016) Pairing smoking-cessation services with lung cancer screening: a clinical guideline from the Association for the Treatment of tobacco use and dependence and the Society for Research on nicotine and tobacco. Cancer 122:1150–1159

  51. 51.

    van der Aalst CM, van den Bergh KA, Willemsen MC et al (2010) Lung cancer screening and smoking abstinence: 2 year follow-up data from the Dutch-Belgian randomised controlled lung cancer screening trial. Thorax 65:600–605

  52. 52.

    Park ER, Ostroff JS, Rakowski W et al (2009) Risk perceptions among participants undergoing lung cancer screening: baseline results from the National Lung Screening Trial. Ann Behav Med 37:268–279

  53. 53.

    Leone FT, Evers-Casey S, Toll BA et al (2013) Treatment of tobacco use in lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 143(5 Suppl):e61S–e77S

  54. 54.

    Brain K, Carter B, Lifford KJ et al (2017) Impact of low-dose CT screening on smoking cessation among high-risk participants in the UK Lung Cancer screening trial. Thorax 72:912–918

  55. 55.

    Pineiro B, Simmons VN, Palmer AM et al (2016) Smoking cessation interventions within the context of low-dose computed tomography lung cancer screening: a systematic review. Lung Cancer 98:91–98

  56. 56.

    van der Aalst CM, van Klaveren RJ, van den Bergh KA et al (2011) The impact of a lung cancer computed tomography screening result on smoking abstinence. Eur Respir J 37:1466–1473

  57. 57.

    Park ER, Gareen IF, Japuntich S et al (2015) Primary care provider-delivered smoking cessation interventions and smoking cessation among participants in the National Lung Screening Trial. JAMA Intern Med 175:1509–1516

  58. 58.

    Tanner NT, Kanodra NM, Gebregziabher M et al (2016) The association between smoking abstinence and mortality in the National Lung Screening Trial. Am J Respir Crit Care Med 193:534–541

  59. 59.

    Treating tobacco use and dependence: 2008 update. U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care 53:1217–1222

  60. 60.

    Bach PB, Mirkin JN, Oliver TK et al (2012) Benefits and harms of CT screening for lung cancer: a systematic review. JAMA 307:2418–2429

  61. 61.

    Huber A, Landau J, Ebner L et al (2016) Performance of ultralow-dose CT with iterative reconstruction in lung cancer screening: limiting radiation exposure to the equivalent of conventional chest X-ray imaging. Eur Radiol 26:3643–3652

  62. 62.

    Hassani C, Ronco A, Prosper AE et al (2018) Forward-projected model-based iterative reconstruction in screening low-dose chest CT: comparison with adaptive iterative dose reduction 3D. AJR Am J Roentgenol 211:548–556

  63. 63.

    Callister ME, Baldwin DR, Akram AR et al (2015) British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax 70(Suppl. 2):ii1–ii54

  64. 64.

    MacMahon H, Naidich DP, Goo JM et al (2017) Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner society 2017. Radiology 284:228–243

  65. 65.

    Travis WD, Brambilla E, Noguchi M et al (2011) International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol 6:244–285

  66. 66.

    Infante M (2015) A conservative approach for subsolid lung nodules: is it safe enough? Eur Respir J 45:592–595

  67. 67.

    Silva M, Prokop M, Jacobs C et al (2018) Long-term active surveillance of screening detected subsolid nodules is a safe strategy to reduce overtreatment. J Thorac Oncol 13:1454–1463

  68. 68.

    Infante M, Cavuto S, Lutman FR et al (2009) A randomized study of lung cancer screening with spiral computed tomography: three-year results from the DANTE trial. Am J Respir Crit Care Med 180:445–453

  69. 69.

    Pastorino U, Rossi M, Rosato V et al (2012) Annual or biennial CT screening versus observation in heavy smokers: 5-year results of the MILD trial. Eur J Cancer Prev 21:308–315

  70. 70.

    Pedersen JH, Ashraf H, Dirksen A et al (2009) The Danish randomized lung cancer CT screening trial—overall design and results of the prevalence round. J Thorac Oncol 4:608–614

  71. 71.

    Zhao Y, de Bock GH, Vliegenthart R et al (2012) Performance of computer-aided detection of pulmonary nodules in low-dose CT: comparison with double reading by nodule volume. Eur Radiol 22:2076–2084

  72. 72.

    Silva M, Schaefer-Prokop CM, Jacobs C et al (2018) Detection of subsolid nodules in lung cancer screening: complementary sensitivity of visual reading and computer-aided diagnosis. Investig Radiol 53:441–449

  73. 73.

    Liang M, Tang W, Xu DM et al (2016) Low-dose CT screening for lung cancer: computer-aided detection of missed lung cancers. Radiology 281:279–288

  74. 74.

    Setio AAA, Traverso A, de Bel T et al (2017) Validation, comparison, and combination of algorithms for automatic detection of pulmonary nodules in computed tomography images: the LUNA16 challenge. Med Image Anal 42:1–13

  75. 75.

    Ciompi F, Chung K, van Riel SJ et al (2017) Corrigendum: towards automatic pulmonary nodule management in lung cancer screening with deep learning. Sci Rep 7:46878

  76. 76.

    Ardila D, Kiraly AP, Bharadwaj S et al (2019) End-to-end lung cancer screening with three-dmensional deep learning on low-dose chest computed tomography. Nat Med 25:954–961

  77. 77.

    Pinsky PF, Gierada DS, Nath PH et al (2017) Lung cancer risk associated with new solid nodules in the National Lung Screening Trial. AJR Am J Roentgenol 209:1009–1014

  78. 78.

    McWilliams A, Tammemagi MC, Mayo JR et al (2013) Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 369:910–919

  79. 79.

    Mets OM, Chung K, Scholten ET et al (2018) Incidental perifissural nodules on routine chest computed tomography: lung cancer or not? Eur Radiol 28:1095–1101

  80. 80.

    Barnett J, Pulzato I, Wilson R et al (2019) Perinodular vascularity distinguishes benign intrapulmonary lymph nodes from lung cancer on computed tomography. J Thorac Imaging 34:326–328

  81. 81.

    Rampinelli C, Calloni SF, Minotti M et al (2016) Spectrum of early lung cancer presentation in low-dose screening CT: a pictorial review. Insights Imaging 7:449–459

  82. 82.

    Scholten ET, Horeweg N, de Koning HJ et al (2015) Computed tomographic characteristics of interval and post screen carcinomas in lung cancer screening. Eur Radiol 25:81–88

  83. 83.

    Lung CT Screening Reporting And Data System (Lung-RADS). American College of Radiology. www.acr.org/Quality-Safety/Resources/LungRADS. Accessed Aug 2019

  84. 84.

    Pinsky PF, Gierada DS, Black W et al (2015) Performance of Lung-RADS in the National Lung Screening Trial: a retrospective assessment. Ann Intern Med 162:485–491

  85. 85.

    International Early Lung Cancer Action Program: Screening Protocol. www.ielcap.org/protocols. Accessed May 2019

  86. 86.

    Revel MP, Bissery A, Bienvenu M et al (2004) Are two-dimensional CT measurements of small noncalcified pulmonary nodules reliable? Radiology 231:453–458

  87. 87.

    Xu DM, Gietema H, de Koning H et al (2006) Nodule management protocol of the NELSON randomised lung cancer screening trial. Lung Cancer 54:177–184

  88. 88.

    Oudkerk M, Devaraj A, Vliegenthart R et al (2017) European position statement on lung cancer screening. Lancet Oncol 18:e754–e766

  89. 89.

    Walter JE, Heuvelmans MA, de Jong PA et al (2016) Occurrence and lung cancer probability of new solid nodules at incidence screening with low-dose CT: analysis of data from the randomised, controlled NELSON trial. Lancet Oncol 17:907–916. https://doi.org/10.1016/S1470-2045(16)30069-9

  90. 90.

    Schabath MB, Massion PP, Thompson ZJ et al (2016) Differences in patient outcomes of prevalence, interval, and screen-detected lung cancers in the CT arm of the National Lung Screening Trial. PLoS One 11:e0159880

  91. 91.

    Heuvelmans MA, Walter JE, Oudkerk M (2018) Management of baseline and new sub-solid nodules in CT lung cancer screening. Expert Rev Respir Med 12:1–3

  92. 92.

    Brodersen J, Schwartz LM, Woloshin S (2014) Overdiagnosis: how cancer screening can turn indolent pathology into illness. APMIS 122:683–689

  93. 93.

    Esserman LJ, Thompson IM Jr, Reid B (2013) Overdiagnosis and overtreatment in cancer: an opportunity for improvement. JAMA 310:797–798

  94. 94.

    Brodersen J, Schwartz LM, Heneghan C et al (2018) Overdiagnosis: what it is and what it isn’t. BMJ Evid Based Med 23:1–3

  95. 95.

    Heleno B, Siersma V, Brodersen J (2018) Estimation of overdiagnosis of lung cancer in low-dose computed tomography screening. JAMA Intern Med 178:1420–1422

  96. 96.

    Patz EF Jr, Pinsky P, Gatsonis C et al (2014) Overdiagnosis in low-dose computed tomography screening for lung cancer. JAMA Intern Med 174:269–274

  97. 97.

    Paci E, Puliti D, Lopes Pegna A et al (2017) Mortality, survival and incidence rates in the ITALUNG randomised lung cancer screening trial. Thorax 72:825–831

  98. 98.

    Heleno B, Siersma V, Brodersen J (2018) Estimation of overdiagnosis of lung cancer in low-dose computed tomography screening: a secondary analysis of the Danish Lung Cancer screening trial. JAMA Intern Med 178:1420–1422

  99. 99.

    Silva M, Sverzellati N, Manna C et al (2012) Long-term surveillance of ground-glass nodules: evidence from the MILD trial. J Thorac Oncol 7:1541–1546

  100. 100.

    Scholten ET, de Jong PA, de Hoop B et al (2015) Towards a close computed tomography monitoring approach for screen detected subsolid pulmonary nodules? Eur Respir J 45:765–773

  101. 101.

    Yip R, Wolf A, Tam K et al (2016) Outcomes of lung cancers manifesting as nonsolid nodules. Lung Cancer 97:35–42

  102. 102.

    Yip R, Li K, Liu L et al (2018) Controversies on lung cancers manifesting as part-solid nodules. Eur Radiol 28:747–759

  103. 103.

    Katki HA, Kovalchik SA, Berg CD et al (2016) Development and validation of risk models to select ever-smokers for CT lung cancer screening. JAMA 315:2300–2311

  104. 104.

    Revel MP (2013) Avoiding overdiagnosis in lung cancer screening: the volume doubling time strategy. Eur Respir J 42:1459–1463

  105. 105.

    Sverzellati N, Silva M, Calareso G et al (2016) Low-dose computed tomography for lung cancer screening: comparison of performance between annual and biennial screen. Eur Radiol 26:3821–3829

  106. 106.

    Brodersen J, McKenna SP, Doward LC et al (2007) Measuring the psychosocial consequences of screening. Health Qual Life Outcomes 5:3

  107. 107.

    Mokkink LB, de Vet HCW, Prinsen CAC et al (2018) COSMIN risk of bias checklist for systematic reviews of patient-reported outcome measures. Qual Life Res 27:1171–1179

  108. 108.

    DeFrank JT, Barclay C, Sheridan S et al (2014) The psychological harms of screening: the evidence we have versus the evidence we need. J Gen Intern Med 30:242–248

  109. 109.

    Hestbech MS, Siersma V, Dirksen A et al (2011) Participation bias in a randomised trial of screening for lung cancer. Lung Cancer 73:325–331

  110. 110.

    Brodersen J, Thorsen H, Kreiner S (2010) Consequences of screening in lung cancer: development and dimensionality of a questionnaire. Value Health 13:601–612

  111. 111.

    Aggestrup LM, Hestbech MS, Siersma V et al (2012) Psychosocial consequences of allocation to lung cancer screening – a randomised controlled trial. BMJ Open 2:e000663

  112. 112.

    Rasmussen JF, Siersma V, Pedersen JH et al (2015) Psychosocial consequences in the Danish randomised controlled lung cancer screening trial (DLCST). Lung Cancer 87:65–72

  113. 113.

    Pompe E, de Jong PA, Lynch D et al (2017) Computed tomographic findings in subjects who died from respiratory disease in the NLST. Eur Respir J 49:1601814

  114. 114.

    Tockman MS, Anthonisen NR, Wright EC et al (1987) Airways obstruction and the risk for lung cancer. Ann Intern Med 106:512–518

  115. 115.

    Jairam PM, van der Graaf Y, Lammers JW et al (2015) Incidental findings on chest CT imaging are associated with increased COPD exacerbations and mortality. Thorax 70:725–731

  116. 116.

    Shemesh J (2016) Coronary artery calcification in clinical practice: what we have learned and why should it routinely be reported on chest CT? Ann Transl Med 4:159

  117. 117.

    Messerli M, Hechelhammer L, Leschka S et al (2018) Coronary risk assessment at X-ray dose equivalent ungated chest CT: esults of a multi-reader study. Clin Imaging 49:73–79

  118. 118.

    Wong PK, Christie JJ, Wark JD (2007) The effects of smoking on bone health. Clin Sci 113:233–241

  119. 119.

    Buckens CF, van der Graaf Y, Verkooijen HM et al (2015) Osteoporosis markers on low-dose lung cancer screening chest computed tomography scans predict all-cause mortality. Eur Radiol 25:132–139

  120. 120.

    Morgan L, Choi H, Reid M et al (2017) Frequency of incidental findings and subsequent evaluation in low-dose computed tomographic scans for lung cancer screening. Ann Am Thorac Soc 14:1450–1456

  121. 121.

    Chung JH, Richards JC, Koelsch TL et al (2018) Screening for lung cancer: incidental pulmonary parenchymal findings. AJR Am J Roentgenol 210:503–513

  122. 122.

    Reiter MJ, Nemesure A, Madu E et al (2018) Frequency and distribution of incidental findings deemed appropriate for S modifier designation on low-dose CT in a lung cancer screening program. Lung Cancer 120:1–6

  123. 123.

    Nguyen XV, Davies L, Eastwood JD et al (2017) Extrapulmonary findings and malignancies in participants screened with chest CT in the national Lung screening trial. J Am Coll Radiol 14:324–330

  124. 124.

    O’Sullivan JW, Muntinga T, Grigg S et al (2018) Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ 361:k2387

  125. 125.

    Munden RF, Carter BW, Chiles C et al (2018) Managing incidental findings on thoracic CT: mediastinal and cardiovascular findings. A white paper of the ACR incidental findings committee. J Am Coll Radiol 15:1087–1096

  126. 126.

    Mayo-Smith WW, Song JH, Boland GL et al (2017) Management of incidental adrenal masses: a white paper of the ACR incidental findings committee. J Am Coll Radiol 14:1038–1044

  127. 127.

    Gore RM, Pickhardt PJ, Mortele KJ et al (2017) Management of incidental liver lesions on CT: a white paper of the ACR incidental findings committee. J Am Coll Radiol 14:1429–1437

  128. 128.

    Megibow AJ, Baker ME, Morgan DE et al (2017) Management of incidental pancreatic cysts: a white paper of the ACR incidental findings committee. J Am Coll Radiol 14:911–923

  129. 129.

    Herts BR, Silverman SG, Hindman NM et al (2018) Management of the incidental renal mass on CT: a white paper of the ACR incidental findings committee. J Am Coll Radiol 15:264–273

  130. 130.

    Levy B, Hu ZI, Cordova KN et al (2016) Clinical utility of liquid diagnostic platforms in non-small cell lung cancer. Oncologist 21:1121–1130

  131. 131.

    Mamdani H, Ahmed S, Armstrong S et al (2017) Blood-based tumor biomarkers in lung cancer for detection and treatment. Transl Lung Cancer Res 6:648–660

  132. 132.

    Nardi-Agmon I, Peled N (2017) Exhaled breath analysis for the early detection of lung cancer: recent developments and future prospects. Lung Cancer (Auckl) 8:31–38

  133. 133.

    Arneth B (2018) Update on the types and usage of liquid biopsies in the clinical setting: a systematic review. BMC Cancer 18:527

  134. 134.

    Shoshan-Barmatz V, Bishitz Y, Paul A et al (2017) A molecular signature of lung cancer: potential biomarkers for adenocarcinoma and squamous cell carcinoma. Oncotarget 8:105492–105509

  135. 135.

    van de Goor R, van Hooren M, Dingemans AM et al (2018) Training and validating a portable electronic nose for lung cancer screening. J Thorac Oncol 13:676–681

  136. 136.

    Sozzi G, Roz L, Conte D et al (2009) Plasma DNA quantification in lung cancer computed tomography screening: five-year results of a prospective study. Am J Respir Crit Care Med 179:69–74

  137. 137.

    Newman AM, Bratman SV, To J et al (2014) An ultrasensitive method for quantitating circulating tumor DNA with broad patient coverage. Nat Med 20:548–554

  138. 138.

    Sozzi G, Boeri M, Rossi M et al (2014) Clinical utility of a plasma-based miRNA signature classifier within computed tomography lung cancer screening: a correlative MILD trial study. J Clin Oncol 32:768–773

  139. 139.

    Plasma microRNA Profiling as First Line Screening Test for Lung Cancer Detection: a Prospective Study (bioMILD). https://clinicaltrials.gov/ct2/show/study/NCT02247453. 2014. Accessed May 2019

  140. 140.

    Montani F, Marzi MJ, Dezi F et al (2015) miR-Test: a blood test for lung cancer early detection. J Natl Cancer Inst 107:djv063

  141. 141.

    World Health Organization Global Status Report on Noncommunicable Diseases (2014) Geneva, World Health Organization, 2014

  142. 142.

    Bleichrodt H, Quiggin J (1999) Life-cycle preferences over consumption and health: when is cost-effectiveness analysis equivalent to cost-benefit analysis? J Health Econ 18:681–708

  143. 143.

    Black WC (1990) The CE plane: a graphic representation of cost-effectiveness. Med Decis Mak 10:212–214

  144. 144.

    Maciosek MV, Coffield AB, Edwards NM et al (2006) Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 31:52–61

  145. 145.

    Cressman S, Peacock SJ, Tammemagi MC et al (2017) The cost-effectiveness of high-risk lung cancer screening and drivers of program efficiency. J Thorac Oncol 12:1210–1222

  146. 146.

    Tomonaga Y, Ten Haaf K, Frauenfelder T et al (2018) Cost-effectiveness of low-dose CT screening for lung cancer in a European country with high prevalence of smoking–a modelling study. Lung Cancer 121:61–69

  147. 147.

    Hofer F, Kauczor HU, Stargardt T (2018) Cost-utility analysis of a potential lung cancer screening program for a high-risk population in Germany: a modelling approach. Lung Cancer 124:189–198

  148. 148.

    Ten Haaf K, Tammemagi MC, Bondy SJ et al (2017) Performance and cost-effectiveness of computed tomography lung cancer screening scenarios in a population-based setting: a microsimulation modeling analysis in Ontario, Canada. PLoS Med 14:e1002225

  149. 149.

    McMahon PM, Kong CY, Bouzan C et al (2011) Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol 6:1841–1848

  150. 150.

    Veronesi GGS, Vanni E, Dieci E et al (2018) Analysis indicates low incremental cost-effectiveness ratio for implementation of lung cancer screening in Italy. J Thorac Oncol 13:S968

  151. 151.

    Kumar V, Cohen JT, van Klaveren D et al (2018) Risk-targeted lung cancer screening: a cost-effectiveness analysis. Ann Intern Med 168:161–169

  152. 152.

    Mehta HJ, Mohammed TL, Jantz MA (2017) The American College of Radiology Lung Imaging Reporting and Data System: potential drawbacks and need for revision. Chest 151:539–543

  153. 153.

    Cassidy A, Myles JP, van Tongeren M et al (2008) The LLP risk model: an individual risk prediction model for lung cancer. Br J Cancer 98:270–276

  154. 154.

    Field JK, Duffy SW, Baldwin DR et al (2016) The UK Lung Cancer screening trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer. Health Technol Assess 20:1–146

  155. 155.

    Horeweg N, Scholten ET, de Jong PA et al (2014) Detection of lung cancer through low-dose CT screening (NELSON): a prespecified analysis of screening test performance and interval cancers. Lancet Oncol 15:1342–1350

  156. 156.

    Lopes Pegna A, Picozzi G, Falaschi F et al (2013) Four-year results of low-dose CT screening and nodule management in the ITALUNG trial. J Thorac Oncol 8:866–875

  157. 157.

    Saghir Z, Dirksen A, Ashraf H et al (2012) CT screening for lung cancer brings forward early disease. The randomised Danish Lung Cancer screening trial: status after five annual screening rounds with low-dose CT. Thorax 67:296–301

  158. 158.

    Field JK, Duffy SW, Baldwin DR et al (2016) UK Lung Cancer RCT pilot screening trial: baseline findings from the screening arm provide evidence for the potential implementation of lung cancer screening. Thorax 71:161–170

  159. 159.

    Infante M, Cavuto S, Lutman FR et al (2015) Long-term follow-up results of the DANTE trial, a randomized study of lung cancer screening with spiral computed tomography. Am J Respir Crit Care Med 191:1166–1175

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We would like to thank John Brodersen for his substantial contribution to the writing of the section “Overdiagnosis and harms” and his single authorship on the sections about the psychological impact of LCS programmes in the section “Overdiagnosis and harms” and in the Supplementary Appendix.

This document was written by the authors on behalf of the European Society of Radiology (ESR) and the European Respiratory Society (ERS). It was endorsed by the ESR Executive Council in September 2019, and by the ERS Executive Committee on 10 September 2019.

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Correspondence to Hans-Ulrich Kauczor.

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Conflict of interest

H-U. Kauczor reports grants, personal fees for lectures and non-financial support from Siemens, grants and personal fees for lectures from Philips, and personal fees for lectures from Boehringer Ingelheim and Bracco, outside the submitted work.

A-M. Baird reports personal fees and non-financial support for meeting attendance from Roche and MSD, outside the submitted work; and is a board member for Lung Cancer Europe (LuCE); LuCE have received support from Abbvie, Amgen, BMS, Boehringer Ingelheim, Lilly, Merck, MSD, Novartis, Pfizer, Roche and Takeda, and, as board member, A-M. Baird has participated on advisory boards for BMS, Takeda and Pfizer, with the fee paid directly to LuCE.

T.G. Blum has nothing to disclose.

L. Bonomo has nothing to disclose.

C. Bostantzoglou has nothing to disclose.

O. Burghuber reports grants from Boehringer Ingelheim, GSK, AstraZeneca, Menarini, Teva, Pfizer, Chiesi, Novartis and Federal State Department of Health, non-financial support (utilities and meeting facilities) from the Municipal Department of Health in Vienna and air liquid, during the conduct of the study; and personal fees for advisory board work and lectures from Boehringer Ingelheim, AstraZeneca, Chiesi, MSD, Menarini, Roche and GSK, outside the submitted work.

B. Čepická is a member of the European Lung Foundation patient advisory group.

A. Comanescu reports sponsorship from Merck Romania and Bristol-Myers Squibb România, during the conduct of the study; and patient advisory panel fees from Bristol-Myers Squibb, outside the submitted work.

S. Couraud reports grants, personal fees and other from Roche, grants and personal fees from AstraZeneca, during the conduct of the study; and grants and personal fees from BMS, AstraZeneca, Lilly and Laidet Medical, grants, personal fees and other from Pfizer, Roche, Chugai, MSD and Boehringer Ingelheim, grants and non-financial support from Sysmex Innostics, grants from Novartis, Merck and Amgen, and personal fees from Exact Science, outside the submitted work.

A. Devaraj has nothing to disclose.

V. Jespersen has nothing to disclose.

S. Morozov has nothing to disclose.

I. Nardi Agmon has nothing to disclose.

N. Peled reports consultancy for and honoraria from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Foundation Medicine, Guardant360, MSD, Novartis, NovellusDx, Pfizer, Roche and Takeda, outside the submitted work; and in addition, has patents WO2012023138, US20130150261 and WO/2015/059646 issued.

P. Powell is an employee of the European Lung Foundation.

H. Prosch reports grants from Siemens, outside the submitted work.

S. Ravara has nothing to disclose.

J. Rawlinson is a member of the patient advisory group of the ERS/European Lung Foundation (as a lung cancer patient) and a patient representative on the NHS England Screening advisory group; neither role is remunerated in any way.

M-P. Revel has nothing to disclose.

M. Silva has nothing to disclose.

A. Snoeckx has nothing to disclose.

B. van Ginneken reports grants and stock/royalties from Thirona, and grants and royalties from Delft Imaging Systems and MeVis Medical Solutions, outside the submitted work.

J.P. van Meerbeeck has nothing to disclose.

C. Vardavas has nothing to disclose.

O. von Stackelberg has nothing to disclose.

M. Gaga reports grants from Novartis, Chiesi, Elpen and Menarini, and personal fees from BMS and MSD, outside the submitted work.

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Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The ESR and ERS agree that Europe’s healthcare systems need to allow citizens to benefit from organised pathways to early diagnosis and reduction of mortality of lung cancer. Now is the time to set up and implement large-scale programmes. http://bit.ly/2miF0cO

This official statement of the European Society of Radiology (ESR) and the European Respiratory Society (ERS) is published jointly in European Radiology https://doi.org/10.1007/s00330-020-06727-7 and the European Respiratory Journal https://doi.org/10.1183/13993003.00506-209. The versions are identical aside from minor differences in typesetting and presentation in accord with the journal styles.

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Kauczor, H., Baird, A., Blum, T.G. et al. ESR/ERS statement paper on lung cancer screening. Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06727-7

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  • Early detection of cancer
  • Tobacco use cessation
  • Lung neoplasms
  • Carcinoma, bronchogenic
  • Cost-benefit analysis