Diagnosing early-stage lung cancer with low-dose CT (LDCT) translates to a 20-year survival rate of 81%, according to a large-scale, 20-year international study published November 7 in Radiology.

And this survival rate is even higher among those diagnosed with Stage 1 disease, at 95%, lead author Claudia Henschke, MD, PhD, of the Icahn School of Medicine at Mount Sinai in New York City said in an RSNA statement.

“[Our study] is the first time that 20-year survival rates from annual screening have been reported,” she said. “This 20-year survival rate of 81% is the estimated cure rate of all participants with lung cancers diagnosed by annual screening. This is a huge benefit compared to waiting for a diagnosis that, in usual care, is symptom-prompted.”

Lung cancer is the primary cause of cancer death in the U.S., and the average lung cancer survival rate is 18.6%, according to the American Lung Association. Only 16% of lung cancers are caught at an early stage, according to the RSNA. And although treatments for advanced lung cancer have become more effective, the best way to reduce mortality is to catch the disease early through LDCT.

Henschke and colleagues have been studying the effectiveness of low-dose CT screening for lung cancer since 1992 and created the International Early Lung Cancer Action Program (I-ELCAP) — an initiative that has included more than 89,000 participants in 80 institutions around the world. In 2006, the team assessed the 10-year survival rate of patients diagnosed with lung cancer on LDCT, finding a rate of 80%. This current analysis shows similar results.

(A, B) Two annual repeat low-dose CT scans in a woman who was 60 years old at baseline enrollment in 1999. At baseline enrollment, she was currently smoking and had a 30-pack-year smoking history. No nodules were identified on baseline low-dose CT scans. On the sixth annual low-dose CT scan (B), a right lower lobe solid nodule (arrow) measuring 4.5 mm in maximum diameter was identified. The nodule could be identified in retrospect on the prior annual CT scan (arrow in A), when it measured 2 mm in maximum diameter. Estimated tumor volume doubling time was 161 days. Lobectomy was performed two months later, and diagnosis of stage 1aN0M0 moderately differentiated adenocarcinoma measuring 6 mm in maximum diameter was made. Expert pathologic panel review (22) of the pathologic specimen updated the diagnosis to adenocarcinoma with mixed subtype (80% acinar, 20% bronchoalveolar carcinoma components) with 5 mm of invasion. Images and caption courtesy of the RSNA.

“We were excited to see that the estimated cure rate we reported in 2006 has persisted after 20 years of follow-up,” Henschke said.

In this analysis, the authors found that, among 1,257 I-ELCAP participants diagnosed with lung cancer, 81% had Stage I disease, and that the long-term survival rate for these patients was 87%.

By treating the cancer when it is small, patients can be effectively cured in the long term, according to Henschke. And that’s why regular LDCT screening is beneficial.

“Lung cancer can be cured if you enroll in an annual screening program using a well-defined protocol and comprehensive management system,” she said. “It is important to return for annual screening.”

Yet even though lung cancer screening improves survival outcomes, its uptake remains low, according to an accompanying editorial written by Lecia Sequist, MD, of Harvard Medical School in Boston, and Coral Olazagasti, MD, of the University of Miami in Florida. Efforts to mitigate this must continue.

“Despite data from I-ELCAP, NLST [the National Lung Screening Trial], NELSON, and many other clinical trials suggesting lung cancer screening is beneficial and expanded guidelines from the U.S. Preventive Services Task Force that render 14.5 million Americans potentially eligible for screening, lung cancer screening implementation in the United States remains extremely suboptimal to date,” they noted. “This is due to myriad systemic and individual factors compounded by stigma and nihilism about tobacco use … Concerted and long-term efforts to change the status quo for lung cancer screening are needed.”

The full article is available here.

The American Cancer Society (ACS) has released an updated lung cancer screening (LCS) guideline, significantly increasing eligibility and bringing it into concordance with the U.S. Preventive Services Task Force’s (USPSTF) recommendation released in 2021.

Published November 1 in CA: A Cancer Journal for Clinicians, the new guidance expands eligibility to include five million more U.S. adults compared to the previous 2013 recommendation, the ACS said. It urges yearly screening for lung cancer via low-dose CT (LDCT) exams for people aged 50 to 80 years old who are current or former smokers and have a 20-year or greater pack-year history.

“This updated guideline continues a trend of expanding eligibility for lung cancer screening in a way that will result in many more deaths prevented by expanding the eligibility criteria for screening to detect lung cancer early,” Dr. Robert Smith, senior vice president, early cancer detection science at the ACS and lead author of the lung cancer screening guideline report said in a press conference. “Recent studies have shown extending the screening age for persons who smoke and formerly smoked, eliminating the ‘years since quitting’ requirement and lowering the pack per year recommendation could make a real difference in saving lives.”

Lung cancer is the overall leading cause of cancer death in the United States and is the second most frequently diagnosed malignancy in both men and women, according to the ACS. This year, the society estimates that 238,340 new cases of lung will be diagnosed and about 127,070 people will die from the disease.

To update its guidance, the ACS used data from a systematic review of lung cancer screening with LDCT that was performed in 2021 for the USPSTF by the Research Triangle Institute (RTI) International-University of North Carolina at Chapel Hill Evidence‐based Practice Center. Its 2023 recommendation differs from the previous 2013 version in the following ways:

The society also stressed that adults with health conditions that limit life expectancy or affect their ability or willingness to get lung cancer treatment if diagnosed should not be screened for the disease.

“The principal benefit of LCS is a reduction in lung cancer‐specific deaths,” the ACS noted. “[Randomized controlled trials] have provided a foundation of evidence that LCS with LDCT is efficacious, and the diagnostic accuracy studies support that it has high sensitivity and acceptable specificity for the early detection of lung cancer in persons judged to be at high risk due to smoking history.”

Quitting smoking is key to reducing lung cancer risk, and efforts should be made to support individuals in this endeavor, Smith said.

“The good news is our research shows the number of new lung cancer cases diagnosed each year continues to decrease, partly because more people are quitting smoking (or not starting),” he noted. “The number of deaths from lung cancer continues to drop as well, due to fewer people smoking and advances in early detection and treatment, but we still have to do better. This updated guideline is a step in the right direction.”

The complete guidance can be found here.

MRI has advantages over transvaginal ultrasound (TVUS) when characterizing adnexal lesions based on the Ovarian-Adnexal Imaging-Reporting-Data System (O-RADS), according to findings published October 27 in the European Journal of Radiology.

A team led by Isabelle Thomassin-Naggara, MD, PhD, from the Assistance Publique–Hôpitaux de Paris in France, found that MRI is on par with TVUS when it comes to sensitivity, but it has higher specificity.

“MRI should be the recommended second-line technique when a mass is discovered during TVUS and is rated O-RADS 4 and 5 over than TVUS by an ultrasound specialist,” the Thomassin-Naggara team wrote.

Accurate characterization of adnexal lesions is important for deciding the best course of action for treatment. TVUS is the first-line option in this area. The researchers pointed out that while both ultrasound and MRI can assess solid lesion components, solid tissues, and components can appear echoic on TVUS. MRI is typically the go-to modality when an adnexal lesion is considered “complex” or “indeterminate” on ultrasound.

The American College of Radiology’s (ACR) O-RADS scoring scale meanwhile aims to standardize the characterization of such lesions, with scores of 4 and 5 indicating intermediate and high risk of malignancy, respectively.

Thomassin-Naggara and co-authors wanted to investigate the diagnostic performance of O-RADS ultrasound performed by an expert sonographer and O-RADS MRI scores to find out for which lesions either modality should be recommended according to O-RADS.

They included data collected between 2013 and 2017 from 227 women who underwent both imaging methods. The women presented for characterization of an adnexal lesion proven by surgery or two years of negative follow-up. The researchers reported that the prevalence of malignancy was 11.1%.

The team found that while MRI and TVUS had the same sensitivity, MRI had a significant advantage when it came to specificity and accuracy.

The researchers also found that when MRI was used after ultrasound, 51 lesions were reclassified correctly by MRI while four lesions were incorrectly reclassified. They also reported that 49 of the lesions that were rated O-RADS ultrasound 4 or 5 and reclassified correctly by MRI were benign.

Finally, the team found that just four lesions were misclassified by MRI but correctly classified by ultrasound.

The study authors suggested that their results show that MRI should be considered for high-risk lesions and that MRI has the added benefit of being able to diagnose epithelial tumors. They pointed out that O-RADS ultrasound does not consider important morphological elements in tissue characterization for epithelial tumors.

“As the role of imaging techniques is to show the highest degree of certainty to be included in management decisions, pelvic MRI should also be recommended for mass rated O-RADS ultrasound 5 in the same time than CT scan for local staging,” the authors wrote.

The study can be found in its entirety here.

Chronic migraine sufferers show increased brain age on MRI compared with healthy counterparts, according to a study published October 6 in the Journal of Headache Pain.

The findings could help illuminate the nature of migraine — a common and disruptive illness, wrote a team led by Rafael Navarro-González, MD, of the Universidad de Valladolid in Spain.

“Migraine is a prevalent and chronic condition known for its recurrent and debilitating headache episodes,” the group noted. “Due to the inherent characteristics of migraine and its widespread occurrence, it imposes a substantial burden on both individuals and society as a whole.”

Neuroimaging studies have demonstrated that migraine is linked to structural and functional brain alterations, but the association of these changes with aging has not been thoroughly investigated, the team noted. To address this knowledge gap, the group created a machine learning model using the Brain Age Gap Estimation (BrainAGE) framework to evaluate connections between brain age and migraine, hypothesizing that migraine patients would exhibit increased differences between estimated and chronological age compared with healthy peers.

Navarro-González and colleagues trained the model using 2,771 T1-weighted MRI scans of healthy controls. They then used the model with a cohort of 247 patients, of whom 82 were healthy, 91 of whom suffered episodic migraines, and 74 of whom experienced chronic migraines.

The researchers found that chronic migraine patients showed an increased gap between estimated and chronological age compared with healthy controls. The gap for episodic migraine sufferers was also higher compared with healthy controls, but this measure was not statistically significant 1.2 years compared with -0.56 years, p = 0.19).

The team did not report any associations between the brain age gap and headache or migraine frequency or duration.

The study indicates that brain-predicted age is a “sensitive biomarker of chronic migraine patients and can help reveal distinct aging patterns in migraine,” the group concluded.

“The Brain Age paradigm has shown to be a promising viewpoint for the study of migraine,” the group wrote.

The complete study can be found here.

Estimating the prevalence and severity of coronary artery calcium (CAC) using data gleaned from nongated chest CT imaging improves risk assessment of postsurgical major clinical events before a patient undergoes noncardiac surgery, according to research published in the October 10 issue of Circulation.

The study results could improve patients’ surgical outcomes, wrote a team led by Daniel Choi, MD, of New York University Grossman School of Medicine in New York City.

“[Our study found that] prevalence and severity of coronary calcium from preexisting, preoperative, nongated chest CT imaging were associated with stepwise increases in perioperative major clinical events after major, noncardiac surgery,” the group noted. “Because many patients have had recent nongated CT chest imaging before the time of preoperative risk assessment, this measure of coronary calcium may enhance clinical risk stratification before noncardiac surgery.”

It’s crucial to assess patients’ preoperative cardiovascular risk before they undergo noncardiac surgery, but doing so can be challenging, Choi and colleagues explained. CAC scores from ECG-gated chest CT exams have been shown to help clinicians predict risk of major perioperative events (i.e., cardiac death or nonfatal myocardial infarction or cardiac arrest), according to the authors, but at perioperative evaluation, patients expected to undergo noncardiac surgery may only have had nongated chest CT studies.

Choi’s group investigated any relationship between CAC severity estimated from previous nongated chest CT imaging exams and perioperative major clinical events after noncardiac surgery, using data from the Existing Nongated CT Coronary Calcium Predicts Operative Risk in Patients Undergoing Noncardiac Surgeries (ENCORES) study. The team conducted a study that included 2,554 adults aged 45 and older who underwent in-hospital, major noncardiac surgery between 2016 to 2020; all patients had nongated chest CT imaging (either with contrast, 58.1%, or without contrast 41.9%) within one year before surgery.

Surgery types included the following:

• General (29.4%)
• Orthopedic (16.8%)
• Neurosurgical (13.9%)
• Thoracic (13.4%)
• Vascular (12.4%)

Most (82.3%) of these procedures used general anesthesia, the team noted.

Exam readers graded coronary calcium for each heart vessel using a 4-point scale (with 0 equal to no calcium, 1 equal to mild calcium, 2 equal to moderate calcium, and 3 equal to severe calcium). The investigators calculated patients’ estimated coronary calcium burden as the sum of scores for each artery (scale of 0 to 9) and assigned a Revised Cardiac Risk Index (RCRI) score to each patient. (RCRI uses six variables — history of ischemic heart disease, heart failure, stroke, insulin-dependent diabetes, chronic kidney disease, and high-risk surgery — to assess risk of perioperative cardiac complications in noncardiac surgeries.)

The team reported the following:

• Median time from nongated chest CT imaging to noncardiac surgery was 15 days.
• Median estimated coronary calcium burden was 1, as was the median RCRI score.
• 5.2% of patients experienced perioperative major clinical events (myocardial infarction or death).
• Patients with any coronary artery calcium had higher risk of perioperative major clinical events than those without, at 6.8% compared with 2.9%.
• An estimated coronary calcium burden equal to or higher than 3 showed a twofold higher odds ratio of perioperative major clinical events than an estimated coronary calcium burden of less than three (odds ratio, 2.11, with 1 as reference).

The group also found that increased coronary calcium burden boosted a patient’s risk of a major perioperative clinical event.

Data from prior nongated chest CT exams shows promise for improving patient care, according to Choi and colleagues.

“Prevalence and severity of coronary calcium obtained from existing nongated chest CT imaging improve preoperative clinical risk stratification before noncardiac surgery,” they concluded.

The complete study can be found here.

Many women younger than 40 who are at high risk for breast cancer are not getting appropriate screening, according to findings published October 11 in the American Journal of Surgery.  

Researchers led by Christine Pestana, MD, from Wake Forest Baptist Health in Winston-Salem, NC, found that of the women younger than 40 in their study, only about 3% underwent appropriate screening despite over one in three meeting high-risk criteria.  

“This analysis highlights a significant discrepancy between those meeting criteria for high-risk screening and those who underwent appropriate screening,” the Pestana team wrote. 

Several health societies, including those in radiology, recommend annual screening mammography to start at age 40 for women with an average risk of developing breast cancer. However, guidelines by the National Comprehensive Cancer Network (NCCN) recommend screening young women with an increased breast cancer risk, meaning a 20% or greater lifetime risk. 

Pestana and colleagues evaluated their health system’s institutional rates of high-risk screening in young breast cancer patients prior to their diagnosis. They investigated risk scores from the Tyrer-Cuzick model and characteristics of breast cancer patients younger than 40, using data collected between 2013 and 2018. 

In all, the team included data from 92 women with an average age of 34.5 in the study. It found that only 3.3 % (n = 3) of the women underwent appropriate screening mammography, despite 35.8 % meeting the high-risk threshold. The group also reported that 74 of the women had their breast cancer discovered via a palpable breast mass.  

“This suggests that the current implementation of screening guidelines may not be adequate,” Pastena and co-authors wrote. 

The team also found that almost all patients (98.9%) underwent genetic testing, with pathogenic mutations identified in 36.5 % of the women. Additionally, 15.3% of the women tested (n = 13) had BRCA1/2 mutations. 

Most of the women (n = 53) underwent bilateral mastectomy as their preferred surgical choice, while 22 underwent unilateral mastectomy and 13 underwent lumpectomy. Six of the women opted not to undergo surgery at all. 

Finally, the researchers found that Black women were more likely to present with advanced-stage disease, at 17.6% compared with white women at 3.3% (p = 0.03). 

“Underutilization of screening has been attributed to decreased awareness among health care providers regarding guidelines for high-risk screening and genetics referral, lack of familiarity with conducting a detailed breast cancer risk assessment, the inaccessibility of centers with onsite MRI or experienced genetic counselors,” the study authors wrote. 

Citing previous studies, the authors also suggested that screening MRI could help detect more cancers for high-risk women. The studies demonstrated that MRI in this area is more sensitive than mammography, able to detect breast cancers at earlier stages, and increases breast cancer survival for high-risk patients. 

Lung cancer incidences continue to increase among younger women, according to a research letter published October 12 in JAMA Oncology.

What’s prompting the trend needs more study, wrote a team led by Ahmedin Jemal, DVM, PhD, of the American Cancer Society in Atlanta.

“[We] found that the higher lung cancer incidence in women than in men has not only continued in individuals younger than 50 years but also now extends to middle-aged adults as younger women with a high risk of the disease enter older age,” the group reported. “[But] reasons for this shift are unclear because the prevalence and intensity of smoking are not higher in younger women compared with men except for a slightly elevated prevalence among those born in the 1960s.”

Lung cancer screening is performed using low-dose CT (LDCT) and is recommended annually for people ages 50 to 80 with a 20-pack-year smoking history who currently smoke or have quit within the past 15 years. Previous ACS research found higher incidence of lung cancer in women than in men in the younger than 50 age group — results contrary to studies that established higher burden of the disease in men that couldn’t be explained by smoking differences, the team wrote. But whether this trend has continued into the present is unclear.

Jemal and colleagues investigated lung cancer incidences patterns by age and sex, using data from 22 registries of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program from between 2000 and 2019. They categorized cases by sex; by age in five-year increments; and by year of diagnosis (2000 to 2004, 2005 to 2009, 2010 to 2014, and 2015 to 2019), then calculated age-specific lung cancer incidence rates per 100,000 person years using SEER*Stat version 8.4.1.3 and female to male rate disease incidence ratios using the Tiwari method.

The group found the following:

• Overall, lung cancer incidence rates showed greater decline in men than in women between 2000 to 2004 and 2015 to 2019; this trend led to a higher incidence in women between the ages of 35 and 54.
• Over the study timeframe in individuals aged 50 to 54 years, the rate of lung cancer per 100,000 person-years decreased by 44% in men and 20% in women.
• The female-to-male incidence rate ratio among people between the ages of 50 and 54 increased from 0.73 (with 1 as reference) between 2000 and 2004 to 1.05 between 2015 and 2019.
• Among those between the ages of 70 and 74, the female-to-male incidence rate ratio increased from 0.62 during 2000 and 2004 to 0.81 during 2015 and 2019.

Further research is needed to explain these lung cancer incidence trends, according to the authors.

“Lung cancer is still the leading cause of cancer death in the U.S. with 80% of cases and deaths caused by cigarette smoking,” Jemal said in a statement released by the ACS. “To mitigate the high burden of the disease in young and middle-aged women, greater effort is needed to promote tobacco cessation at provider and community levels, improve access to tobacco cessation aids and programs through expansion of Medicaid, and increase lung cancer screening in eligible women. Also, further research is needed to shed light on the reasons for the higher lung cancer incidence in younger and middle-aged women.”

The complete study can be found here.