Growing small solid nodules in lung cancer screening: safety and efficacy of a 200 mm3 minimum size threshold for multidisciplinary team referral

The optimal management of small but growing nodules remains unclear. The SUMMIT study nodule management algorithm uses a specific threshold volume of 200 mm3 before referral of growing solid nodules to the multidisciplinary team for further investigation is advised, with growing nodules below this threshold kept under observation within the screening programme. Malignancy risk of growing solid nodules of size >200 mm3 at initial 3-month interval scan was 58.3% at a per-nodule level, compared with 13.3% in growing nodules of size ≤200 mm3 (relative risk 4.4, 95% CI 2.17 to 8.83). The positive predictive value of a combination of nodule growth (defined as percentage volume change of ≥25%), and size >200 mm3 was 65.9% (29/44) at a cancer-per-nodule basis, or 60.5% (23/38) on a cancer-per-participant basis. False negative rate of the protocol was 1.9% (95% CI 0.33% to 9.94%). These findings support the use of a 200 mm3 minimum volume threshold for referral as effective at reducing unnecessary multidisciplinary team referrals for small growing nodules, while maintaining early-stage lung cancer diagnosis

Uptake of invitations to a lung health check offering low-dose CT lung cancer screening among an ethnically and socioeconomically diverse population at risk of lung cancer in the UK (SUMMIT): a prospective, longitudinal cohort study

BACKGROUND: Lung cancer screening with low-dose CT reduces lung cancer mortality, but screening requires equitable uptake from candidates at high risk of lung cancer across ethnic and socioeconomic groups that are under-represented in clinical studies. We aimed to assess the uptake of invitations to a lung health check offering low-dose CT lung cancer screening in an ethnically and socioeconomically diverse cohort at high risk of lung cancer. METHODS: In this multicentre, prospective, longitudinal cohort study (SUMMIT), individuals aged 55-77 years with a history of smoking in the past 20 years were identified via National Health Service England primary care records at practices in northeast and north-central London, UK, using electronic searches. Eligible individuals were invited by letter to a lung health check offering lung cancer screening at one of four hospital sites, with non-responders re-invited after 4 months. Individuals were excluded if they had dementia or metastatic cancer, were receiving palliative care or were housebound, or declined research participation. The proportion of individuals invited who responded to the lung health check invitation by telephone was used to measure uptake. We used univariable and multivariable logistic regression analyses to estimate associations between uptake of a lung health check invitation and re-invitation of non-responders, adjusted for sex, age, ethnicity, smoking, and deprivation score. This study was registered prospectively with ClinicalTrials.gov, NCT03934866. FINDINGS: Between March 20 and Dec 12, 2019, the records of 2 333 488 individuals from 251 primary care practices across northeast and north-central London were screened for eligibility; 1 974 919 (84·6%) individuals were outside the eligible age range, 7578 (2·1%) had pre-existing medical conditions, and 11 962 (3·3%) had opted out of particpation in research and thus were not invited. 95 297 individuals were eligible for invitation, of whom 29 545 (31·0%) responded. Due to the COVID-19 pandemic, re-invitation letters were sent to only a subsample of 4594 non-responders, of whom 642 (14·0%) responded. Overall, uptake was lower among men than among women (odds ratio [OR] 0·91 [95% CI 0·88-0·94]; p<0·0001), and higher among older age groups (1·48 [1·42-1·54] among those aged 65-69 years vs those aged 55-59 years; p<0·0001), groups with less deprivation (1·89 [1·76-2·04] for the most vs the least deprived areas; p<0·0001), individuals of Asian ethnicity (1·14 [1·09-1·20] vs White ethnicity; p<0·0001), and individuals who were former smokers (1·89 [1·83-1·95] vs current smokers; p<0·0001). When ethnicity was subdivided into 16 groups, uptake was lower among individuals of other White ethnicity than among those with White British ethnicity (0·86 [0·83-0·90]), whereas uptake was higher among Chinese, Indian, and other Asian ethnicities than among those with White British ethnicity (1·33 [1·13-1·56] for Chinese ethnicity; 1·29 [1·19-1·40] for Indian ethnicity; and 1·19 [1·08-1·31] for other Asian ethnicity). INTERPRETATION: Inviting eligible adults for lung health checks in areas of socioeconomic and ethnic diversity should achieve favourable participation in lung cancer screening overall, but inequalities by smoking, deprivation, and ethnicity persist. Reminder and re-invitation strategies should be used to increase uptake and the equity of response. FUNDING: GRAIL

The role of computer-assisted radiographer reporting in lung cancer screening programmes

OBJECTIVES: Successful lung cancer screening delivery requires sensitive, timely reporting of low-dose computed tomography (LDCT) scans, placing a demand on radiology resources. Trained non-radiologist readers and computer-assisted detection (CADe) software may offer strategies to optimise the use of radiology resources without loss of sensitivity. This report examines the accuracy of trained reporting radiographers using CADe support to report LDCT scans performed as part of the Lung Screen Uptake Trial (LSUT). METHODS: In this observational cohort study, two radiographers independently read all LDCT performed within LSUT and reported on the presence of clinically significant nodules and common incidental findings (IFs), including recommendations for management. Reports were compared against a 'reference standard' (RS) derived from nodules identified by study radiologists without CADe, plus consensus radiologist review of any additional nodules identified by the radiographers. RESULTS: A total of 716 scans were included, 158 of which had one or more clinically significant pulmonary nodules as per our RS. Radiographer sensitivity against the RS was 68-73.7%, with specificity of 92.1-92.7%. Sensitivity for detection of proven cancers diagnosed from the baseline scan was 83.3-100%. The spectrum of IFs exceeded what could reasonably be covered in radiographer training. CONCLUSION: Our findings highlight the complexity of LDCT reporting requirements, including the limitations of CADe and the breadth of IFs. We are unable to recommend CADe-supported radiographers as a sole reader of LDCT scans, but propose potential avenues for further research including initial triage of abnormal LDCT or reporting of follow-up surveillance scans. KEY POINTS: • Successful roll-out of mass screening programmes for lung cancer depends on timely, accurate CT scan reporting, placing a demand on existing radiology resources. • This observational cohort study examines the accuracy of trained radiographers using computer-assisted detection (CADe) software to report lung cancer screening CT scans, as a potential means of supporting reporting workflows in LCS programmes. • CADe-supported radiographers were less sensitive than radiologists at identifying clinically significant pulmonary nodules, but had a low false-positive rate and good sensitivity for detection of confirmed cancers

The JCMT Gould Belt Survey: SCUBA-2 Data Reduction Methods and Gaussian Source Recovery Analysis

The James Clerk Maxwell Telescope (JCMT) Gould Belt Survey (GBS) was one of the first legacy surveys with the JCMT in Hawaii, mapping 47 deg2 of nearby (<500 pc) molecular clouds in dust continuum emission at 850 and 450 μm, as well as a more limited area in lines of various CO isotopologues. While molecular clouds and the material that forms stars have structures on many size scales, their larger-scale structures are difficult to observe reliably in the submillimeter regime using ground-based facilities. In this paper, we quantify the extent to which three subsequent data reduction methods employed by the JCMT GBS accurately recover emission structures of various size scales, in particular, dense cores, which are the focus of many GBS science goals. With our current best data reduction procedure, we expect to recover 100% of structures with Gaussian σ sizes of ≤30'' and intensity peaks of at least five times the local noise for isolated peaks of emission. The measured sizes and peak fluxes of these compact structures are reliable (within 15% of the input values), but source recovery and reliability both decrease significantly for larger emission structures and fainter peaks. Additional factors such as source crowding have not been tested in our analysis. The most recent JCMT GBS data release includes pointing corrections, and we demonstrate that these tend to decrease the sizes and increase the peak intensities of compact sources in our data set, mostly at a low level (several percent), but occasionally with notable improvement

Detection of COPD in the SUMMIT Study Lung Cancer Screening Cohort using Symptoms and Spirometry

BACKGROUND: COPD is a major comorbidity in lung cancer screening (LCS) cohorts, with a high prevalence of undiagnosed COPD. Combining symptom assessment with spirometry in this setting may enable earlier diagnosis of clinically significant COPD and facilitate increased understanding of lung cancer risk in COPD. In this study, we wished to understand the prevalence, severity, clinical phenotype and lung cancer risk of individuals with symptomatic undiagnosed COPD in a LCS cohort. METHODS: 16 010 current or former smokers aged 55-77 attended a Lung Health Check as part of the SUMMIT Study [NCT03934866]. A respiratory consultation and spirometry were performed alongside LCS eligibility assessment. Those with symptoms, no previous COPD diagnosis and airflow obstruction were labelled as undiagnosed COPD. Baseline low-dose CT was performed in those at high risk of lung cancer (PLCOm2012 score >1.3% and/or meeting USPSTF 2013 criteria). RESULTS: One in five (19.7%) met criteria for undiagnosed COPD. Compared to those previously diagnosed, those undiagnosed were more likely to be male (59.1% versus 53.2%, p<0.001), currently smoking (54.9% versus 47.6%, p<0.001) and from an ethnic minority group (p<0.001). Undiagnosed COPD was associated with less FEV1 impairment (GOLD grades 1&2 85.3% versus 68.4%, p<0.001) and lower symptom/exacerbation burden (GOLD A&B groups 95.6% versus 77.9%, p<0.001) than those with known COPD. Multivariate analysis demonstrated that airflow obstruction was an independent risk factor for lung cancer risk on baseline LDCT (adjOR 2.74, 95% CI 1.73-4.34; p<0.001), with a high risk seen in those with undiagnosed COPD (adjOR 2.79, 95% CI 1.67-4.64, p<0.001). CONCLUSIONS: Targeted case-finding within LCS detects high rates of undiagnosed symptomatic COPD in those most at risk. Individuals with undiagnosed COPD are at high risk for lung cancer

The JCMT Gould Belt Survey: SCUBA-2 data reduction methods and Gaussian source recovery analysis

The James Clerk Maxwell Telescope (JCMT) Gould Belt Survey (GBS) was one of the first legacy surveys with the JCMT in Hawaii, mapping 47 deg2 of nearby (<500 pc) molecular clouds in dust continuum emission at 850 and 450 μm, as well as a more limited area in lines of various CO isotopologues. While molecular clouds and the material that forms stars have structures on many size scales, their larger-scale structures are difficult to observe reliably in the submillimeter regime using ground-based facilities. In this paper, we quantify the extent to which three subsequent data reduction methods employed by the JCMT GBS accurately recover emission structures of various size scales, in particular, dense cores, which are the focus of many GBS science goals. With our current best data reduction procedure, we expect to recover 100% of structures with Gaussian σ sizes of ≤30'' and intensity peaks of at least five times the local noise for isolated peaks of emission. The measured sizes and peak fluxes of these compact structures are reliable (within 15% of the input values), but source recovery and reliability both decrease significantly for larger emission structures and fainter peaks. Additional factors such as source crowding have not been tested in our analysis. The most recent JCMT GBS data release includes pointing corrections, and we demonstrate that these tend to decrease the sizes and increase the peak intensities of compact sources in our data set, mostly at a low level (several percent), but occasionally with notable improvement

Thigh-length compression stockings and DVT after stroke

Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease

Lung Screen Uptake Trial: results from a single lung cancer screening round

The Lung Screen Uptake Trial tested a novel invitation strategy to improve uptake and reduce socioeconomic and smoking-related inequalities in lung cancer screening (LCS) participation. It provides one of the first UK-based 'real-world' LCS cohorts. Of 2012 invited, 1058 (52.6%) attended a 'lung health check'. 768/996 (77.1%) in the present analysis underwent a low-dose CT scan. 92 (11.9%) and 33 (4.3%) participants had indeterminate pulmonary nodules requiring 3-month and 12-month surveillance, respectively; 36 lung cancers (4.7%) were diagnosed (median follow-up: 1044 days). 72.2% of lung cancers were stage I/II and 79.4% of non-small cell lung cancer had curative-intent treatment