Lung cancer screening with low-dose CT in Europe: strength and weakness of diverse independent screening trials

A North American trial reported a significant reduction of lung cancer mortality and overall mortality as a result of annual screening using low-dose computed tomography (LDCT). European trials prospectively tested a variety of possible screening strategies. The main topics of current discussion regarding the optimal screening strategy are pre-test selection of the high-risk population, interval length of LDCT rounds, definition of positive finding, and post-test apportioning of lung cancer risk based on LDCT findings. Despite the current lack of statistical evidence regarding mortality reduction, the European independent diverse strategies offer a multi-perspective view on screening complexity, with remarkable indications for improvements in cost-effectiveness and harm-benefit balance. The UKLS trial reported the advantage of a comprehensive and simple risk model for selection of patients with 5% risk of lung cancer in 5 years. Subjective risk prediction by biological sampling is under investigation. The MILD trial reported equal efficiency for biennial and annual screening rounds, with a significant reduction in the total number of LDCT examinations. The NELSON trial introduced volumetric quantification of nodules at baseline and volume-doubling time (VDT) for assessment of progression. Post-test risk refinement based on LDCT findings (qualitative or quantitative) is under investigation. Smoking cessation remains the most appropriate strategy for mortality reduction, and it must therefore remain an integral component of any lung cancer screening programme.