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MS10 - Lung Cancer Screening, Opportunistic Evaluation of Findings (ID 73)
- Event: WCLC 2019
- Type: Mini Symposium
- Track: Screening and Early Detection
- Presentations: 7
- Now Available
MS10.01 - COPD/Emphysema (Now Available) (ID 3492)
15:45 - 17:15 | Presenting Author(s): Javier Zulueta
Lung cancer and COPD are now the second and third most frequent causes of death in the US. Mortality from COPD has increased by 86% in the last 25 years (1), but remains a greatly underdiagnosed disease. Furthermore, COPD, and in particular emphysema, has been shown to signficantly increase the risk of having, and dying from, lung cancer (2-4). In spite of these facts, the USPSTF continues to recommend against screening for COPD mainly because there is no evidence showing that any treatment or intervention can have an impact on the outcome of COPD. In this presentation we will review the latest data showing that lung cancer screeing may be an opportunity to uncover a large proportion of patients with underdiagnosed COPD, and that screening for lung cancer may have an impact on long term outcome of COPD. In addtition, the presence of COPD and/or specific subtypes of emphysema may be key in improving the selection of optimal candidates for lung cancer screening. Questions regarding the potential harms involved in screening for lung cancer in individuals with COPD/emphysema will be addressed.
1. Mulshine. AJPH 2018; 108:1294-5
2. de Torres et al. Chest 2007;132:1932-8
3. Zulueta et al. Chest. 2012;141(5):1216-23
4. Wilson et al. Am J Respir Crit Care Med. 2008;178:738
5. Gonzalez et al. PLoS One 2019; in press.
MS10.02 - Coronary Artery Diseases (Now Available) (ID 3493)
15:45 - 17:15 | Presenting Author(s): Joseph Shemesh
Coronary artery calcification (CAC) on low dose chest CT for lung screening
J. Shemesh MD
Professor emeritus of cardiology
Sheba Medical Center
CT-based Coronary artery calcification (CAC) Agatston score on Lung cancer screening has an unequivocal prognostic contribution to future cardiovascular (CV) events and mortality.
Aim: To provide the radiologists with helpful information regarding on how to diagnose, quantify and routinely report on CAC while reading low dose chest CT (LDCT) performed for lung cancer screening.
Current understandings: CAC can be easily detected and its extent can be quantify or semi-quantify while reading the chest CT without extra radiation, efforts or cost. Most of the target subjects for lung screening are at the same time at high risk to develop cardiovascular (CV) events and mortality (1) . Reporting on CAC enhances the lung screening benefit by providing the clinicians with an additive powerful risk stratification tool that can improve the management of primary prevention of CV events particularly the need for statin . Recently the Society of Cardiovascular Computed Tomography (SCCT) and the Society of Thoracic Radiology (STR) have jointly published guidelines for coronary artery calcium scoring derived from non contrast noncardiac chest CT scans (2). The experts of this guideline , recommend reporting on CAC as Class I indication.
It has been shown that the absence , presence and severity of CAC identify those who are most likely to benefit from statin therapy for primary prevention (3) Comparing those with and without statin exposure, statin therapy was associated with reduced risk of MACE in patients with CAC but not in patients without CAC . They further found that the effect of statin use on MACE was significantly related to the severity of CAC , with the number needed to treat to prevent 1 initial MACE outcome over 10 years ranging from 100 (CAC 1 to 100) to 12 (CAC >100).
The most recent guidelines recognize the CAC score as disease score that can individualize the CVD risk and recommended its use to refine the risk estimation in order to better allocate asymptomatic subjects to statin treatment,intensification or avoidance, for primary prevention of CVD (4). The Multi-Ethnic Study of Atherosclerosis (MESA) score is a new score that incorporates the Agatston CAC score in addition to traditional risk factors to estimate the 10 years cardiac risk (5)
In summary: CAC is the most prevalent incidental finding on LDCT. It can be easily detected measured and reported on lung screening CT without extra radiation, efforts or cost. CAC score helps to avoid or recommend life time statin or aspirin treatment .
10 Take home messages
Most of the target subjects for lung screening are at the same time at high risk to develop cardiovascular (CV) events and mortality.
CAC is the most prevalent incidental finding on LDCT
CAC is the best biologic prognostic marker for the prediction of CV events and mortality.
The measure of CAC is now accepted as common practice for primary prevention of CV events.
CAC can and should be measured and reported on chest CT done for lung cancer screening.
CAC is associated strongly and in a graded fashion with 10-year risk of incident ASCVD as it is for CHD, independent of standard risk factors, and similarly by age, gender, and ethnicity. While those with zero CAC are almost exclusively below 5% 10 years risk (statin is not indicated), those with CAC ≥ 100 were consistently above 7.5% (statin is indicated).
In a large-scale cohort without baseline ASCVD, the presence and severity of CAC identified patients most likely to benefit from statins for the primary prevention of CVDs:
There was no benefit of statins in those with no CAC and low or intermediate baseline risk.
Patients with a CAC >100 had a 64-71% reduction in MACE even with low (<5%) or intermediate risk (5-20%).
Reporting on CAC enhances the lung screening benefit by providing the clinicians with an additive powerful risk stratification tool that can improve the management of primary prevention of CV events particularly for the initiation / withhold / intensification / avoidance of statin treatment.
CAC can be estimated as none, mild, moderate or severe but it is recommended to perform the Agatston CAC score.
CAC score can recategorize up to half of those who underwent chest CT into a higher or lower CV risk category.
Hecht HS, Henschke CI, Yankelevitz D et al. Combined detection of coronary artery disease and lung cancer. Eur Heart J. 2014;35:2792–6
Harvey S. Hecht, Paul Cronin Michael J. Blaha et al 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. Journal of Cardiovascular Computed Tomography 2017, Volume 11, Issue 1, Pages 74–84
Mitchell JD, Fergestrm N, Gage BF, et al. Impact of statins cardiovascular outcomes following coronary artery calcium scoring. J Am Coll Cardiol 2018:72:3233-3244
2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Grundy SM et al. J Am Coll Cardiol. (2018)
McClelland RL, Jorgensen NW, Budoff M, et al. 10-Year Coronary Heart Disease Risk Prediction Using Coronary Artery Calcium and Traditional Risk Factors: Derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) With Validation in the HNR (Heinz Nixdorf Recall) Study and the DHS (Dallas Heart Study). J Am Coll Cardiol. 2015;66:1643–53
INTRODUTION: Smoking is a major risk factor for both cardiovascular disease and lung cancer. Low-dose computed tomography (LDCT) screening for lung cancer provides an opportunity to identify both diseases in asymptomatic smokers (1). The extent of aortic valve calcification (AVC) is the predominant driver of degenerative aortic valve stenosis (AS) (2), which is an underdiagnosed and undertreated disease. Cardiovascular morbidity and mortality is higher for people with moderate/severe AVC as compared to those with none or mild AVC as demonstrated on echocardiography (3). Our study aimed to assess sensitivity and reliability of visual AVC scoring on LDCT for predicting AS in older smokers. In addition, we aimed to determine the frequency of any AVC and its significant predictors in a program of LDCT screening for lung cancer, separately on baseline and annual repeat screenings.
MOTHODS: We reviewed 1225 consecutive participants in annual LDCT screening for lung cancer at the Mount Sinai Hospital before July 2018, who had at least two LDCTs without aortic valve replacement (AVR) before enrolled. The baseline LDCT was the first scan obtained at the time of enrollment and the most recent LDCT was the last LDCT obtained before July 2018, unless the participant had either AVR or had died before July 2018; for these cases, the last LDCT scan before surgery or death was used. Sensitivity and specificity of moderate/severe visual AVC score on LDCT to identify AS on echocardiogram was calculated for 126 participants who had both tests within 12 months. Using regression analyses, risk factors for AVC at baseline, for progression, and for new AVC on annual rounds of screening were identified. Reliability of AVC assessment on LDCT was assessed by comparing AVC visual scores with 1) standard-dose, electrocardiography (ECG)-gated CT for 31 participants who had both tests within 12 months, 2) with Agatston scores of 1225 participants on the most recent follow-up LDCT, and 3) by determining the intra-reader agreement on baseline LDCTs and separately for the most recent LDCTs of all participants.
RESULTS: Among these 126 participants who had LDCT and echocardiography within 12 months, 7 (5.6%) were diagnosed with moderate/severe AS, 3 (2.4%) were diagnosed with mild AS, 37 (29.4%) with aortic sclerosis, and 79 (62.7%) with no sclerosis or AS (Table 1). Of the 3 diagnosed as severe AS on echocardiography, all 3 had severe (grade 3) AVC on LDCT and of the 4 diagnosed as moderate AS on echocardiography, all 4 had moderate (grade 2) AVC on LDCT. Visual AVC scores on LDCT had substantial agreement with the severity of AS on echocardiography (weighted kappa=0.68, 95% CI: 0.56, 0.80). In addition, correlation was significant between the AVC visual scores on LDCT and both the echocardiographically determined mean pressure gradient (p = 0.02) and aortic valve area (p = 0.02) in these 10 participants with AS. Sensitivity and specificity of moderate/severe visual AVC scores for moderate/severe AS on echocardiogram was 100% and 94%, respectively.
There is substantial inter- (total weighted kappa of 0.73) and excellent intra-observer agreement (Baseline LDCT: weighted Kappa=0.91, 95% CI: 0.88-0.95; The most recent LDCT: weighted Kappa=0.90, 95% CI: 0.88-0.92).
Of the 1225 participants, no AVC was identified on the baseline LDCT in 1081 (88.2%), while 116 had mild AVC (grade 1), 26 moderate AVC (grade 2), and 2 severe AVC (grade 3). On the most recent LDCT, median follow-up time from baseline LDCT was 10.9 years (IQR: 4.2 to 15.1 yrs.), 865 (70.6%) had no AVC, 262 (21.4%) mild AVC, 80 (6.5%) moderate AVC, and 18 (1.5%) severe AVC. Multivariable logistic regression analysis showed significant predictors for baseline AVC were male sex (OR=3.39), age (OR=1.11) and CAC score (OR=1.28), for AVC progression after baseline, was pack-years of smoking (HR=1.01), and for new AVC on annual LDCT, were male sex (HR=1.65), age (HR=1.06), and BMI (HR=1.06).
CONCLUSIONS: Our results suggest that moderate to severe AVC scores could be reliably obtained on LDCT, should also be reported on screening LDCTs and further workup by echocardiography should be recommended as finding moderate or severe AVC on LDCT was associated with a high probability of AS in asymptomatic smokers.
1. Lu MT, Onuma OK, Massaro JM, D'Agostino RB, Sr., O'Donnell CJ, Hoffmann U. Lung Cancer Screening Eligibility in the Community: Cardiovascular Risk Factors, Coronary Artery Calcification, and Cardiovascular Events. Circulation. 2016;134(12):897-9.
2. Nguyen V, Cimadevilla C, Estellat C, et al. Haemodynamic and anatomic progression of aortic stenosis. Heart. 2015;101(12):943-7.
3. Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. The New England journal of medicine. 1999;341(3):142-7.
TABLE 1. Agreement of AVC Score on LDCT by Extent of Aortic Stenosis on Echocardiogram Among Those Who Had Both Tests Within 12 Months.
Aortic stenosis categories based on Echocardiography*
No Aortic Stenosis
Visual AVC scores ꝉ
Weighted Kappa=0.68 (95% CI: 0.56, 0.80).
FIGURE 1. Visual and Agatston AVC Scoring.
MS10.04 - Liver - Pulmonary Disease (Now Available) (ID 3495)
15:45 - 17:15 | Presenting Author(s): Andrea D Branch
Evidence of an Association between Pulmonary Dysfunction and Fatty Liver Disease
Background: There is an epidemiological association between pulmonary dysfunction and fatty liver disease.
Aim: To investigate the association between pulmonary dysfunction and liver steatosis in members of the World Trade Center General Responder Cohort and other populations.
Methods: FIB-4 scores were calculated from the most recent data in electronic health records; fibrosis was defined as a FIB-4 score ≥ 2.67, which is associated with a 43-fold increased risk of liver-related mortality. Fatty liver was determined by automated analysis of non-contrast chest CT scans; attenuation < 40 Hounsfeld Units (HU) indicated moderate-to-severe steatosis, which means that ≥ 30% of hepatocytes contain excessive lipid. Primary liver cancer was identified by filtering on international classification of diseases (ICD9/10) codes 155/C22, and verifying the diagnosis by chart review. Multivariable logistic (MVL) regression was used to identify factors independently associated with liver fibrosis and steatosis. All reported findings are significant at p < 0.05.
Results: Among 18,231 responders, 414 (2.3%) had liver fibrosis, which was associated with lower body mass index (BMI), obstructive pulmonary disease, male sex, smoking history, alcohol history, and less education. Among 7227 responders who denied smoking and/or heavy alcohol consumption, 112 (1.5%) had liver fibrosis, which was again associated with lower BMI, reduced pulmonary function, male sex, and less education. Among 1248 responders with CT scans available for analysis of liver status, 184 (15%) had moderate-to-severe steatosis. Fatty liver was associated with arrival at the WTC site on 9/11 and higher values of ALT, AST, bilirubin, neutrophils, and BMI. Among the responders with fatty liver, 38 (21%) were not obese (BMI < 30 kg/m2). The non-obese responders had higher values of ALT, AST, and bilirubin, and lower values of platelets, indicating that they had more advanced liver disease. Thirty-three responders had primary liver cancer.
Conclusions: Among WTC responders, liver fibrosis was associated with pulmonary dysfunction and lower BMI; excessive weight and metabolic disease were not the primary drivers. Among responders with liver fat, those with lower BMI had more extensive liver damage, as often occurs in toxicant-associated steatohepatitis (FAMRI, NIOSHU01OH011489).
MS10.05 - Osteoporosis (Now Available) (ID 3496)
15:45 - 17:15 | Presenting Author(s): Jessica Gonzalez-Gutierrez
Abstract not provided
MS10.06 - Interstitial Lung Diseases (Now Available) (ID 3497)
15:45 - 17:15 | Presenting Author(s): Mary Salvatore
Lung Cancer in patients with Lung Fibrosis
Mary M. Salvatore MD, MBA
Patients with a history of smoking are enriched population for studying pulmonary fibrosis and as patients are living longer with fibrosis, they are becoming an enriched population for studying lung cancer (1). Usual interstitial Pneumonitis is the most frequent pattern of pulmonary fibrosis in the United States. There are 48,000 new patients with IPF each year in the US and 40,000 die (2). Ozawa found that the cumulative incidence of lung cancer is 3.3%, 15.4%, and 54.7% at 1, 5, and 10 years of IPF (3). Adenocarcinoma is most common lung cancer in the general population. Kawasaki found that of 53 patients with IPF and lung cancer, there was no predominant histology. There are similarities between lung cancer and fibrosis, which include invasion of normal tissue, lack of monoclonality, mutation of tumor suppressor genes and epithelial mesenchymal transformation (4). The tumor microenvironment often causes cancers in fibrosis to have shorter doubling times. The survival of patients with lung fibrosis and cancer is poor with up to 93% 5-year mortality (5). Screening for lung cancer in patients with fibrosis is different from screening in non-fibrotic patients because of the potential rapid growth of some cancers.
Lung cancer occurring in a patient with fibrosis are different from lung cancer occurring in a patient with emphysema. The patients are often not candidates for surgery. If they have surgery, it should be as limited as possible to decrease the risk of exacerbation (6). Chemotherapy increase risk of an exacerbation as does immunotherapy (7). Radiation has an increased risk of exacerbation as well; perhaps proton therapy may have better outcomes (8). In summary as patients are living longer with fibrosis the incidence of lung cancer is increasing however the treatments for early cancer in patients with lung cancer increase the risk of fibrosis exacerbation and further study is necessary in this area to make recommendations for best practices.
1. Salvatore M, Henschke CI, Yip R, Jacobi A, Eber C, Padilla M, Knoll A, Yankelevitz D. JOURNAL CLUB: Evidence of Interstitial Lung Disease on Low-Dose Chest CT Images: Prevalence, Patterns, and Progression. AJR Am J Roentgenol 2016 Mar; 206(3):487-94.
2. G. Raghu, S.Y. Chen, Q. Hou, W.S. Yeh, H.R. Collard, Incidence and prevalence of idiopathic pulmonary fibrosis in US adults 18-64 years old, Eur. Respir. J.48 (1) (2016).
3. Ozawa Y, Suda T, Naito T, Enomoto N, Hashimoto D, Fujisawa T, Nakamura Y, Inui N, Nakamura H, Chida K.: Cumulative incidence of and predictive factors for lung cancer in IPF. Respirol. Carlt. Vic., 14 (5) (2009), pp. 723-728.
4. H. Kawasaki, K. Nagai, T. Yokose, J. Yoshida, M. Nishimura, K. Takahashi Clinicopathological characteristics of surgically resected lung cancer associated with idiopathic pulmonary fibrosis. J. Surg. Oncol., 76 (1) (2001), pp. 53-57.
5. Teixeira MR, Heim S. Cytogenetic analysis of tumor clonality. Adv Cancer Res. 2011; 112: 127–149.
6. Joo S, Kim DK, Sim HJ, Lee GD, Hwang SK, Choi S, Kim HR, Kim YH, Park SI. Clinical results of sublobar resection versus lobectomy or more extensive resection for lung cancer patients with idiopathic pulmonary fibrosis. J Thorac Dis. 2016; 8(5): 977–984.
7. E Watanabe N, Taniguchi H, Kondoh Y, Kimura T, Kataoka K, Nishiyama O, Kondo M, Hasegawa Y. Efficacy of chemotherapy for advanced non-small cell lung cancer with idiopathic pulmonary fibrosis. Respiration 2013; 85(4): 326–331.
8. Hakyoung Kim, Hongryull Pyo, Jae Myoung Noh, Woojin Lee, Byoungsuk Park, Hye Yun Park and Hongseok Yoo. Preliminary result of definitive radiotherapy in patients with non-small cell lung cancer who have underlying idiopathic pulmonary fibrosis: comparison between X-ray and proton therapy. Radiat Oncol. 2019 Jan 28; 14(1):19.
MS10.07 - Breast Evaluation (Now Available) (ID 3498)
15:45 - 17:15 | Presenting Author(s): Laurie Margolies
Opportunistic Evaluation of the Breast on Cross Sectional Imaging
Breast tissue is visualized on Chest CT, Chest MRI and to a limited extent on cross sectional imaging of the abdomen; much information about the breasts can be obtained. While cross sectional imaging does not substitute for mammography, for those women who have not had recent mammograms it may be the only opportunity for the breasts to be evaluated. Additionally, there are portions of the medial and posterior breast which can sometimes be seen to better advantage on cross sectional imaging.
Breast Density is a known risk factor for breast cancer development and can mask tumors on mammography. Traditionally, it has been taught that breast density can only be determined by mammography, but it can be reliably determined by evaluating the breasts on CT.[i] (figure shows a Chest CT of a woman with heterogenously dense breasts and corresponding cranio-caudal mammogram image) Reporting of breast density on Chest CT can better inform the patient of her risk and possible imaging strategies.
Masses and some calcifications can be seen on CT. Some are known and require no further evaluation, others are classically benign and also require no further evaluation, but some appear new or changed and do require dedicated breast imaging. By using a breast assessment and recommendatin score (BARCS) system to evaluate and report breast CT findings one can communicate to referring physicians what the next steps if any might be. This is similar to the BI-RADS system used for reporting mammography A BARCS score of 1 or 2 is analogous to the commonly used BI-RADS 1 or 2 and indicates that the findings are negative or benign and no special evaluation is needed. A CT-BI-RADS 2 might be used, for example, in the setting of a classic fibroadenoma. A mass that does not exhibit classic benign features, however, might be given a BARCS 0 and the patient referred for dedicated breast imaging (or review and correlation with prior breast imaging) as the imaging evaluation is incomplete. [ii] Some of these findings will be breast cancer (figure 2 shows a mass in the medial right breast that is easier to see on Chest CT than on mammogram where there is only a developing asymmetry - arrows). The opportunity to fully include and evaluate the breasts on cross sectional imaging should not be missed.[iii] Breast masses can also be an incidental MRI finding.[iv]
Dedicated breast imaging also has the opportunity to detect lung and other disease. Breast MRI, for example, typically includes portions of the lung and abdomen where osseous, lung, liver and renal lesions can be seen.[v] Mammography can detect lymphoma, metastatic melanoma and other systemic diseases such as congestive heart failure [vi] or even be the first indication of re-activation of Tuberculosis.[vii]Cardiovascular disease can manifest itself with breast arterial calcification evident on mammography; this often correlates with coronary artery calcification despite the differences in the pathogenesis of the calcifications. [viii]
Patients[ix] and providers[x] want interpreting radiologists to report on all the imaging findings; chest imagers have the opportunity to detect breast disease and promote appropriate evaluation of findings as well as to assist in personalizing breast cancer screening algorithms.
[i] Salvatore M, Margolies L, Kale M, et al. Breast Density: Comparison of Chest CT with Mammography. Radiology 2014 270:1, 67-73.
[ii] Margolies, LR, Salvatore M, Yip R, et al. The chest radiologist's role in invasive breast cancer detection. Clinical Imaging 2018, Volume 50, 13 - 19.
[iii] Salvatore M, Margolies, L, Bertolini, A, et al. The need to be all inclusive: Chest CT scans should include imaged breast parenchyma. Clinical Imaging 2018 Volume 50, 243-245.
[iv] Bignotti B, Succio G, Nosenzo F, et al. Breast findings incidentally detected on body MRI. Springerplus. 2016;5(1):781.
[v] Gao Y, Ibidapo O, Toth HK and Moy L. Delineating Extramammary Findings at Breast MR Imaging. Radiographics. 2017; 37:10–31.
[vi] Cao MM, Hoyt AC, Bassett LW. Mammographic Signs of Systemic Disease. RadioGraphics 2011 31:4, 1085-1100
[vii] Hwang E, Szabo J, Federman A and Margolies LR. Reactivation tuberculosis presenting with unilateral axillary lymphadenopathy. Radiology Case Reports. 2018: 13(6): 1188-1191.
[viii] Margolies L, Salvatore M, Hecht HS, et al. Digital Mammography and Screening for Coronary Artery Disease. JACC Cardiovasc Imaging. 2016 Apr;9(4):350-60.
[ix] Margolies LR, Yip R. Hwang E, et al. Breast Arterial Calcification in the Mammogram Report: The Patient Perspective. AJR Am J Roentgenol. 2019 Jan;212(1):209-214.
[x] Nasir K and McEvoy JW. Recognizing Breast Arterial Calcification as Atherosclerotic CVD Risk Equivalent. JACC: Cardiovascular Imaging Apr 2016, 9 (4) 361-363.
EP1.11 - Screening and Early Detection (ID 201)
- Event: WCLC 2019
- Type: E-Poster Viewing in the Exhibit Hall
- Track: Screening and Early Detection
- Presentations: 1
- Now Available
- Coordinates: 9/08/2019, 08:00 - 18:00, Exhibit Hall
EP1.11-21 - Lung Cancer Screening Pilot in Israel (Now Available) (ID 2278)
08:00 - 18:00 | Author(s): Dorith Shaham
Lung cancer kills more people than any other cancer, both in Israel and worldwide. In israel 2000 die from the disease each year where the prevalence of smoking is 22.5% above age 21. There is not yet a national lung cancer screening program in Israel, therefore the Israeli Lung Cancer foundation (ILCF) initiated and funded in cooperation with Assuta Medical centers, a pilot program, ILCF-A, calling participants at risk to come and get checked. The activity took place during the international Lung Cancer awareness month, November 2018.Method
A call for free lung cancer screening was published and promoted on Facebook. People who enlisted filled a questionnaire to evaluate eligibility for screening, which was age 55–74 years, 30 pack-year of smoking history and current smokers or ones who quited within 15 years. There was only a screening arm and LDCT was performed for all subjects. CT reporting and management was performed using LUNGRADS.Result
Overall 90 subjects were eligible and underwent screening of which, 45% were women and 55% men. The average age of subjects was 63 and the average pack years was 45. Most of the subjects were current smokers. In one third of the subjects, nodules were not detected., when detected, average size of nodules was 3.25 mm. Of all subjects, eight were classified with positive results. Four with LUNGRAD score of 3 are under LDCT follow-up. Of the four who had LUNGRAD score of 4, One subject was diagnosed with stage 1 Lung Cancer and had a successful surgery, two subjects were found to be healthy by PET-CT and Bronchoscopy and 1 is still under investigation. Lung Cancer detection rate was 1.11% and FP rate was 7.7%.Conclusion
The ILCF-A trial provided evidence that Lung Cancer Screening in Israel is beneficial. In addition, raising awareness and calling the public to come get screened via digital media has an impact. Despite the limitation of this small study, results of cancer detection rate and FP rates were comparable with NLST and NELSON trials. Although the smoking rate of women in Israel is more then half then that of men (12% compared with 27%), their responsiveness for undergoing screening was as high. Based on this promising evidence, Lung Cancer National Screening program in Israel is recommended and feasible.