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Lungenkrebsscreening: Aktuelle Entwicklungen

Lung cancer screening: current trends

  • Leitthema
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Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz Aims and scope

Zusammenfassung

Screeningstudien zum konventionellen Röntgen der Lunge und zu Sputumuntersuchungen konnten keine Reduktion der Lungenkrebsmortalität belegen. Hingegen scheint das Screening mittels Low-Dose-Computertomographie (LDCT) Erfolg versprechender zu sein, da es bei vergleichsweise geringer Strahlenbelastung die Entdeckung von Tumorherden in frühen Stadien ermöglicht. In zwei kleineren, randomisierten klinischen Studien zum LDCT-Screening in Europa konnte keine Reduktion der Lungenkrebsmortalität nachgewiesen werden. In der mit Abstand größten Studie, dem US-amerikanischen National Lung Screening Trial (NLST), wurde jedoch eine deutliche Reduktion der Lungenkrebsmortalität um relativ 20,0 % (95 % Konfidenzintervall: 6,8–26,7 %) und der Gesamtmortalität um relativ 6,7 % (95 % KI: 1,2–13,6 %) berichtet. Ein gravierender Nachteil des LDCT ist der NLST-Studie zufolge der niedrige positive prädiktive Wert von positiven Screeningergebnissen: Nur bei 4 von 100 positiven Testergebnissen lag tatsächlich ein Lungenkrebs vor.

Im vorliegenden Beitrag werden Vor- und Nachteile des LDCT-Screenings sowie offene Fragen systematisch diskutiert. Der möglichen Senkung der lungenkrebsspezifischen und der gesamten Mortalität stehen als Nachteile falsch-positive Befunde, Überdiagnosen und die Strahlenbelastung gegenüber: Der Anteil der Überdiagnosen wird in der NLST-Studie je nach Auswertungsstrategie auf 11,0–18,5 % geschätzt, die Strahlenbelastung liegt mit etwa 1,5 mSv pro Scan deutlich unter dem Wert für eine Röntgenthoraxaufnahme mit etwa 8 mSv pro Scan. Offene Fragen beziehen sich darauf, wem das Screening angeboten werden soll, in welchen Zeitabständen gescreent werden soll und mit welchem Algorithmus durch das Screening entdeckte Knoten abgeklärt werden sollen.

Abstract

Screening studies on conventional chest X‑rays and on sputum cytology did not show a reduction in lung cancer mortality. However, screening by low-dose computed tomography (LDCT) is more promising because it allows tumor detection in early stages at fairly low radiation levels. No reduction of lung cancer mortality was found in two small, randomized clinical studies on LDCT screening in Europe. However, in the by far largest LDCT trial, the National Lung Screening Trial (NLST) in the USA, a relative reduction of lung cancer mortality by 20.0% (95% confidence interval: 6.8–26.7%), and a relative reduction of total mortality by 6.7% (95% CI: 1.2–13.6%) was reported. According to the NLST, an important disadvantage of LDCT is the low positive predictive value of abnormal screening results: lung cancer was confirmed in only 4 of 100 abnormal screening results.

In this paper, benefits and disadvantages of LDCT screening and related open questions are systematically discussed. A possible reduction of lung cancer specific and total mortality must be weighed against false positive results, overdiagnoses, and radiation exposure. In NLST, the proportion of overdiagnoses is estimated to be 11.0 to 18.5%, depending on the strategy of analysis; radiation exposure is about 1.5 mSv per scan, and thus much lower than radiation exposure in chest X‑ray, which is about 8 mSv per scan. Open questions refer to who should be offered the screening, how long the time intervals between screening rounds should be, and which algorithms should be used to clarify screen-detected nodules.

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Authors and Affiliations

  1. Zentrum für Klinische Epidemiologie, c/o Institut für Medizinische Informatik, Biometrie und Epidemiologie, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Deutschland

    Bernd Kowall & Andreas Stang

  2. Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partnerstandort, Universitätsklinikum Essen, Essen, Deutschland

    Karl-Heinz Jöckel & Andreas Stang

  3. Institut für Medizinische Informatik, Biometrie und Epidemiologie, Universitätsklinikum Essen, Essen, Deutschland

    Karl-Heinz Jöckel

  4. School of Public Health, Department of Epidemiology, Boston University, Boston, MA, USA

    Andreas Stang

Authors
  1. Bernd Kowall
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  2. Karl-Heinz Jöckel
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  3. Andreas Stang
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Corresponding author

Correspondence to Bernd Kowall.

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Interessenkonflikt

B. Kowall, K.-H. Jöckel und A. Stang geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Kowall, B., Jöckel, KH. & Stang, A. Lungenkrebsscreening: Aktuelle Entwicklungen. Bundesgesundheitsbl 61, 1551–1558 (2018). https://doi.org/10.1007/s00103-018-2834-8

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