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Introduction: Lung cancer screening saves lives by detecting cancers early, but continued adherence to screening rounds is required for participants to experience the maximum clinical benefit. Here we describe factors associated with screening adherence in the Yorkshire Lung Screening Trial., Methods: All eligible individuals following baseline (prevalent) screening were invited for a biennial incident screen in a community setting. Participants were contacted by phone (up to two attempts) to arrange an appointment or sent a pre-arranged appointment letter if non-contactable. Characteristics of attenders versus non-attenders were compared using univariate and multivariable models., Results: Of 6,650 individuals who attended baseline screening, 5,975 were eligible for the second round. The mean age of those eligible was 70.5 years, 45.2 % were female, 31.7 % were from the most socio-economically deprived quintile and 33.9 % reported current smoking at the time of the baseline scan. Of these, 5,184 (86.8 %) attended their second screen and 791 (13.2 %) did not. Factors associated with lower attendance following multivariable analysis were socio-economic deprivation (OR 0.78, 95 % CI 0.60-1.02, most versus least deprived quintile) and current smoking (OR 0.57, 95 % CI 0.48-0.66, current versus previously quit). Sex, age, and ethnicity were not associated with attendance. Attendance was more likely in people who had an indeterminate (OR 2.10, 95 % CI 1.61-2.73; n = 871) or positive (OR 3.16, 95 % CI 0.98-10.19; n = 60) baseline scan compared to a negative baseline scan., Discussion: Adherence was good overall but lower adherence amongst people who currently smoke and those from deprived populations is a concern due to their greater risk of lung cancer death. Further research is needed into interventions that increase adherence in these high-risk populations., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Philip Crosbie reports consulting fees and stock options from Everest Detection; lecture honoraria from AstraZeneca; designing a questionnaire for Novartis; and designing a study for North West eHealth; outside the submitted work. Samantha Quaife declares payment or honoraria from the Global Lung Cancer Coalition, and support for attending meetings from the Roy Castle Lung Cancer Foundation. All other authors declare no conflicts of interest., (Copyright © 2025 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Low-dose computed tomography screening for lung cancer reduces lung cancer mortality, but there is a lack of international consensus regarding the optimal eligibility criteria for screening. The Yorkshire Lung Screening Trial was designed to evaluate lung cancer screening (LCS) implementation, and a primary objective was prospective evaluation of three predefined eligibility criteria., Methods: Individuals who had ever smoked, aged 55 to 80 years, who responded to written invitation, underwent telephone risk assessment and if eligible by at least one criterion (PLCO M2012 ≥ 1.51%, LLP v2 ≥ 5%, USPSTF 2013 ) were offered biennial low-dose computed tomography screening., Results: Of 44,957 individuals invited, 22,814 responded and underwent eligibility assessment, of whom a total of 7826 were eligible according to any of the three LCS criteria. Comparing PLCO M2012 ≥ 1.51%, LLP v2 ≥ 5%, and USPSTF 2013 , the proportions of responders eligible for screening were 28.0%, 20.5%, and 18.9%, respectively (p < 0.0001 for each comparison), and the proportion of all cancers detected 91.1%, 77.0%, and 62.8%, respectively (p ≤ 0.0002 for each comparison). When risk thresholds were selected to result in equivalent numbers of people eligible for screening, cancer detection proportions were higher for PLCO M2012 (74.5%) and LLP v2 (71.3%) than USPSTF 2013 (62.8%) (p = 0.0002 and p = 0.032, respectively), but there was no significant difference between the two risk models. Reducing the LLPv2 risk threshold from 5% to 2.5% (as currently used in the English LCS program) and reducing the pack-year requirement for the USPSTF 2021 versus the USPSTF 2013 criteria increased the numbers eligible for screening, but subsequent cancer yield was not measured in this study., Conclusion: The PLCO M2012 ≥ 1.51% criteria identified more people eligible for screening in Yorkshire Lung Screening Trial and resulted in more screen-detected lung cancers than LLP v2 ≥ 5% or USPSTF 2013 . When compared in equivalent populations, there was no significant difference between risk models in terms of lung cancer detection and each appeared more efficient at screening population selection than USPSTF 2013 ., Competing Interests: Disclosure Prof. Baldwin declares receiving grants from Horizon Europe, SBRI, Innovate UK, and NIHR artificial intelligence; receiving payment or honoraria from AstraZeneca, Merck Sharp & Dohme, and Roche; and is a clinical advisor to the UK National Screening Committee. Prof. Callister declares receiving grants from Yorkshire Cancer Research and NIHR. Prof. Crosbie declares receiving grants from Yorkshire Cancer Research; receiving payment or honoraria from Bayer; and having stock options in Everest Detection. Prof. Booton is a Clinical Director at INHEALTH and has received payment. Prof. Murray has received grants from Yorkshire Cancer Research, CRUK, Horizon 2020, and UK Prevention Research Partnership; received consulting fees from Action on Smoking and Health; received payment or honoraria and support to attend meetings from AstraZeneca; and is a trustee of Action on Smoking and Health and a member of the Royal College of Physicians Tobacco Advisory Group. Prof. Neal declares receiving consulting fees from GRAIL Bio Inc. as part of the NHS-Galleri trial. Prof. Janes declared receiving grants from GRAIL Bio Inc. Dr. Quaife declares receiving funding from Yorkshire Cancer Research and the Barts Charity; grants from CRUK, UCLH, IARC, and Prostate Cancer UK; payment or honoraria from the Global Lung Cancer Coalition; and support for attending meetings from the Roy Castle Lung Cancer Foundation. The remaining authors declare no conflict of interest. Competing interest forms are available from the corresponding author., (Copyright © 2024 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Objective: As lung cancer screening is rolled-out, there is a need to develop an effective quality assurance (QA) framework around radiology reporting to ensure optimal implementation. Here, we report a structured QA process for low-dose CT (LDCT) scans performed in the Yorkshire Lung Screening Trial., Methods: Negative LDCT scans were single read after using computer-aided detection software. The radiology QA process included reviewing 5% of negative scans selected at random, and all cases with a subsequent diagnosis of extrapulmonary cancer or interval lung cancer not detected on the baseline scan. Radiologists were not informed of the reason for review and original radiology reports were scored as either "satisfactory", "satisfactory with learning points", or "unsatisfactory"., Results: From 6650 participants undergoing LDCT screening, 208 negative scans were reviewed alongside 11 cases with subsequent extrapulmonary cancer and 10 cases with interval lung cancer. Overall, only three reports were ultimately judged "unsatisfactory", 1% of randomly selected negative scans ( n = 2/208) and one interval lung cancer scan ( n = 1/10). Four out of a total of five cases judged "satisfactory with learning points" were related to oesophageal abnormalities where the participant was subsequently diagnosed with oesophageal cancer., Conclusion: The described process attempts to minimise bias in retrospective review of screening scans, and may represent a framework for future QA of national screening programmes., Advances in Knowledge: This study describes a structured QA process for a lung cancer screening programme, involving blinded second-read of LDCT screening scans to ensure fair, constructive audit of clinical performance., Competing Interests: Conflicts of interestProfessor Philip Crosbie has received consulting fees from and owns stock options in Everest Detection and payments or honoraria from Astra Zeneca, Novartis and North West eHealth. No other authors have any conflicts of interest to declare.

Introduction: Interstitial lung abnormalities (ILA) are relatively common incidental findings in participants undergoing low-dose CT screening for lung cancer. Some ILA are transient and inconsequential, but others represent interstitial lung disease (ILD). Lung cancer screening therefore offers the opportunity of earlier diagnosis and treatment of ILD for some screening participants., Methods: The prevalence of ILA in participants in the baseline screening round of the Yorkshire Lung Screening Trial is reported, along with the proportion referred to a regional ILD service, eventual diagnoses, outcomes and treatments., Results: Of 6650 participants undergoing screening, ILA were reported in 169 (2.5%) participants. Following review in a screening review meeting, 56 participants were referred to the ILD service for further evaluation (0.8% of all screening participants). 2 participants declined referral, 1 is currently awaiting review and the remaining 53 were confirmed as having ILD. Eventual diagnoses were idiopathic pulmonary fibrosis (n=14), respiratory bronchiolitis ILD (n=4), chronic hypersensitivity pneumonitis (n=2), connective tissue disease/rheumatoid arthritis-related ILD (n=4), asbestosis (n=1), idiopathic non-specific interstitial pneumonia (n=1), sarcoidosis (n=1) and pleuroparenchymal fibroelastosis (n=1). Twenty five patients had unclassifiable idiopathic interstitial pneumonia. Overall, 10 people received pharmacotherapy (7 antifibrotics and 3 prednisolone) representing 18% of those referred to the ILD service and 0.15% of those undergoing screening. 32 people remain under surveillance in the ILD service, some of whom may require treatment in future., Discussion: Lung cancer screening detects clinically significant cases of ILD allowing early commencement of disease-modifying treatment in a proportion of participants. This is the largest screening cohort to report eventual diagnoses and treatments and provides an estimate of the level of clinical activity to be expected by ILD services as lung cancer screening is implemented. Further research is needed to clarify the optimal management of screen-detected ILD., Trial Registration Number: ISRCTN42704678., Competing Interests: Competing interests: PAJC has received consulting fees from and owns stock options in Everest Detection and payments or honoraria from Astra Zeneca, Novartis and North West eHealth. PB has received consulting fees from and has been supported to attend meetings by Boehringer Ingelheim., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Symptom awareness campaigns have contributed to improved early detection of lung cancer. Previous research suggests that this may have been achieved partly by diagnosing lung cancer in those who were not experiencing symptoms of their cancer. This study aimed to explore the relationship between frequency of chest x-ray in the three years prior to diagnosis and stage at diagnosis., Settings: Lung cancer service in a UK teaching hospital., Participants: Patients diagnosed with lung cancer between 2010 and 2013 were identified. The number of chest x-rays for each patient in the three years prior to diagnosis was recorded. Statistical analysis of chest x-ray frequency comparing patients with early- and late-stage disease was performed., Results: One-thousand seven-hundred fifty patients were included - 589 (33.7%) with stage I/II and 1,161 (66.3%) with stage III/IV disease. All patients had at least one chest x-ray in the six months prior to diagnosis. Those with early-stage disease had more chest x-rays in this period (1.32 vs 1.15 radiographs per patient, P = 0.009). In the period 36 months to six months prior to lung cancer diagnosis, this disparity was even greater (1.70 vs 0.92, radiographs per patient, P < 0.001)., Conclusions: Increased rates of chest x-ray are likely to contribute to earlier detection. Given the known symptom lead time many patients diagnosed through chest x-ray may not have been experiencing symptoms caused by their cancer. The number of chest x-rays performed could reflect patient and/or clinician behaviours in response to symptoms.

Background: The accuracy of the chest x-ray (CXR) in the identification of lung cancer amongst symptomatic individuals is uncertain., Purpose: To determine the diagnostic accuracy of the CXR for the detection of non-small cell carcinomas (NSCLC) and all primary intrathoracic malignancies., Methods: A prospective cohort study of consecutive CXR reports obtained within a primary care open access initiative. Eligibility criteria were symptoms specified by National Institute for Clinical Excellence as indicative of possible lung cancer and age over 50-yrs. A positive test was a CXR which led directly or indirectly to investigation with CT. The reference standards were malignancies observed within a one- or two-year post-test period., Results: 8,948 CXR outcomes were evaluated. 496 positive studies led to a diagnosis of 101 patients with primary intrathoracic malignancy including 80 with NSCLC. Within two-years, a cumulative total of 168 patients with primary intrathoracic malignancies including 133 NSCLC were observed. The sensitivity and specificity for NSCLC were 76% (95 %CI 68-84) and 95% (95 %CI 95-96) within 1-year and 60% (95 %CI 52-69) and 95% (95 %CI 95-96) within 2-years. The 2-yr positive and negative likelihood ratios were 12.8 and 0.4. The results did not differ for NSCLC compared to all primary malignancies. Within this symptomatic population a negative test reduced the 2-year risk of lung cancer to 0.8%., Conclusions: A positive test strongly increases the probability of malignancy whereas a negative test does not conclusively exclude the disease. The findings allow the risk of malignancy following a negative test to be estimated., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: Surgery is the standard of care for early-stage lung cancer, with stereotactic ablative body radiotherapy (SABR) a lower morbidity alternative for patients with limited physiological reserve. Comparisons of outcomes between these treatment options are limited by competing comorbidities and differences in pre-treatment pathological information. This study aims to address these issues by assessing both overall and cancer-specific survival for presumed stage I lung cancer on an intention-to-treat basis., Methods: This retrospective intention-to-treat analysis identified all patients treated for presumed stage I lung cancer within a single large UK centre. Overall survival, cancer-specific survival, and combined cancer and treatment-related survival were assessed with adjustment for confounding variables using Cox proportional hazards and Fine-Gray competing risks analyses., Results: 468 patients (including 316 surgery and 99 SABR) were included in the study population. Compared with surgery, SABR was associated with inferior overall survival on multivariable Cox modelling (SABR HR 1.84 (95% CI 1.32-2.57)), but there was no difference in cancer-specific survival (SABR HR 1.47 (95% CI 0.80-2.69)) or combined cancer and treatment-related survival (SABR HR 1.27 (95% CI 0.74-2.17)). Combined cancer and treatment-related death was no different between SABR and surgery on Fine-Gray competing risks multivariable modelling (subdistribution hazard 1.03 (95% CI 0.59-1.81)). Non-cancer-related death was significantly higher in SABR than surgery (subdistribution hazard 2.16 (95% CI 1.41-3.32))., Conclusion: In this analysis, no difference in cancer-specific survival was observed between SABR and surgery. Further work is needed to define predictors of outcome and help inform treatment decisions., Competing Interests: Conflict of interest: K.L. Spencer has nothing to disclose. Conflict of interest: M.P.T. Kennedy has nothing to disclose. Conflict of interest: K.L. Lummis has nothing to disclose. Conflict of interest: D.A.B. Ellames has nothing to disclose. Conflict of interest: M. Snee has nothing to disclose. Conflict of interest: A. Brunelli has nothing to disclose. Conflict of interest: K. Franks reports personal fees for advisory board work from Pfizer and BMS, personal fees for advisory board work and support for conference attendance from AstraZeneca, and personal fees for educational meetings and support for conference attendance from Boehringer Ingelheim, outside the submitted work. Conflict of interest: M.E.J. Callister has nothing to disclose., (Copyright ©ERS 2019.)

Significant advances in the management of both early and advanced stage lung cancer have not yet led to the scale of improved outcomes which have been achieved in other cancers over the last 40 years. Diagnosis of lung cancer at the earliest stage of disease is strongly associated with improved survival. Therefore, although recent advances in oncology may herald breakthroughs in effective treatment, achieving early diagnosis will remain crucial to obtaining optimal outcomes. This is challenging, as most lung cancer symptoms are non-specific or are common respiratory symptoms which usually represent benign disease. Identification of patients at risk of lung cancer who require further investigation is an important responsibility for general practitioners (GPs). Diagnosis has historically relied upon plain chest X-ray (CXR), organised in response to symptoms. The sensitivity of this modality, however, compares unfavourably with that of computed tomography (CT). In some jurisdictions screening high-risk individuals with low dose CT (LDCT) is now recommended. However uptake remains low and the eligibility for screening programmes is restricted. Therefore, even if screening is widely adopted, most patients will continue to be diagnosed after presenting with symptoms. Achieving early diagnosis requires GPs to maintain an appropriate level of suspicion and readiness to investigate in high-risk patients or those with non-resolving symptoms. This article discusses the early detection of lung cancer from a primary care perspective. We outline risk factors and epidemiology, the role of screening and offer guidance on the recognition of symptomatic presentation and the investigation and referral of suspected lung cancer.

Background: Lung cancer outcomes in the UK are worse than in many other developed nations. Symptom awareness campaigns aim to diagnose patients at an earlier stage to improve cancer outcomes., Methods: An early diagnosis campaign for lung cancer commenced in Leeds, UK in 2011 comprising public and primary-care facing components. Rates of community referral for chest X-ray and lung cancer stage (TNM seventh edition) at presentation were collected from 2008 to 2015. Linear trends were assessed by χ 2 test for trend in proportions. Headline figures are presented for the 3 years pre-campaign (2008-2010) and the three most recent years for which data are available during the campaign (2013-2015)., Findings: Community-ordered chest X-ray rates per year increased from 18 909 in 2008-2010 to 34 194 in 2013-2015 (80.8% increase). A significant stage shift towards earlier stage lung cancer was seen (χ 2 (1)=32.2, p<0.0001). There was an 8.8 percentage point increase in the proportion of patients diagnosed with stage I/II lung cancer (26.5% pre-campaign vs 35.3% during campaign) and a 9.3% reduction in the absolute number of patients diagnosed with stage III/IV disease (1254 pre-campaign vs 1137 during campaign)., Interpretation: This is the largest described lung cancer stage-shift in association with a symptom awareness campaign. A causal link between the campaign and stage-shift cannot be proven but appears plausible. Limitations of the analysis include a lack of contemporary control population., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)