By James L. Mulshine, MD, Scientific Leadership Board, GO2 for Lung Cancer, Professor, Internal Medicine, Rush University

We had another home run for the lung cancer community.  On February 6, 2020 the New England Journal of Medicine published the long awaited results of the NELSON Trial (the Dutch-Belgium Lung Cancer Screening trial). This is the European counterpart to our National Lung Screening Trial (NLST), which in 2011, following over 50,000 people, proved the life-saving benefits of screening for lung cancer using low-dose computed tomography (CT) in a high-risk population.

The NELSON trial followed 13,195 Dutch/Belgian males over ten years and found a 24% reduction in death due to lung cancer compared to outcomes with a control arm. They also reported a smaller sub-study of 2,594 women, who actually had a 33% mortality reduction benefit with ten-year

Both studies were set up as randomized trials.  Both studies were powered by large numbers of participants.  Both studies incorporated low dose CT technology in their trial design. Both studies showed significant mortality benefits in both men and women despite using differing trial designs.

Consider the following:

In the NLST, the comparison of annual CT screening was with a control arm in which all subjects received annual chest X-ray screening. The control arm of the Dutch trial entailed advising the control subjects to stop smoking. The eligibility criteria for the Dutch trial included tobacco-exposed populations age 50 or older, whereas the NLST threshold age criteria was 55 years old. The Dutch trial included individuals that had lower levels of tobacco use (more than 15 cigarettes a day for over 25 years or more than 10 cigarettes a day for over 30 years) compared to the NLST requirement (at least 30-pack-years of tobacco use). The NLST eligibility cut-off for smoking cessation was 15 years, whereas for the Dutch trial it was 10 years.

The Dutch trial also included routine computer-based measurement of the volume of all suspicious pulmonary nodules. Using this approach, the efficiency of case-work-up was greatly improved. The overall false positivity rate for all rounds of screening was very low and no adverse effects were reported in this regard.

The net effect of all these eligibility differences and nodule work-up enhancements was that the Dutch trial achieved a similar result to the NLST but potentially in a younger and less tobacco-exposed cohort than enrolled in the NLST.  So just as our NLST helped inform Europe – so too has the European trial given information to U.S. public health leadership on who to screen and when to screen.

A strongly held view by GO2 for Lung Cancer, among others, is that the current US guidelines are too restrictive and are missing those at a younger age with a shorter smoking history, as validated in the NELSON trial.

In addition, GO2 for Lung Cancer supports the collect of additional real world data related to family histories of the disease and occupational exposures known to cause lung cancer. These risk factors need to be considered in defining screening eligibility beyond tobacco use alone. The more information that can be gathered the better. We can benefit from other research—like the NELSON trial; let’s leverage the opportunity.

Clearly, this is positive validation of the public health benefit of CT-based lung cancer screening.  The central challenge now is in making lung cancer screening widely available and implemented carefully to ensure the quality of care is high and that it is accessible in communities all across the country. GO2 for Lung Cancer has been helping drive this process via its work to develop and expand a network of hospitals offering excellence in screening and care.

Lung cancer screening saves lives and the newest study provides additional validation. Let’s go forward with this knowledge and put it to work transforming survivorship.