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"If you build it, they will come," is the hallmark line from the 1989 baseball movie "." Unfortunately, that hasn't necessarily proven true in low-dose CT lung cancer screening (LCS). Hitting a home run with widespread programming has been a challenge in the U.S., and despite health insurance coverage for lung cancer screening in the United States since 2015, "fewer than 10% of eligible persons" participate in LCS, noted international researchers.

In a review in the , Raymond U. Osarogiagbon, MBBS, of Baptist Cancer Center in Memphis, and colleagues took a global look at LCS implementation barriers, guideline-concordant management, and "ongoing efforts in Asia to explore the possibility of LCS in populations in whom lung cancer risk is relatively independent of smoking."

East Asian women in particular bear the burden of that high prevalence of non-smoking-related lung cancer. Possible risk factors in this population include age, family history of lung cancer or other cancers, second-hand or passive smoking, and air pollution.

"Current guidelines and recommendations on lung cancer screening eligibility in Western populations focus mainly on people who smoke," Osarogiagbon's group pointed out. "The implementation of lung cancer screening should be tailored to the population at risk and to the resources available to local health care systems." The team noted that in 2023, an expert panel produced a for LCS in Asia.

Meanwhile, in the U.S., the ongoing Female Asian Nonsmoker Screening Study () is assessing the feasibility of an LCS program in that group. Elaine Shum, MD, of NYU Langone Perlmutter Cancer Center in New York City, reported at the 2023 ASCO annual meeting.

What was the impetus for the FANSS trial?

Shum: In Asia, approximately 60% to 80% of women lung cancer patients have never smoked, suggesting that this is a high-risk population for developing lung cancer. The reasons are not well known. In Taiwan, the study offered low-dose CT scans to those who had never smoked and had an additional risk factor such as family history of lung cancer.

The researchers reported an overall lung cancer detection rate of 2.6%, which included adenocarcinoma in situ. When excluding for minimally invasive lung adenocarcinoma, the detection rate was 1.5%. FANSS was designed as a pilot study to assess the feasibility of LCS in Asian women who have not smoked in the U.S.

What are some of the preliminary results from FANSS?

Shum: The majority of participants did have Lung-RADS [] 1 or 2. There were 13 participants who had Lung-RADS 3 and 4, and three of the 201 participants were found to have lung cancer, for a lung cancer detection rate of 1.5%.

In a breakdown of the Lung-RADS 3 and 4 cases, you could see that the nodules were at least 6 mm as well as ground glass opacities that were sub-cm in size. Those who had a nodule greater than 1 cm were recommended for follow-up, including repeat scans, and the participant who has a 4.6-cm nodule is currently still undergoing work-up.

Of the three lung cancer cases that were detected, the radiographic presentation varies from large solid masses, to the last patient, who was noted to have multiple ground-glass opacities with solid component. All three were able to have surgical resections, and all three were noted to have EGFR mutations and are now on adjuvant osimertinib.

How do the FANSS findings thus far compare with TALENT data?

Shum: The definition of a positive screen varies -- for example, a ground-glass opacity is noted to be positive based on Lung-RADS in FANSS if it is over 30 mm, whereas in TALENT, a ground glass opacity of 5 mm was considered to be positive. While our lung cancer detection rate was noted to be 1.5%, it is possible that our lung cancer detection rate could be higher if we applied the TALENT criteria to our somewhat similar population.

What's the take-home message from the preliminary FANSS results?

Shum: LCS for Asian women who do not smoke in the United States is feasible. Our preliminary results demonstrate an invasive lung adenocarcinoma detection rate of 1.5%, which is comparable to TALENT, and all the lung cancers detected in our study were noted to have EGFR mutations and are receiving adjuvant osimertinib as per .

We all know that the biology of lung cancer in those who have smoked and those who have not smoked is different, and so perhaps separate management guidelines for LCS are needed. We continue to enroll and expand FANSS to additional sites throughout the United States.

We plan to analyze the plasma-based cell free DNA samples as well as considering alternative management guidelines of low-dose CT scans for Asian population nonsmokers -- for example, the definition of a positive screen as well as the timing of interval follow-up scans.

Read the review here.