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CT Screening for Lung Cancer: We’re not there yet

CT Screening for Lung Cancer: We’re not there yet. Jyoti D. Patel, MD Division of Hematology/Oncology Feinberg School of Medicine, Northwestern University Chicago, IL . Free Screening?. FACT :  Lung cancer is the leading cause of cancer death among both men and women worldwide

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CT Screening for Lung Cancer: We’re not there yet

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  1. CT Screening for Lung Cancer:We’re not there yet Jyoti D. Patel, MD Division of Hematology/Oncology Feinberg School of Medicine, Northwestern University Chicago, IL

  2. Free Screening? FACT:  Lung cancer is the leading cause of cancer death among both men and women worldwide FACT:  There is no routine screening for lung cancer FACT:Lahey Clinic is trying to change that If you are between the ages of 50 and 74, currently a smoker (or have quit within the past 15 years) and have a history of smoking at least a pack of cigarettes a day for 20 years, you may qualify for a free low-dose CT lung screening. The screening is quick and painless and you do NOT have to be a Lahey patient to receive this free screening. However, your primary care doctor must order the test. To learn more, please call 1-855-CT-CHEST between 8:30am–4:30pm, Monday through Friday to complete a screening questionnaire. Thank you!

  3. Many Stakeholders • People who have smoked • Families of smokers • People with Lung Disease • Health care professionals involved in the care of people at risk for lung cancer • Organizations involved in public health and clinical issues • Policy makers within government • Healthcare organizations

  4. NLST: Preliminary Results10/2010—DSMB stopped trial based on pre-specified monitoring plan

  5. Guidelines for Screening

  6. Recommendation by Risk Status Bach, JAMA, 5/2/2012 http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#detection http://www.lung.org/lung-disease/lung-cancer/lung-cancer-screening-guidelines/lung-cancer-screening.pdf

  7. Perception: Six Blind Men and The Elephant—An Indian Tale

  8. Quantifying Benefits:Explaining Risk and Probability • Relative Risk • Gives a comparison or ratio • Shows the strength of the relationship between a risk factor and particular type of cancer • Risk seems greater when put in terms of relative risk • Absolute Risk • The actual numerical chance of developing cancer during a time period • Lifetime Risk: the probability that an individual will develop cancer during the course of a lifetime 20% relative decrease in deaths from lung cancer! The chance of dying of lung cancer was 0.33% less over the study period in pts with LDCT. 310 individuals are screened to prevent 1 lung cancer death.

  9. Quantifying Harm • Detection of Abnormalities • Complications of Diagnostic Procedures • Overdiagnosis • Radiation Exposure • Quality of Life deGonzales. Lancet. 2004 363:345

  10. NCCN: High Risk Individual* • In addition to age > 50 and > 20 pack year history of smoking tobacco, one additional factor (second hand smoke does not count): consider screening(2B) • Occupational Exposure • Residential Radon Exposure • Cancer History • Family History of Lung Cancer • History of Lung Disease • Moderate risk--age > 50 and > 20 pack year history of smoking tobacco, no risk factors-- no screening (2A) NCCN Guidelines on Lung Cancer Screening

  11. Relative Risk of Developing Lung Cancer 1 MMWR 2008; 2 Surgeon General, 2010; 3 Peto, BMJ, 2000; 4 Driscoll, Ma J Ind Med 2005; 5 Lubin, J Natl Cancer Inst, 1997; 6 Brenner, PLoS 2011 7 Hubbard, Am J RespirCrit Care Med 2000

  12. Relative Risk of Developing Lung Cancer with History of Cancer 1 Tucker, J Natl Cancer Inst, 1997; 2 Travis, J Natl Cancer Inst, 2002; 3 Matakidou, Br J Cancer, 2005

  13. Former Smokers Peto, R., Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two-case control studies. BMJ, 2000

  14. Duration of Screening? • ASCO/ACCP—not known • NCCN—NLST cohort—annually until patients are 74 Brenner, NEJM 2007

  15. Lung Cancer Risk Prediction Etzel and Bach, Seminars in Reps and Crit Care Med, 2011; Bach J Natl Cancer Inst. 2003 Mar; Spitz Cancer Prev Res (Phila). 2008 ; Cassidy. Int J Oncol. 2006 May

  16. Areas of Uncertainty • Currently, screening needs to be in a center similar to those where NLST was conducted • Screened individuals should be entered into a registry to assess long term impact • Quality metrics need to be developed • Demonstration projects need to planned to evaluate implementation • Establishment of task forces to assess ever changing technology • Develop better predictors of lung cancer risk

  17. Screening is a PROCESS, not a test • Complete health history, assessment of comorbidities • Smoking cessation • Benefits/risks of screening, possible procedures • Costs—health insurance reimbursement, time, and personal costs • Center with multidisciplinary approach

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