500 likes | 874 Vues
<?xml version="1.0"?><AllQuestions />.
E N D
<?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Vertical</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>255,255,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Answer Bullets</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllAnswers /> Lung Cancer Screening David Koh, MD, FCCP March 1, 2014
Objectives • Define the historical aspects of smoking and its relation to lung cancer • Describe the current process of lung cancer screening • State the newly recommended guidelines for lung cancer screening • Describe the new technology for the screening of lung cancer
Prevalence of Smoking • 1.3 billion smokers globally1. • 47% of men and 12% of women are smokers worldwide. • 45 Million adults in the US smoke2. • 23.5% males, 18.5% females. • There has been a decline in the percentage of smokers from 42% in 1965 to the 20.8% in 2006. 1. WHO Tobacco Free Initiative. 2004 2.CDC. MMWR 2005
Cost of Smoking 157 billion dollars MMWR 2002
What is in Smoke? • A pack-a-day smoker puffs more than 70,000 times a year. • 92-95% of the total weight of mainstream smoke is present in the gas phase. • Nitrogen, oxygen, and carbon dioxide account for 85% of smoke’s weight.
Mortality Rates • More than 399,000 US deaths annually are attributable to cigarette smoking. • Every 8 seconds, someone dies from tobacco use. • 40% of neoplasms are related to tobacco. • 22% of ischemic heart disease is caused by tobacco. • On average, male smokers lose 13.2 years and females lose 14.5 years of life expectancy CDC. MMWR. 2005
Death Rates • Lung cancer accounts for 32% of all cancer deaths in men and for 25 % of all cancer deaths in women making lung cancer the leading cause of cancer deaths. • For women, incidence rates dropped for cancers of the breast, colon/rectum, uterus, ovary, cervix, and oral cavity but increased for cancers of the lung, thyroid, pancreas, brain/nervous system, bladder, and kidney, as well as for leukemia, non-Hodgkin lymphoma, and melanoma. CDC. MMWR. 2008
Top 12 States for New Lung Cancer Cases in 20121 • California (18,060) • Florida (17,860) • Texas (14,810) • New York (13,620) • Pennsylvania (10,890) • Ohio (10,270) • Illinois (9,190) • Michigan (8,210) • North Carolina (7,950) • Georgia (6,570) • Tennessee (6,140) • New Jersey (5,990) 1. 2012, American Cancer Society, Inc., Surveillance Research
Reality Then Carbone, PPNIH Conference Annals of Internal Medicine (1970) 73:1003 • At present lung cancer is recognized late. • Opportunities to improve survival are through earlier detection, accurate diagnosis, accurate localization, and curative therapy.
Reality Now Sources: • NLST Research Team, N Engl J Med 365:395-409, 2011 • IELCAP Investigators, N Engl J Med 355:1763-1771, 2006 National Lung Screening Trial (NLST): • 8-year trial (2002 – 2010) compared low-dose ct screening to chest x-ray • 53,454 current/former smokers, at high risk for lung cancer • Results Released in November 2010: Those who received LDCT had a 20% lower risk of dying from lung cancer than those who received CXR.1 International Early Lung Cancer Action Program (I-ELCAP): • 31,567 current/former smokers, at high risk for lung cancer • 484 were diagnosed with lung cancer, 412 at Stage I • Results Published in October 2006: Over 80% of patients who have a lung cancer detected by CT screening can be cured. When the lung cancer is found early, and the patient receives surgical removal right away, the cure rate rises to 92%.2 International Association for the Study of Lung Cancer (IASLC): • “The publication of the NLST trial is a major turning point in lung cancer, which demonstrates the enormous potential of CT screening as an early detection tool, which, in combination with smoking cessation programs, is likely to have a major impact on lung cancer.” - Prof. John K Field, MA, PhD, BDS FRCPath, Chair of IASLC - June 29, 2011
What was available • CT guided needle biopsy: • Pneumothorax reates reported anywhere from 10-60% with average of 25%. • In Ohno’s study, the lowest occurrences of PTX happened at a rate of 28.4% but a positive diagnosis in 77% when: • FEV1 > 70% • Single puncture • Needle path < 4 cm. Ohno, Y et al. AJR, AM J Roentgenology, 2003
Newer Bronchoscopy Techniques • EBUS: Endobronchial ultrasonography: Preferred method for sampling lymph nodes without general anesthesia. • ENB: Electromagnetic navigational bronchoscopy. Uses GPS to get to peripheral nodule. • Reconstruction guided bronchoscopy.
Prior to Navigational Bronchoscopy • Eberhardt, R et al. Am J Resp Critical Care Medicine. 2007 • Schenk et al. Chest. 2003 • Schreiber, G et al. Chest. 2003 • Difficult to get to peripheral nodules because we were looking at a 2-D image. • PTX rates were lower at 4%1. • Positive diagnosis 402 -603 %
Now With Navagational Bronchoscopy • Hogarth. Bronchol Intervent Pulmonal. 2011 • Minnich, DJ. Abstract at Society of Thoracic Surgeon’s Meeting. 2012 • For difficult cases, the yield was 77%1. • Overall, the ENB has an accuracy rate of 89% and a negative predictive value of 79%2.
Electromagnetic Navigation Bronchoscopy (ENB)Procedure Overview CT-Scan DICOM CD Planning Software Planned Pathway File Navigation Biopsy Treatment
Lung Cancer Screening • Released in April 2012: “Providing Guidance for Lung Cancer Screening: The ALA Interim Report on Lung Cancer Screening” • Key Points: • Best way to prevent lung cancer is to never start or quit smoking • Low Dose CT (LDCT) should be recommended for those meeting NLST criteria: • Current or former smoker, ages 55-74 • Smoking history of at least 30 pack-years • Those that smoked in the last 15 years. • No history of lung cancer • Individuals should not receive a Chest X-ray (CXR) for lung cancer screeningFor hospitals offering screening: • Ethical policies for advertising and promotion of screening should be set • Develop educational materials to assist patients in discussions on lung cancer screening • Provide screening services with access to a multidisciplinary team that can provide the needed follow-up evaluation of nodules
Take Home Message • For smokers with a greater than 30 pack years. • Current smokers and former smokers that quit less than 15 years ago. • Age 55-74 years old. • Annual Screening with low-dose CT annually.
What about JAMA • Panel of experts from ACS, ACCP, ASCO and NCCN who reviewed 8 Randomized Clinical Trials and 13 Cohort Studies • 20% in each round of screening had a positive result, requiring some degree of follow-up and approximately 1% had lung cancer • Screening must be done in a center that has the capabilities to evaluate and management findings with a multidisciplinary team • Low Dose CT (LDCT) screening appears promising, but is also considered to be in it’s infancy • Quality Improvements measures should be reviewed to determine the “right” group to screen, how often and for how long
Risks of Second Hand Smoke • 3,423-8,866 deaths from lung cancer. • 22,700-69,600 deaths from cardiac causes. • SIDS 430 deaths. • Childhood asthma (new and exacerbations) 202,300. • Increases risk of COPD by 55%2. • Doubles the risk of CVA3. CDC. Surgeon General’s Report. 2006. 2. Eisner, MD. Eviron Health. 2005. 3. Goldstein, LB. Stroke. 2006
Conclusions • Lung cancer can now be reduced by 20%. • Cancer screening is the key to lowering deaths due to lung cancer by finding lung cancers at an early stage when lung cancer is still curable. • Who should be screened? • People from ages 55-74. • Greater than 30 pack years of smoking. • Smoked within 15 years. • No history of lung cancer. • Repeat CT for 3 consecutive years.