Transcript See Spot, Now What- Lung Cancer Screening

Lung Cancer Screening For The
Primary Care Physician: See Spot,
Now What ?!?!?
Brad Vincent, MD, FCCP
Interventional Pulmonary Clinic
Critical Care Medicine Service
Our Lady of the Lake RMC
Mary Bird Perkins Cancer Center
Disclosure
Dr. Vincent has no relevant financial relationships with commercial
interest to disclose.
His presentation will include discussion of commercial products and
or services.
Linda Lee, Cancer Center Administrator, OLOL RMC/ Mary Bird
Perkins is the activity planner. She has no relevant financial
relationships with commercial interest to disclose.
The OLOL CME Committee has no relevant financial relationships
with commercial interest to disclose.
Thank you!
Our Lady of the Lake Regional Medical
Center
Doc, I was told
I have a Spot
on my lung.
What does
this mean???
Characteristics of solitary
pulmonary nodules
What to do??
 Patients can be very fearful (obviously)
 The main question is obviously : Is this a lung cancer ?
 With advent of near universal imaging in healthcare
setting more and more nodules are being detected
 The difficulty is avoiding invasive procedures on benign
entities while maximizing early intervention on
malignancy
 With recent recommendations regarding lung cancer
screening, the above scenario will only become more
common
Primum non nocere
 First, do no harm
 Reassure patient that they will be treated appropriately
 Compile a symptoms review with focus on constitutional
symptoms such as weight loss and pulmonary specific
symptoms such as cough, hemoptysis and dyspnea
 Physical examination with careful attention to chest
findings and digital clubbing
 Obtain an accurate history of tobacco use and
occupational history to screen for exposure to radon or
asbestos
Most common symptom with
early lung cancer??
NONE!!!!
Additional Initial Steps
 Obtain family history
 Schedule CT imaging if appropriate
 AVOID the temptation to refer them to an oncologist
 DO make a referral to a pulmonologist
Overview of Lung Cancer
 Largest cancer killer of men and women in the USA for
over three decades
 Occurs almost exclusively in smokers
 Louisiana has one of the highest incidences of lung cancer
in the country (roughly 90 cases per 100,000 yearly)
Cancer Statistics 2014
Lung Cancer
American Cancer Society, Cancer Statistics; 2014
Lung Cancer Incidence
Stage vs Survival
Dr. Alton Ochsner was one of the first physicians
to make the link between cigarette smoking and
lung cancer
Stage I non -small cell cancer
Stage II non -small cell cancer
Stage III (a and b)
Stage IV
 Any tumor size with any node involvement with
extrathoracic metastasis
Growth Model of Lung Cancer
Bach BP et al. Chest 2007
Cancer Screening
Fundamentals of Screening
Definition
Screening can be defined as the systematic testing
of individuals who are asymptomatic with respect to
some target disease. The purpose of screening is to
prevent, interrupt, or delay the development of
advanced disease in the subset with a pre-clinical
form of the target disease through early detection
and treatment.
Hillman et al. JACR 2004;1(11):861-864
Fundamentals of Screening
 Characteristics of a good screening test and program:
 Reasonable sensitivity and specificity
 Accessible with a low cost
 Low associated morbidity
 There should be an effective treatment at an early
stage of the disease
Timeline of Disease
PRECLINICAL
CLINICAL
DPCP
Onset of
Disease
Detectable
by Test
DPCP= Detectable pre-clinical phase
Signs or
Symptoms
Death from
Disease or
Other causes
Screening Effective
DPCP
Onset of
Disease
Detectable
by Test
Signs or
Symptoms
Critical Point
Death from
Disease or
Other causes
Screening Ineffective
DPCP
Onset of
Disease
Detectable
by Test
Critical Point
Signs or
Symptoms
Death from
Disease or
Other causes
Screening Unnecessary
DPCP
Onset of
Disease
Detectable
by Test
Signs or
Symptoms
Death from
Disease or
Other causes
Critical Point
Patient Population
 High risk for preclinical disease
 No clinical signs or symptoms of disease
 Willing and able to undergo screening or not
 Willing and able to undergo workup and treatment
 Willing and able to undergo follow-up
Cancer Screening Principles
 Problems with cancer screening:
 Bias (lead time, length bias, overdiagnosis,etc)
 Involves cost to a large group of people who do not need




treatment
Stress and anxiety of a false positive test
Unnecessary testing following false positive
False sense of security of a negative test which may delay
diagnosis
Potential HARM due to effects of test (radiation exposure) or
procedures done as a result of screening test (unnecessary
surgery or biopsy)
Screening Bias
Patz EF et al. New Eng J Med 2000
Screening Bias
Black WC. Cancer 2007
The Studies
 3 Randomized controlled trials comparing CT to annual chest
radiograph (CXR)
 The largest of any trial to date is the NLST (National Lung
Screening Trial)
 Multiple center study over five years
 Enrolled 53,454 patients
 3 annual rounds of screening (baseline, T+1 year and T+ 2 years)
 20% relative decrease in lung cancer death compared to chest
radiograph over a median of 6.5 years of follow up (443 cancer
deaths in control group compared to 356 cancer deaths in CT group)
 Both groups had similar rates of death NOT attributable to lung
cancer
Four Main Questions Posed
 What are the potential benefits of screening with LDCT in
patients with elevated risk of lung cancer?
 What are the potential harms of screening with LDCT in
patients with elevated risk of lung cancer?
 Which groups are most likely to benefit or not benefit from
screening?
 In what setting is screening most likely to be effective?
Totals
 142,520 Patients screened
 29,567 Nodules
 1,298 Lung cancer nodules
 1,838 Patients diagnosed with lung cancer over the study
period
Bottom Line
Potential Benefits
 Effect on Mortality: The NLST showed that three rounds of
screening with LDCT reduced the relative risk of death due
to lung cancer by 20% versus chest radiograph over a 6.5
year period
 In absolute terms the risk of cancer death was 33% less
over the study period in the LDCT group (87 deaths
avoided in over 26000 patients) meaning 310 individuals
must participate in at least three rounds of screening to
prevent one death
Potential Harms
 Actual detection of abnormalities. The average nodule detection
rate was 20% but varied greatly amongst the many studies
 Complications of diagnostic procedures. Major complication
frequency in LDCT screened individuals was 33 per 10,000
individuals. Rate of major complications in those who underwent
surgery for lung cancer was 14%
 Overdiagnosis: diagnosis of histologic abnormality that
otherwise would not have altered the patient’s life if left
untreated.
 Radiation exposure: Estimate is 1 cancer death due to radiation
per 2500 persons screened
Radiation
Procedure
Effective dose (mSv)
Chest radiograph (PA view)
0.02
Low Dose CT chest
0.7
Mammography
0.4
Nuclear bone imaging
6.3
Chest CT
7
Abdomen CT
8
Chest angio-CT
15
Diagnostic cardiac cath.
15
Radiation
 Low dose CT
Baldwin DR et al. Thorax 2011
Patients likely to benefit
 Enrollment criteria for studies varied widely
 NLST “high risk” criteria previously decribed
 Controversy over how to best identify the at risk
population and screen them in the critical period where
screening may be beneficial
Effective Setting
 Recommended setting is one with a multidisciplinary
approach including:
 Interventional pulmonology
 Thoracic surgery
 Radiation oncology
 Thoracic radiology
 Medical oncology
Overview of Treatment for Early
Stage Lung Cancer
 Standard treatment for stage I and II lung cancer has
traditionally been surgical resection
 Chemotherapy is added post resection based on pathologic
stage
 Mortality rate very low overall (roughly 2%) but increases with
pneumonectomy significantly
Non-surgical treatment
 For patients with inadequate lung function to tolerate
surgery, stereotactic radiosurgery is recommended
 For small tumors may have an equivalent result when
compared to surgery
 For larger and more central tumors has a higher failure
rate
 Often combined with chemotherapy
 For patients with Stage III and IV disease,
chemoradiotherapy is primary treatment modality
Future Directions
Potential Biomarkers for
Screening
 Airway epithelial cells
 Gene expression profiling
 Chromosomal aneusomy – FISH
 Gene methylation
 Blood biomarkers
 Serum proteins
 Autoantibodies to tumor antigens
 Gene expression profiles
 Breath analysis
 Urine markers of carcinogens
Lung Cancer Risk Prediction:
PLCO Model
Age
Education
Body Mass Index
Family History Lung Cancer
History of COPD
Chest x-Ray Past Three Years
Smoking Status (NS, F, C)
Pack-Years Smoked
Smoking Duration
Quit Time in Former Smokers
Tammemagi et al. JNCI 2011; 103: 1058-68
What are we doing at OLOLMBPCC?
 LDCT screening offered to population of patients similar to
NLST
 Cost is 99$
 CT interpreted by radiologist
 Any positive findings are followed up based upon Fleichsner
Society guidelines
 Will be plugged into pathway including consultation with a
pulmonologist
 Patient navigator will ensure proper follow up
Fleischner Society Guidelines
McMahon, Swenson et al. Radiology 2005
What diagnostic modalities are
available at OLOL-MBPCC?
 CT guided trans-thoracic biopsy of nodules/masses
 Endobronchial ultrasound guided biopsy
 Navigational bronchoscopy
 Thoracic surgery
CT-Guided FNA/Biopsy
 90% accuracy
 15% Risk of pneumothorax
 1-5% Risk of major bleeding
 Typically an outpatient procedure
 Limited in patients with deeper/more central lesions and
those with emphysema/bleb disease
Mass
Lymph node
EBUS-TBNA
EBUS-TBNA
 Real-time visualization of lymph nodes
 Much better diagnostic yield compared to blind TBNA
 Very low risk (<1% risk of major complications)
 Outpatient
 On-site cytopath can give patients and physician a rapid
preliminary report
 Can biopsy nodes of very small size
 Can biopsy masses more centrally located (even small ones)
Navigational Bronchoscopy
 So-caled “GPS” for lung biopsy
 80% yield in nodules over 1.2cm
 Lower risk of pneumothorax compared to CT guided FNA
 Uses 3-D reconstruction to guide instruments to lesion
 Needle, brush and forceps available
Getting with the program…
Societies Endorsing Screening
with LDCT:
 American Cancer Society (ACS)
 American College of Chest Physicians (ACCP)
 National Comprehensive Cancer Network (NCCN)
 American Society of Clinical Oncology (ASCO)
 U.S. Preventative Task Force (USPTF)
Summary
 General principles of good screening tests must be adhered to when
considering screening for any cancer
 Individuals at high risk for lung cancer may benefit from LDCT
screening yearly
 There are potential harms and pitfalls to consider with LDCT
screening for lung cancer
 LDCT screening is best performed where all available diagnostic and
therapeutic modalities are available
 Disagreement remains even amongst experts as to whether or not
LDCT screening will be beneficial
 We must continue to search for more effective ways to better
identify who will benefit from screening and improve test modalities