Transcript Economic aspects of the Solitary Pulmonary Nodule

Interventional Pulmonology:
Potentials, limits & QoL
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Ethical: “being in accordance with the
accepted principles that govern the
conduct of a profession”
Utility: “the quality or condition of
being useful”
Palliative and curative approach
ACCP Lung Cancer Guidelines (1)
ACCP guidelines (1)
• At every stage, patients and their relatives should be
offered clear, full and prompt information in both verbal
and written form
• Patient preferences should take precedence over the views
of relatives, and caregivers should be involved in
decision making when patients wish
ACCP Guidelines (2)
• Toxitiy of palliative interventions must be weighed
against benefits, and choice of treatment discussed with
individual patient
• Treatment should be directed towards extending life
rather than prolonging death, towards reducing suffering
both physical and spiritual, towards achieving acceptance
rather than denial or delusion
Friday afternoon’s case
• Old lady, living alone, no relatives, heavy smoker, referred by GP,
clinical end-stage (malignancy?), severe stridor SaO2 60%, imminent
death due to respiratory failure, major airways obstruction
• No advanced directives, was impossible to communicate
• Your bronchoscopy team is against intervention. “There is too much
risk, let her die”
Questions:
Q1: You are responsible (not team): YES NO
Q2: You treat her:
YES NO
Liberalism vs. individualism
Proxy, Euthanasia & Forbid to treat declarations
Case 2: images
Case 2: images
Follow-up  “Dutch” reality
•Rigid + biopsy and stenting (Noppen technique)  immediate
relief
•Monday diagnosis: >st. IIIB NSCLC  “I do not want to live
any longer nor accept any proposal for further therapy”
•Euthanasia request - granted (Dutch law!) (Wednesday)
•Pathologist at post-mortem (Thursday): “Tom, your stent is
perfectly positioned”
• Good QoL of the patient, bad QoL of the team
Chest 2001;120:1811-1814
The et al. BMJ 2000;321:1376
cutting edge vs. double edged sword
“Endoscopic phototherapy with a
hematoporphyrin derivative has been
described as an alternative to surgical
resection in carefully selected patients”
Preservation of QoL: smokers’ health with
poor cardio-vascular-respiratory fitness
balanced against
Technical advancements: diagnostics and
therapeutics becoming increasingly non- and
minimally invasive and succesful
Staging: Chest 2001; 120:1327, Clin Can Res 2005;111:6186

T 2-3 mm
PET+ but N0!

Superficial intraluminal N0, visible borders by AFB
Argon plasma + electrocautery, cryotherapy,
[Nd-YAG laser, PDT, HDR brachytherapy]
Argon Plasma Coagulation for occult cancer
A case of occult cancer
• 54-yrs old >40 pack years - slight hemoptysis
referred Feb. 2000: severe dysplasia on brush
cytology
• Regular follow-up 4-monthly with HRCT and
AFB
• Aug. 2004: repeat AFB UDB suspicious; distal
margin invisible at least severe dysplasia; brush
cytology suspicious for malignant cells
Left upper division bronchus
Questions:
Q3: 1. Follow-up
2. Intraluminal treatment
3. Intraluminal then surgery
4. Surgical resection
Clinical decision and treatment
• Distal microinvasion cannot be ruled out
→ argon plasma coagulation followed by
radical left upper lobectomy and SND
• Resected specimen: squamous metaplastic
field, no residual CIS, N0 stage!
Questions:
Q4: This case shows:
1. Local treatment is effective
2. Early intervention saves life
3. Screening & early intervention justifiable
MDCT: multidetector CT (64 bits)
VERY sensitive but very LOW positive predictive value
PET negative lesion (Q5)
75 years-old previous laryngeal ca. & RU lobectomy,
subsequent SPN left upper lobe → cytology negative
→ at highest risk for a third primary!
Treatment (resection/stereotactic RT)?: YES vs. NO
PET negative 3rd primary (Q 6)
Lobectomy upper lobe N0 BAC Noguchi type A → died
of resp failure, treatment is however justifiable?
YES or NO ?
PET negative 3rd primary lesion
Lobectomy upperlobe N0 BAC A → resp failure died!
How likely will this BAC A become the cause of death?
Why not a “delayed” intervention?
Lepidic (benign) ↔ hilic (malignant)
“Benign” → local treatment
Biology malignant thus
nodal & distant mets
Randomized: stage shift?
Gohagan et al. Lung Cancer 2005; 47:9-15
Screening method:
LDCT
X-ray
n
1,660
1,658
Compliance baseline
1st- year
96%
86%
93%
80%
Suspicious
25.8%
8.7%
Lung Cancer baseline
One-year
1.9%
0.57%
0.45
0.68
40
19 (48%)
16 (40%)
20
6 (40%)
9 (45%)
n cancers:
Stage I
Stage III-IV
No stage shift: 5-year prospective LDCT;
1,118 individuals  3,356 NCNs;
 17 stage I; mean Ø 14.4 mm
Swensen et al. Radiology 2005; 235: 259
Conclusions:
“CT allows detection of early-stage lung
cancers. Benign nodule detection rate is
high. Results suggest no stage shift”
Cure rate increase may equal the
cohort biologically benign lesions!
“under diagnosis” is mortal
Cure rate ↑without treatment “benign” cancer
↓ baseline shift equals overdiagnosis rate?
Pathology review MLP Cancer 2002; 95:2361
•
•
•
•
3 pathologists “blinded” (Colby, Tazelaar, Travis)
Slides: 105/167 Mayo (366 total)
 stats: type tumor 0.65; invasiveness 0.67-0.84
77 screened vs 28 control:
– 7 CIS all in the screened
– 7 preinvasive in the screened vs one in control
– Proportional CIS + pre-invasive 13/77=16.8%!
Potentials, limits & QoL:
1. The odds against science ( guidelines!)
2. Medicine-bronchoscopy is culture ( (f)laws!)
3. Interventional pulmonology is a fashionable
science within a cultural context
Everything can be done, should it be done?
The pride of Holland
Survive with competitive risks
Died at 114 years with stomach cancer at post-mortem
How early?
Overdiagnosis vs. Calvinistic perception
If early treatment of (lung cancer or) any disease is
successful, additional disease (human suffering) is:
1. Due to successful treatment that allow you to live
2. Despite successful treatment as disease is not always
mortal
Last question
You have only enough money to pay one insurance
premium every year and have therefore to choose:
1. pay health care insurance
2. pay death coverage and funeral insurance
Questions:
The more science knows, the bigger are the
profits of insurance companies
QoL and stage shift?
www.bronchoscopy.org