early detection of lung cancer & beyond guia elena imelda r. ladrera, md lung center of the...
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Early Detection ofLung Cancer
& Beyond
GUIA ELENA IMELDA R. LADRERA, MD
Lung Center of the Philippines
Objectives
• Present available statistics on Lung Cancer.• Present data on the early detection of lung
cancer.• Present the LCP Algorithm in the approach to
lung cancer suspect.• Present LCP research results in the treatment
& prevention of Lung Cancer.
Incidence of Lung Cancer• Lung Cancer is the most common cause of cancer
related death worldwide• Overall 5 year survival - < 15%CANCER Principles and Practice of Oncology DeVita et al 8th Edition p896
• Philippines- 15,881 deaths are expected this year - Median survival of 6 months- Five-year survival of 5.28% & a 10-year survival of 2.68%
2005 Philippine Cancer Facts & Estimates
Estimated Five Leading Cancer Sites in 2005, Both Sexes
2005 Philippine Cancer Facts & Estimates
Number of Cases
Five Leading Causes of Cancer Deaths in 2005, Both Sexes
2005 Philippine Cancer Facts & Estimates
2000 - 2004
Lung Center of the Philippines Tumor Registry
Patients with Diagnosis of Bronchogenic Cancer at the Lung Center of the Philippines
2000 - 2004Histology 2000 2001 2002 2003 2004
BCA Unspecified NSCLC or SCLC
20 21 31 36 57
NSCLC AdenoCA Squamous CA Large cell CA Unspecified NSCLC Others
TOTAL NSCLC
88504
39
181
117440
54
215
142871488
2 *
333
168653
67
1+
304
167723
84
326
SCLC 26 40 48 46 46
TOTAL 227 276 412 386 429* Adeno-Squamous CA +Neuroendocrine CA
Number of Patients with Lung Cancer (NSCLC & SCLC) 2000 – 2004
Lung Center of the Philippines Tumor Registry
Histopathologic Types of NSCLCLung Center of the Philippines Tumor Registry
Distribution of Patients with Lung Cancer 2000 – 2004
Lung Center of the Philippines Tumor Registry
Distribution of NSCLC According to Stage of the Disease
Lung Center of the Philippines Tumor Registry
Survival of Patients with Lung Cancer
Lung Center Tumor Registry
Stage 1 (T1-2 N0 M0) 96.8%
Stage II (T1-2 N1 M0) 94%
Stage IIIA (T1-2 N2 M0) 88.9%
Bronchogenic Carcinoma (152 cases)1986 - 1991
LCP Tumor Registry 1994
Lung Center of the Philippines
1 Year Survival by Stage
Average 1 Year Survival for all Types
93.2%
Lung Center of the PhilippinesBronchogenic Carcinoma (152 cases)
1986 - 1991
LCP Tumor Registry 1994
Philippines
- 15,881 deaths are expected this year - Median survival of 6 months
- Five-year survival of 5.28% & a 10-year survival of 2.68%
2005 Philippine Cancer Facts & Estimates
Overall 5 year survival is LESS THAN 15%
Diagnostic Algorithm for Lung Cancer
Lung Center of the Philippines 2008
ALGORITHM IN THE GENERAL APPROACH IN THE DIAGNOSIS OF SUSPECTED LUNG CANCER
SPECIAL SITUATIONS
Follow-up every 3 months
*
Negative or low
suspicion of
neoplasm
Positive for pulmonary
mass
Establish diagnosis
Central
lesion
TTNAB/ Sputu
m cytolo
gy
High risk
Bronchoscopy with cytology and biopsy
Positive
Negative
Further testing:TTNA/TBNAEBUS-NAVATS
Bronchoscopy with Biopsy / Sputum cytology
Confirmdiagnos
is
Negative for malignancyor Non-specificdiagnosis
Do stagin
g
Low suspicion/ risk
High suspicion/ risk
Exploratory thoracoscopyother invasive procedures
Increase in mass
sizeNo change
inmass size
Positive
Negative
Repeat
biopsy
No further testing
Unresolved pneumonia of >1 month with abnormal CXR or asymptomatic with abnormal CXR
CT of chest/MR
I
CXR andENT Exam
Normal ENT examination with negative or positive CXR
Abnormal ENT examination
Refer to
ENT
Follow-up
evaluation
*B
*
B
Presence of extrapulmonary lymph
nodePleural effusion
Multiple pulmonary nodules
Atelectasis
Biopsy of lymph node, if accessible
Diagnostic thoracentesisPleural fluid cytology or pleural biopsyThoracoscopyVideo-assisted Thoracic Surgery (VATS)Open lung biopsy CT guided biopsyFiberoptic bronchoscopy (FOB)
* * *
Definition: *Low risk – age < 40 years old, non-smoker with (-) family History. *High risk – age > 40 years old, smoker/ passive (+) family History.
RAD/jbl06
CLINICAL PRESENTATION
Peripheral
lesionCough
or dyspnea
CXR
Pulmonary mass
Negative
A
Hemoptysis
(1)
(2)
(3)
Treat other diseases as indicated or follow up visit every 1 mo.
Low risk
* * *
Go to B
**
Inconclusive
Follow-up
Appropriate treatment
Go to B
Treatment of Lung Cancer
Lung Center of the Philippines
Lung Center of the Philippines
1986 - 1991
Total no. Of cases - 3,338
Total no. Of 0perations - 152 (4.55%)
Bronchogenic Carcinoma
LCP Tumor Registry 1994
Lung Center of the Philippines
Bronchogenic Carcinoma
LCP Tumor Registry 1994
Resection Rate of Operated cases
1982 – 1986 68.6%
1986 – 1991 92.7%
Percentage of Patients with Early Stage NSCCA who Underwent Surgery
2000 – 2004 Lung Center of the Philippines Tumor Registry
Number of Patients (%)
Stage I TOTAL With Surgery
58 22 (38%)
Stage IITOTAL With Surgery
44 8 (18%)
Stage IIIATOTAL With Surgery
128 14 (11%)
Lung Center of the Philippines Early Lung Cancer Detection Program
Lung Center OF THE Philippines Program, R. Montevirgen, MD
Study period: 1991 -1996
Subjects120 initial participants enrolled
• High risk individuals• Q 6 months CXR until age 75
Results- 3/120 (+) to have lung cancer.- 2 patients presented with late stage disease upon enrolment. - 1 patient detected with early disease (0.83%)
Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytology
L.L. Humphrey MD et al Ann Intern Med 2004;140:740-753 Study Sample Intervention Prevalence
n (%)Mortality rate per 1000 Person-Yrs
Northwest London Mass Radiography Service (1960)
29,733Men of >40 yrs; 19% former smokers; 67% current smokers
CXR & sputum cytology IG: 31 (0.10)
CG: 20 (0.08)
3 yr ff up IG: 0.7
CG: 0.8
Kaiser Permanente Study (1964)
10, 713Age 35-45 yrs; 17% smokers
CXR NR 16 yr ff upIG: 8.6CG: 7.6
Mayo L ung Project (1971)
10,933Male smokers age ≥ 45 yrs
CXR & sputum cytology vs usual care
91 (0.83) 20 yr ff upIG: 4.4CG: 3.9
Johns Hopkins Lung Project (1973)
10,387Male smokers age ≥ 45yrs
CXR & sputum cytology DSG: 39 (0.75)
CxG:40 (0.78)
5 to 8 yr ff upDSG: 3.4CxG: 3.8
Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytology
L.L. Humphrey MD et al Ann Intern Med 2004;140:740-753
Study Sample Intervention Prevalencen (%)
Mortality rate per 1000 Person-Yrs
Memorial Sloan Kettering Study (1974)
10,040 Male smokers age ≥ 45yrs
CXR & sputum cytology DSG:30 (0.6)
CxG: 23 (0.46)
5 to 8 yr ff upDSG: 2.7CxG: 2.7
Czech Study (1975)
6,345 Male smokers 40-64 yrs
CXR 19 (0.30) 15 yr ff up
Summary
• Two RCTs (JHLP & MSKLP) which used sputum cytology for screening. No mortality benefit was found.
• MLP used CXR & sputum cytology compared to usual care. No mortality benefit was found.
• CLP used q 6m CXR for 3 years, then yearly CXR for 3 years compared to annual CXR. No mortality benefit was found.
Cohort Trials of Low Dose CT ScreeningCANCER Principles and Practice of Oncology DeVita et al 8th Edition p 685 Table III
Project name Enrolled Baseline Annual
Lung Cancer PrevalenceBaseline Annual
% of Stage I Survival Rate
ELCAP (1993- 1999)>60y, >10Pk-yr
10001184
2.9%0.6%
85%86%
Nagano, Japan(1996-1998)>40y, Pk-yr not req’d
5,4838,303
0.4%0.4%
100%86%
ALCA-NCC,Japan(1993 – 2000)>40y, Pk-yr not req’d
1,6117,891
0.9%0.3%
79%82%
5 yr OS baseline : 71%
Hitachi, Japan(2001 – 2002)>40 y Pk-yr not req’d
7,9565,568
0.5%0.1%
85%100%
Cohort Trials of Low Dose CT ScreeningCANCER Principles and Practice of Oncology DeVita et al 8th Edition p 685 Table III
Project name Enrolled Baseline Annual
Lung Cancer PrevalenceBaseline Annual
% of Stage I Survival Rate
Mayo Clinic (1999 – 2004)Age>50,Pk yrs >20, quit < 10 y
15204,472
2.0%0.8%
77%71%72%
Instituto Tumori, Italy(2000 – 2001)Age >50y,Pk yrs >20
1,035996
1.7%0.5%
100%85%
I-ELCAP(1993-2006)Age>40y, Pk yrs not req’d
31, 56727,456
1.3%0.3%
86% 10yr OS : 80%
Summary
• The lung cancer prevalence rate depends on risk characteristics.
• The ratio of baseline to annual cancers is much higher for CT scan than it was for CXR. Or sputum cytology.
• High proportion of finding Stage I disease.
No major medical professional organization currently recommends
screening for lung cancer
Alternatives to Lung Cancer
Screening ?????
National Smoking Prevalence Study
Research & Development, Lung Center of the PhilippinesPhil. Journal Int. Medicine 27: 133 – 156, May – June 1989
Adult population - 46.52% smokers Urban population – 40.92%Rural population – 49.94%
Young Population - 22.70% Urban population – 18.98% Rural population – 26.20%
21 February 2008
1 Unweighted data for the sample of responders
Manila, Philippines Prevalence of ever smoking in population1 ages >40 by
sex
Men Women83% 31%
Overall = 55%
Philippine BOLD Study . AS Buist et al, The Lancet 2007, Vol 370 pp 741 - 50
Cigarette Smoking Among Hospitalized Patients in Metro Manila
JCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp65 - 73
• Results :1. 34% current smokers 43% former smokers
2. Of all current smokers <30y, 65% NEVER thought of attempting to quit. For those >30y, 66% attempted to quit
3. Of those who attempted to quit, 52% had 5-10x attempts.
Attitudes & Beliefs of Smokers
More than half of population thought seriously about quitting.2.5-3x serious attempts to quit – Urban group1 serious attempt to quit - Rural group
Cigarette Smoking Among Hospitalized Patients in Metro ManilaJCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp65 - 73
Young People as Smokers• Overall – 22.70%
- Urban : 18.98%- Rural : 26.20%
• Mean age for starting is 11 – 12 y
• Major reason for starting – Peer group pressure
Cigarette Smoking Among Hospitalized Patients in Metro ManilaJCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp65 - 73
Teaching Lung Cancer Prevention to the Filipinos: an Inter-Agency Collaboration
Department of Research & Development, Lung Center of the PhilippinesScientific Proceedings 1995 Vol 3 pp47- 52
• Aim is to develop a curriculum material on both elementary and HS levels on Lung Cancer prevention.
• Modules are designed to develop awareness among students of the health hazards of smoking and its direct link to lung cancer.
SUMMARY
• Lung cancer is the leading cause of cancer diagnosis and deaths worldwide and locally.
• Lung cancer screening is currently not advocated even for high risk population.
• Standardization of diagnostic evaluation for patients with suspected lung cancer is recommended.
• Prevention of smoking through education, implementation of tobacco regulation law may help curb the incidence of lung cancer.