Lung Cancer Lung Cancer ScreeningScreening

David Koh, MD, David Koh, MD, FCCP March 1, FCCP March 1,

2014 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

When did we know?When did we know?

Prevalence of SmokingPrevalence of Smoking

1.3 billion smokers globally1.3 billion smokers globally1.. 47% of men and 12% of women are 47% of men and 12% of women are

smokers worldwide.smokers worldwide. 45 Million adults in the US smoke45 Million adults in the US smoke22..

23.5% males, 18.5% females.23.5% males, 18.5% females. There has been a decline in the There has been a decline in the

percentage of smokers from 42% in percentage of smokers from 42% in 1965 to the 20.8% in 2006.1965 to the 20.8% in 2006.

1. WHO Tobacco Free Initiative. 2004 2.CDC. MMWR 2005

Cost of SmokingCost of Smoking

157 billion dollars157 billion dollars

MMWR 2002

What is in Smoke?What is in Smoke?

A pack-a-day smoker puffs more A pack-a-day smoker puffs more than 70,000 times a year.than 70,000 times a year.

92-95% of the total weight of 92-95% of the total weight of mainstream smoke is present in the mainstream smoke is present in the gas phase.gas phase.

Nitrogen, oxygen, and carbon Nitrogen, oxygen, and carbon dioxide account for 85% of smokedioxide account for 85% of smoke’’s s weight.weight.

Selected Cigarette Selected Cigarette Smoke Constituents in Smoke Constituents in

Particulate PhaseParticulate PhaseSubstance EffectsTar Carcinogen

Polynuclear aromatic hydrocarbons

Carcinogen

Nicotine Neuro stimulant and depressant, addicting

Phenol Carcinogen and irritant

Cresol Carcinogen and irritant

- Naphthylamine Carcinogen

N-Nitrosonornicotine Carcinogen

Benzo-pyrene Carcinogen

Trace metals (arsenic, polonium 210)

Carcinogen

Indole Tumor accelerator

Carbazole Tumor accelerator

Catechol Carcinogen

Selected Cigarette Selected Cigarette Smoke Constituents in Smoke Constituents in

Gas PhaseGas PhaseSubstance EffectsCarbon Monoxide Impairs oxygen transport

Hydrocyanic acid Ciliotoxin and irritant

Acetaldehyde Ciliotoxin and irritant

Acrolein Ciliotoxin and irritant

Ammonia Ciliotoxin and irritant

Formaldehyde Ciliotoxin and irritant

Oxides of nitrogen Ciliotoxin and irritant

Nitrosamines Carcinogen

Hydrazine Carcinogen

Vinyl Chloride Carcinogen

Mortality RatesMortality Rates More than 399,000 US deaths annually More than 399,000 US deaths annually

are attributable to cigarette smoking.are attributable to cigarette smoking. Every 8 seconds, someone dies from Every 8 seconds, someone dies from

tobacco use.tobacco use. 40% of neoplasms are related to tobacco.40% of neoplasms are related to tobacco. 22% of ischemic heart disease is caused 22% of ischemic heart disease is caused

by tobacco.by tobacco. On average, male smokers lose 13.2 On average, male smokers lose 13.2

years and females lose 14.5 years of life years and females lose 14.5 years of life expectancyexpectancy

CDC. MMWR. 2005

CDC. MMWR. 2005

CDC. MMWR. 2005

Death RatesDeath Rates Lung cancer accounts for 32% of all Lung cancer accounts for 32% of all

cancer deaths in men and for 25 % of all cancer deaths in men and for 25 % of all cancer deaths in women making lung cancer deaths in women making lung cancer the leading cause of cancer deaths.cancer the leading cause of cancer deaths.

For women, incidence rates dropped for For women, incidence rates dropped for cancers of the breast, colon/rectum, cancers of the breast, colon/rectum, uterus, ovary, cervix, and oral cavity but uterus, ovary, cervix, and oral cavity but increased for cancers of the lung, thyroid, increased for cancers of the lung, thyroid, pancreas, brain/nervous system, bladder, pancreas, brain/nervous system, bladder, and kidney, as well as for leukemia, non-and kidney, as well as for leukemia, non-Hodgkin lymphoma, and melanoma.Hodgkin lymphoma, and melanoma.

CDC. MMWR. 2008

Death RatesDeath Rates

Top 12 States for New Lung Top 12 States for New Lung Cancer Cases in 2012Cancer Cases in 201211

1.1. California (18,060)California (18,060)2.2. Florida (17,860)Florida (17,860)3.3. Texas (14,810)Texas (14,810)4.4. New York (13,620)New York (13,620)5.5. Pennsylvania (10,890)Pennsylvania (10,890)6.6. Ohio (10,270)Ohio (10,270)7.7. Illinois (9,190)Illinois (9,190)8.8. Michigan (8,210)Michigan (8,210)9.9. North Carolina (7,950)North Carolina (7,950)10.10. Georgia (6,570)Georgia (6,570)11.11. Tennessee (6,140)Tennessee (6,140)12.12. New Jersey (5,990)New Jersey (5,990)

1. 2012, American Cancer Society, Inc., Surveillance Research

Local Lung CancerLocal Lung Cancer

Local Lung Cancer RateLocal Lung Cancer Rate

Reality ThenReality Then

At present lung cancer is recognized late.At present lung cancer is recognized late. Opportunities to improve survival are through Opportunities to improve survival are through

earlier detection, accurate diagnosis, accurate earlier detection, accurate diagnosis, accurate localization, and curative therapy.localization, and curative therapy.

Carbone, PPNIH Conference Annals of Internal Medicine (1970) 73:1003

Reality NowReality NowNational Lung Screening Trial (NLST):National Lung Screening Trial (NLST): 8-year trial (2002 – 2010) compared low-dose ct screening to chest x-ray8-year trial (2002 – 2010) compared low-dose ct screening to chest x-ray 53,454 current/former smokers, at high risk for lung cancer53,454 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 Results Released in November 2010: Those who received LDCT had a 20% lower risk of dying

from lung cancer than those who received CXR.from lung cancer than those who received CXR.11

International Early Lung Cancer Action Program (I-ELCAP):International Early Lung Cancer Action Program (I-ELCAP): 31,567 current/former smokers, at high risk for lung cancer31,567 current/former smokers, at high risk for lung cancer 484 were diagnosed with lung cancer, 412 at Stage I484 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 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 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%.surgical removal right away, the cure rate rises to 92%.22

International Association for the Study of Lung Cancer (IASLC):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 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 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.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, 2011Prof. John K Field, MA, PhD, BDS FRCPath, Chair of IASLC - June 29, 2011

Sources:1.NLST Research Team, N Engl J Med 365:395-409, 20112.IELCAP Investigators, N Engl J Med 355:1763-1771, 2006

What was availableWhat was available

CT guided needle biopsy:CT guided needle biopsy: Pneumothorax reates reported Pneumothorax reates reported

anywhere from 10-60% with average of anywhere from 10-60% with average of 25%.25%.

In OhnoIn Ohno’’s study, the lowest occurrences s study, the lowest occurrences of PTX happened at a rate of 28.4% but of PTX happened at a rate of 28.4% but a positive diagnosis in 77% when:a positive diagnosis in 77% when: FEV1 > 70%FEV1 > 70% Single punctureSingle puncture Needle path < 4 cm.Needle path < 4 cm.

Ohno, Y et al. AJR, AM J Roentgenology, 2003

Ohno, Y et al. AJR, AM J Roentgenology, 2003

Newer Bronchoscopy Newer Bronchoscopy TechniquesTechniques

EBUS: Endobronchial EBUS: Endobronchial ultrasonography: Preferred method ultrasonography: Preferred method for sampling lymph nodes without for sampling lymph nodes without general anesthesia.general anesthesia.

ENB: Electromagnetic navigational ENB: Electromagnetic navigational bronchoscopy. Uses GPS to get to bronchoscopy. Uses GPS to get to peripheral nodule.peripheral nodule.

Reconstruction guided Reconstruction guided bronchoscopy.bronchoscopy.

Prior to Navigational Prior to Navigational BronchoscopyBronchoscopy

Difficult to get to peripheral nodules Difficult to get to peripheral nodules because we were looking at a 2-D because we were looking at a 2-D image.image.

PTX rates were lower at 4%PTX rates were lower at 4%11.. Positive diagnosis 40Positive diagnosis 4022 -60 -6033 % %

1. Eberhardt, R et al. Am J Resp Critical Care Medicine. 2007

2. Schenk et al. Chest. 2003

3. Schreiber, G et al. Chest. 2003

Now With Navagational Now With Navagational BronchoscopyBronchoscopy

For difficult cases, the yield was For difficult cases, the yield was 77%77%11..

Overall, the ENB has an accuracy Overall, the ENB has an accuracy rate of 89% and a negative rate of 89% and a negative predictive value of 79%predictive value of 79%22..

1. Hogarth. Bronchol Intervent Pulmonal. 2011

2. Minnich, DJ. Abstract at Society of Thoracic Surgeon’s Meeting. 2012

Electromagnetic Navigation Bronchoscopy Electromagnetic Navigation Bronchoscopy (ENB)(ENB)

Procedure OverviewProcedure Overview

CT-Scan DICOM CD Planning Software Planned Pathway File Navigation Biopsy Treatment

Lung Cancer ScreeningLung Cancer Screening Released in April 2012: Released in April 2012: ““Providing Guidance for Lung Cancer Providing Guidance for Lung Cancer

Screening: The ALA Interim Report on Lung Cancer ScreeningScreening: The ALA Interim Report on Lung Cancer Screening”” Key Points:Key Points:• Best way to prevent lung cancer is to never start or quit smokingBest way to prevent lung cancer is to never start or quit smoking• Low Dose CT (LDCT) should be recommended for those meeting NLST Low Dose CT (LDCT) should be recommended for those meeting NLST

criteria:criteria:• Current or former smoker, ages 55-74Current or former smoker, ages 55-74• Smoking history of at least 30 pack-yearsSmoking history of at least 30 pack-years• Those that smoked in the last 15 years.Those that smoked in the last 15 years.• No history of lung cancerNo history of lung cancer

• Individuals should not receive a Chest X-ray (CXR) for lung cancer Individuals should not receive a Chest X-ray (CXR) for lung cancer screeningscreeningFor hospitals offering screening:For hospitals offering screening:

• Ethical policies for advertising and promotion of screening should Ethical policies for advertising and promotion of screening should be setbe set

• Develop educational materials to assist patients in discussions on Develop educational materials to assist patients in discussions on lung cancer screeninglung cancer screening

• Provide screening services Provide screening services with access to a multidisciplinary with access to a multidisciplinary team team that can provide the needed follow-up evaluation of nodulesthat can provide the needed follow-up evaluation of nodules

What does the ACCT recommend?What does the ACCT recommend?

Take Home MessageTake Home Message

For smokers with a greater than 30 For smokers with a greater than 30 pack years.pack years.

Current smokers and former Current smokers and former smokers that quit less than 15 years smokers that quit less than 15 years ago.ago.

Age 55-74 years old.Age 55-74 years old. Annual Screening with low-dose CT Annual Screening with low-dose CT

annually.annually.

What about JAMAWhat about JAMA• Panel of experts from ACS, ACCP, ASCO and NCCN who Panel of experts from ACS, ACCP, ASCO and NCCN who

reviewed 8 Randomized Clinical Trials and 13 Cohort reviewed 8 Randomized Clinical Trials and 13 Cohort StudiesStudies

• 20% in each round of screening had a positive result, 20% in each round of screening had a positive result, requiring some degree of follow-up and approximately 1% requiring some degree of follow-up and approximately 1% had lung cancerhad lung cancer

• Screening must be done in a center that has the Screening must be done in a center that has the capabilities to evaluate and management findings with a capabilities to evaluate and management findings with a multidisciplinary teammultidisciplinary team

• Low Dose CT (LDCT) screening appears promising, but is Low Dose CT (LDCT) screening appears promising, but is also considered to be in italso considered to be in it’’s infancys infancy

• Quality Improvements measures should be reviewed to Quality Improvements measures should be reviewed to determine the determine the ““rightright”” group to screen, how often and for group to screen, how often and for how longhow long

Risks of Second Hand Risks of Second Hand SmokeSmoke

3,423-8,866 deaths from lung cancer.3,423-8,866 deaths from lung cancer. 22,700-69,600 deaths from cardiac 22,700-69,600 deaths from cardiac

causes.causes. SIDS 430 deaths.SIDS 430 deaths. Childhood asthma (new and Childhood asthma (new and

exacerbations) 202,300.exacerbations) 202,300. Increases risk of COPD by 55Increases risk of COPD by 55%2%2.. Doubles the risk of CVADoubles the risk of CVA33..

CDC. Surgeon General’s Report. 2006. 2. Eisner, MD. Eviron Health. 2005. 3. Goldstein, LB. Stroke. 2006

ConclusionsConclusions Lung cancer can now be reduced by 20%.Lung cancer can now be reduced by 20%. Cancer screening is the key to lowering Cancer screening is the key to lowering

deaths due to lung cancer by finding lung deaths due to lung cancer by finding lung cancers at an early stage when lung cancer cancers at an early stage when lung cancer is still curable.is still curable.

Who should be screened?Who should be screened? People from ages 55-74.People from ages 55-74. Greater than 30 pack years of smoking.Greater than 30 pack years of smoking. Smoked within 15 years.Smoked within 15 years. No history of lung cancer.No history of lung cancer. Repeat CT for 3 consecutive years.Repeat CT for 3 consecutive years.