10/10/2017 DISCLOSURES NONE LUNG CANCER SCREENING: REAL WORLD - - PDF document

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10/10/2017 DISCLOSURES NONE LUNG CANCER SCREENING: REAL WORLD - - PDF document

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10/10/2017 DISCLOSURES NONE LUNG CANCER SCREENING: REAL WORLD PERSPECTIVES Sachin Gupta MD, FCCP Division of Pulmonary & Critical Care Medicine Kaiser Permanente San Francisco @ DoctorS achin AGENDA FOR THIS TALK

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LUNG CANCER SCREENING: REAL WORLD PERSPECTIVES

Sachin Gupta MD, FCCP Division of Pulmonary & Critical Care Medicine Kaiser Permanente – San Francisco @ DoctorS achin

DISCLOSURES

  • NONE

AGENDA FOR THIS TALK

  • Background
  • Lung Cancer Statistics
  • Review of Cancer Screening Modalities
  • Review of the National Lung Screening Trial

(NLS T)

  • Lung Cancer Screening at Kaiser Permanente
  • S

ummary

  • References
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Case details:

  • 87 YO male with a PMHx of OA, severe OS

A, HLP , Afib on warfarin, CV A is referred after rib XR after a fall suggested a lung lesion.

  • Former 30 pack year smoking history.
  • CT:2.6 x 2.1 cm spiculated nodule in the left upper lobe, suspicious

for lung cancer. Mild precarinal lymphadenopathy.

  • PET: 1. Intensely hypermetabolic spiculated LUL mass is suspicious for

lung cancer.

  • 2. Mildly hypermetabolic mediastinal and bilateral hilar nodes are
  • nonspecific. This nodes may be inflammatory or metastatic in nature.

NSCLC accounts for ____ %

  • f all cases of

lung cancer.

  • 25%
  • 55%
  • 85%
  • 95%

P ATHOLOGY:

Adenocarcinoma

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ADENOCARCINOMA

  • Foreign born > US

born risk of NS CLC

  • Larger proportion of Bronchioalveolar Carcinoma in Asians than Caucasians
  • Elevated risk of Adenocarcinoma compared to other NS

CLC in Asians

  • +EGFR mutations
  • Vietnamese > Filipino > Chinese > Korean > Japanese > S
  • uth Asian

P ATHOLOGY:

Squamous cell carcinoma

S QUAMOUS CELL CARCINOMA

  • Smoking is the maj or risk factor.
  • 30%
  • f all lung cancer cases.
  • TP53, NFE2L2, CDKN2A are upcoming genetic targets.
  • African Americans disproportionately affected.

LUNG CANCER RIS K F ACTORS

1. Current or history of tobacco use: cigarettes, pipes, and cigars. 2. Exposure to cancer-causing substances in secondhand smoke. 3. Radiation exposure from any of the following:

1. Radiation therapy to the breast or chest. 2. Radon exposure in the home or workplace. 3. Medical imaging tests, such as computed tomography (CT) scans. 4. Atomic bomb radiation.

4. Occupational exposure to asbestos, arsenic, chromium, beryllium, nickel, and other agents. 5. Living in an area with air pollution. 6. Family history of lung cancer. 7. Human immunodeficiency virus infection. 8. Beta carotene supplements in heavy smokers. 9. History of tuberculosis.

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SMOKING

  • 1. For smokers, the risk for lung cancer is on

average 10X higher than in lifetime nonsmokers (defined as a person who has smoked <100 cigarettes in his or her lifetime).

  • 2. Former smokers continue to have an elevated

risk for lung cancer for years after quitting.

  • 3. Asbestos exposure may exert a synergistic

effect with cigarette smoking on lung cancer risk.

S MOKING IN CHINA

  • China is the largest consumer of tobacco

in the world with over 300 million current smokers

  • >50%
  • f Chinese men are smokers
  • <3%
  • f Chinese women
  • Estimated 422,000 males and 175,000

females in China died of lung cancer in 2012 alone

LUNG CANCER S TATS NUMBER OF NEW CAS ES AND DEATHS

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WHO GETS LUNG CANCER? WHO DIES OF LUNG CANCER? S MOKING RATES BY ETHNICITY REFERENCES FOR ALL OTHER LUNG CANCER S CREENING TRIALS

  • Early Chest Radiographic S

creening RCTs

  • Memorial Sloan-Kettering Study
  • John Hopkins Study
  • Mayo Lung Proj ect
  • Trial conducted in Czechoslovakia
  • The Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial
  • Single-Arm Studies Evaluating Low-Dose CT Screening
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S CREENING

  • Sachin to insert header from NLST article

P ARTICIP ANTS BAS ED ON RACE IN THE NLS T

Patient Population Under Consideration

  • Age: 55-74
  • > 30 pack-year CIGARETTE smoking history
  • 1 pack/ day X 30 years
  • 2 pack/ day X 15 years
  • ½ pack/ day X 60 years
  • Current smoker – OR – quit within the last 15 years
  • No new symptom that suggests underlying malignancy

Criteria for Considering Exclusion/ Discontinuing Screening:

 S ymptoms that warrant cancer workup  Active cancer other than non-melanoma skin cancer, or history of cancer within the last 5 years  Recent lung infection (back to pre-illness baseline for at least 1 preferably 2 months)  On supplemental oxygen  Health problem that substantially limits life expectancy or limits their ability or willingness to have curative lung cancer surgery  Screening of eligible former smokers should stop once they reach 15 years from their quit date or age 74, whichever comes FIRST

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National Lung S creening Trial (NLS T): Details

  • Over 3 rounds of LDCT screening, an absolute reduction in lung

cancer mortality of 3 per 1000 compared with 3 rounds of CXR.

  • 20%

relat ive reduct ion in deat h =>oft en communicat ed as 20% reduct ion

  • 2/ 3 of NLS

T participants <65 years of age

  • NLS

T trial participants healthier, fewer co-morbidities in general compared with community

  • Thoracic surgery mortality rate ~1%

in NLS T

  • Nat ional rat e ~3-4%

KP EXPERIENCES WITH LDCT Demographics – Gender, Race, Age (n=111)

Female 34% Male 53% No Response 13%

Gender

Am Indian/ Alaskian Nat ive 1% Asian 8% Black 8% Hispanic 5% Whit e 67% No Response 11%

Race Average Age = 65.5 years

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S moking Profile (n=137)

Every day 48% Not at all 40% S

  • me days

9% No response 3%

Q2 - Do you currently smoke?

< 10 9% 10-19 25% 20-29 36% 30-39 6% 40-49 7% 50+ 1% No response 16%

Q3 - How many cigarettes do / did you smoke on average per day?

Median = 20 cigarettes

Q6 – How interested are you in talking about quitting smoking? (n=17)

5 10 15 20 25 30 35 40 45 50 1 - Not willing at all 2 3 4 5 - Very willing I don't currently smoke No response

Percent

SUMMAR Y

  • Lung cancer is the leading cause of cancer related death.
  • Smoking cessation is likely to have a larger impact on overall

mortality than is screening.

  • S

creening with low-dose CT has been found to reduce lung cancer mortality in high risk patients.

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SUMMAR Y

  • Centers nationwide, including Kaiser Permanente, have

successfully launched lung cancer screening programs.

  • On-going studies will determine the further reach of screening.
  • Patient education must be tailored for Asian populations.

REFERENCES

  • Alberg AJ, Ford JG, S

amet JM, et al.: Epidemiology of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 132 (3 S uppl): 29S

  • 55S

, 2007

  • Tulunay OE, Hecht S

S , Carmella S G, et al.: Urinary metabolites of a tobacco-specific lung carcinogen in nonsmoking hospitality workers. Cancer Epidemiol Biomarkers Prev 14 (5): 1283-6, 2005.

  • Anderson KE, Kliris J, Murphy L, et al.: Metabolites of a tobacco-specific lung carcinogen in nonsmoking casino patrons. Cancer Epidemiol Biomarkers Prev 12

(12): 1544-6, 2003.

  • S

traif K, Benbrahim-Tallaa L, Baan R, et al.: A review of human carcinogens--part C: metals, arsenic, dusts, and fibres. Lancet Oncol 10 (5): 453-4, 2009.

  • Friedman DL, Whitton J, Leisenring W, et al.: S

ubsequent neoplasms in 5-year survivors of childhood cancer: the Childhood Cancer S urvivor S

  • tudy. J Natl Cancer

Inst 102 (14): 1083-95, 2010.

  • Gray A, Read S

, McGale P, et al.: Lung cancer deaths from indoor radon and the cost effectiveness and potential of policies to reduce them. BMJ 338: a3110, 2009.

  • Berrington de González A, Kim KP, Berg CD: Low-dose lung computed tomography screening before age 55: estimates of the mortalit y reduction required to
  • utweigh the radiation-induced cancer risk. J Med S

creen 15 (3): 153-8, 2008.

  • S

himizu Y, Kato H, S chull WJ: S tudies of the mortality of A-bomb survivors. 9. Mortality, 1950-1985: Part 2. Cancer mortality based on the recently revised doses (DS 86). Radiat Res 121 (2): 120-41, 1990.

  • Katanoda K, S
  • bue T, S

atoh H, et al.: An association between long-term exposure to ambient air pollution and mortality from lung cancer and respiratory diseases in Japan. J Epidemiol 21 (2): 132-43, 2011.

  • S

un, Yihua, et al. "Lung adenocarcinoma from East Asian never-smokers is a disease largely defined by targetable oncogenic mutant kinases." Journal of clinical

  • ncology 28.30 (2010): 4616-4620.
  • Raz, Dan J., et al. "Epidemiology of non-small cell lung cancer in Asian Americans: incidence patterns among six subgroups by nativity." Journal of Thoracic

Oncology 3.12 (2008): 1391-1397.

REFERENCES

  • Cao J, Y

ang C, Li J, et al.: Associat ion bet ween long-t erm exposure t o out door air pollut ion and mort alit y in China: a cohort st udy. J Hazard Mat er 186 (2-3): 1594-600, 2011.

  • Hales S

, Blakely T , Woodward A: Air pollut ion and mort alit y in New Zealand: cohort st udy. J Epidemiol Communit y Healt h 66 (5): 468-73, 2012.

  • Lissowska J, Foret ova L, Dabek J, et al.: Family hist ory and lung cancer risk: int ernat ional mult icent re case-cont rol st udy in East ern and Cent ral Europe

and met a-analyses. Cancer Causes Cont rol 21 (7): 1091-104, 2010.

  • Shiels MS, Cole SR, Kirk GD, et al.: A met a-analysis of t he incidence of non-AIDS cancers in HIV-infected individuals. J Acquir Immune Defic S

yndr 52 (5): 611-22, 2009.

  • The effect of vit amin E and bet a carot ene on t he incidence of lung cancer and ot her cancers in male smokers. The Alpha-Tocopherol, Bet a Carot ene

Cancer Prevent ion S t udy Group. N Engl J Med 330 (15): 1029-35, 1994.

  • Omenn GS

, Goodman GE, Thornquist MD, et al.: Effect s of a combinat ion of bet a carot ene and vit amin A on lung cancer and cardiovascular disease. N Engl J Med 334 (18): 1150-5, 1996.

  • Tanner NT

, Kanodra NM, Gebregziabher M, et al: The associat ion bet ween smoking abst inence and mort alit y in t he Nat ional Lung S creening Trial. Am J Respir Crit Care Med 2016; 193: pp. 534-541

  • Molina, Julian R., Alex A. Adj ei, and James R. Jet t . "Advances in chemot herapy of non-small cell lung cancer." CHES

T Journal 130.4 (2006): 1211-1219.

  • Veronesi, Giulia, et al. "Diagnost ic performance of low-dose comput ed t omography screening for lung cancer over five years." Journal of Thoracic

Oncology 9.7 (2014): 935-939.

  • Li Q, Hsia J, Y

ang G. Prevalence of smoking in China in 2010. The New England j ournal of medicine. 2011;364(25):2469–

  • 70. Epub 2011/ 06/ 24.

pmid:21696322

  • Levy D, Rodriguez-Buno RL, Hu TW, Moran AE. The pot ent ial effect s of t obacco cont rol in China: proj ect ions from t he China S

imS moke simulat ion model. Bmj . 2014;348:g1134. pmid:24550245

S peaker Information

S achin.Gupta@ kp.org @ DoctorS achin https:/ / www.linkedin.com/ in/ sachinguptamd/

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Extra S lides INCIDENCE RATES BY RACE/ ETHNICITY AND S EX INCIDENCE RATES BY RACE/ ETHNICITY AND S EX

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  • BACKGROUND
  • a cancer prevention trial conducted

by the U.S. National Cancer Institute (NCI) and the National Institute for Health and Welfare of Finland from 1985 to 1993

  • PURPOSE
  • to determine whether certain vitamin

supplements would prevent lung cancer and other cancers in a group

  • f 29,133 male smokers in Finland.

ALPHA-TOCOPHEROL, BETA-CAROTENE CANCER PREVENTION (ATBC) STUDY

  • CONCLUSION
  • No reduction in the incidence of lung

cancer among male smokers after five to eight years of dietary supplementation with alpha- tocopherol or beta carotene. In fact, this trial raises the possibility that these supplements may actually have harmful as well as beneficial effects

ALPHA-TOCOPHEROL, BETA-CAROTENE CANCER PREVENTION (ATBC) STUDY

VETERANS ADMIN EXPERIENCE WITH NLS T

  • V

A study:

  • 8 academic VHA hospitals among 93 033 primary care patients who were assessed on

screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015.

  • Of the 4246 patients who met the criteria for LCS

, 2452 (57.7% ) agreed to undergo screening and 2106 (2028 men and 78 women; mean [S D] age, 64.9 [5.1] years) underwent LCS . Wide variation in processes and patient experiences occurred among the 8 sites.

  • Of the 2106 patients screened, 1257 (59.7%

) had nodules; 1184 of these patients (56.2% ) required tracking, 42 (2.0% ) required further evaluation but the findings were not cancer, and 31 (1.5% ) had lung cancer.

  • A variety of incidental findings, such as emphysema, other pulmonary abnormalities,

and coronary artery calcification, were noted on the scans of 857 patients (40.7% ).

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What is the average annual death rate per 100,000 for breast cancer?

  • A. 15
  • B. 20
  • C. 25
  • D. 45

What is the average annual death rate per 100,000 for colon cancer?

  • A. 15
  • B. 20
  • C. 25
  • D. 45
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What is the average annual death rate per 100,000 for prostate cancer?

  • A. 15
  • B. 20
  • C. 25
  • D. 45

What is the average annual death rate per 100,000 for lung cancer?

  • A. 15
  • B. 20
  • C. 25
  • D. 45
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Q7, 8, 9 - Knowledge of Benefits / Harms

(n=111)

Statement True False Unsure No Response All smokers should be screened for lung cancer 51.4% 28.8% 15.3% 4.5%

It lowers your chances of getting lung cancer

22.5% 63.1% 6.3% 8.1%

It can cure cancer

9.9% 74.8% 5.4% 9.9%

It lowers your chances of dying from lung cancer

60.4% 23.4% 8.1% 8.1%

It lowers your chances of developing lung cancer nodules (n=17)

17.7% 52.9% 29.4% 0%

Y

  • u may find some things in your lungs that

are not cancer but would need an extra test to check

86.5% 0.9% 6.3% 6.3%

Y

  • u may need to get an extra test which

can cause complications

77.5% 8.1% 5.4% 9.0%

There are no harms associated with screening

11.7% 67.6% 7.2% 13.5%

Note: Yellow highlights represent “ correct” response.