Lung Cancer: Screening and Treatment

Joseph J. Muscato, MD, FACPMedical Director

Stewart Cancer Center, Boone Hospital

Lung Cancer Burden

There will be 240,000 new cases of lung cancer in the U.S. in 2014.

There will be 160,000 deaths due to lung cancer (vs. 40,000 from breast cancer).

The leading cause is smoking, although 15% of lung cancers occur in non-smokers.

Lung Cancer Burden

The average smoker will die between the ages of 40-79.

Ultimately, almost 20% of smokers will get lung cancer.

Most lung cancers are found in a more advanced stage where cure rates are low or zero. They are not symptomatic in early stages, the most curable stages.

Prevention

Lung Cancer Prevention

There is only one known way to prevent lung cancer, and that is to not smoke.

Second-hand smoke should be avoided. Therefore we would suspect benefit from laws

against smoking in restaurants.

Rare causes: Radon gas, uranium, asbestos.

Early Detection

Lung Cancer Screening

The only current way to reliably cure lung cancer is surgery on small cancers. (Even then, the cure rate is only 60-70%.)Routine chest X-rays are of no benefit for early detection. Most cancers found on X-ray are not curable.More recently, studies have shown that low-dose CT scans (LDCT) can find some cancers early enough to decrease the death rate.

Lung Cancer Screening

A major problem in lung cancer screening is that we are looking at only one point in time and hoping to see an early cancer.

At the same time, a CT will show many tiny nodules that are not cancer.

The rules for follow-up of an abnormal CT are complicated.

National Lung Screening Trial (NLST)

People eligibleCurrent or former smokers aged 55-74At least 30 pack years history of smoking (a “pack-year” = 1 pack per day for one year)Former smokers had to have quit less then 15 years before (risk falls with time off smoking).

They were randomized to get either a CT scan or a chest X-ray yearly for 3 years

NLST Results

CT CXR0

2000

4000

6000

8000

Abn scanCancer

292 lung cancers 190 lung cancers

Number of Stage IA Cancers

CT CXR0

50

100

150

200

Stage IAOthers

How are Abnormal Results Evaluated?

Depending on the size of the pulmonary nodules different follow-up is indicated.If nodules are small, perhaps another CT at 6 months (this one with IV contrast).If larger, might get a CT sooner, or if getting close to 1 cm in size, a biopsy or bronchoscopy.If a cancer is diagnosed at an early stage then surgery will be the recommended approach.

Lung Cancer Survival

Stage 1 Stage 2 Stage 3 Stage 40

10203040506070

5-yr survival %

Does Screening Effect the Behavior of the Study

Participants?

Study of Behavior in Lung Screening Participants:

Elyse Park, PhD, MPH

Behavior in NLST

Of those who were still smoking at the time of entrance in the trial, 10% quit smoking at 1 year but 7% of former smokers started again.

There was no change in risk perception over time. A negative scan does not appreciably reassure smokers that their risk is lower.

The Stewart Cancer Center Lung Screening Program

SCC Lung Screening

This follows the NLST recommendationsCurrent or former smokers 55-74, 30+ pack-year smoking history and quit less than 15 years ago.Current or former smokers 50 or over with 20+ pack-year smoking history and additional risk factors.Yearly low-dose CT yearly x 3 years.If abnormal then repeat CT, PET and/or biopsy depending on CT findings.

CT directed biopsy

Electromagnetic Navigational Bronchoscopy

http://youtu.be/yRCGhpAeoCI

Summary

Lung cancer is the major cancer killer in the world. More than 1 million people a year die world-wide, and more than 160,000 die in the U.S.

Smoking is the huge risk factor. After stopping, the risk decreases over the next 15-20 years, but never back to the level of never-smokers.

Summary

Prevention (not smoking) is the best approach.

For those at risk, early detection and treatment improves survival.

Our methods still require screening a large number of patients to find one with treatable lung cancer.

SummaryThe Stewart Cancer Center Lung Screening Program has been carefully developed to deliver the best care for this problem.

Coupled with the low-dose CT is a team of radiologists, pulmonary physicians, technicians and a nurse navigator to allow for timely and appropriate evaluation of these patients.

If a nodule is found, the Nodule Clinic is ready to aid in the process.

Lung Cancer Screening

If you have any questions, don’t hesitate to call the Nurse Navigator at 573-815-3583.