Lung Cancer Screening - Cleveland Clinic€¦ · 3 Men Women Total • Est. new cases 115,060 106,070 221,130 • Est. deaths 85,600 71,340 156,940 Lung cancer stats - 2011 5 DOS

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DOS CME Course 20111 October 20101Confidential

Lung Cancer Screening

Raul J Seballos, MD, FACPVice-Chair, Preventive MedicineWellness Institute

Cleveland Clinic

© Cleveland Clinic 20111 DOS CME Course 2012

• Your 60 yo female patient with well-controlled HTN presents to you for her yearly physical exam– Asymptomatic and has run 3 miles 3 days/week for years

– Has a 30 pack-yr history of smoking but quit 10 years ago

• PE is normal

• She recently read an article (on her new Kindle that she received as a Christmas present) showing a benefit to screening for lung cancer with CT and asks you whether screening her is appropriate

• What do you tell her?

Adapted from Annals 2011:155:540

A Clinical Question

DOS CME Course 20122

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2011 Estimated US Cancer Cases*

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2011 Estimated US Cancer Deaths


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Men Women Total

• Est. new cases 115,060 106,070 221,130

• Est. deaths 85,600 71,340 156,940

Lung cancer stats - 2011


• Burden of lung cancer deaths 150,000/yr

• Only 15% of lung cancer diagnosed with early-stage (stage I or II)

• Overall 5-yr survival = 16%, no change in past 30 yrs

• 5-yr survival based on stage: – 30% (early) vs 4% (stage IV)

• USPSTF (1996) – Concludes that the evidence is insufficient to recommend for or

against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests (I statement)

Lung Cancer


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JAMA. Nov 2011;306:1865

• 154,901 participants, age 55-74

• Annual CXR x 4 yrs vs usual care

• 1213 lung cancer deaths (intervention group) vs 1230 lung cancer deaths (usual care group) through 13 years

• Conclusion– Annual screening with chest radiograph did not reduce lung

cancer mortality compared with usual care

– CXR should not be performed in this context

PLCO


JAMA. Nov 2011;306:1865

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DOS CME Course 2012

Figure 3. Lung Cancer Mortality by Year

Oken, M. M. et al. JAMA 2011;306:1865-1873

Copyright restrictions may apply.


NEJM 2011;365:395

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• RCT of low dose CT (LDCT) vs CXR

• High risk patients– Age 55-74

– Smoking hx > 30 pack-yr

– Former smokers who have quit within 15 yrs

• Yearly LDCT or CXR for 3 yrs, no additional screening

• Followed for a median of 6.5 yrs

• 53,454 screened from 33 US centers

National Lung Screening Trial (NLST)


• In LDCT group– 63% of lung cancer diagnosed at Stage I

– 70% diagnosed at Stage I or II (early stage)

– 92.5% of Stage I cases treated with surgery

– Fewer cases of Stage IV found at 2nd and 3rd rounds of screeningthan the CXR group

• In CXR group– More lung cancer cases diagnosed after screening period ended

suggesting that CXR missed cancers during screening period



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LDCT CXR

Number of lung CA deaths 356 443

Deaths/100,000 person-yr 247 309

20% decrease in lung cancer deaths is single greatest advance in decreasing lung cancer deaths (except for smoking cessation)

Overall mortality 1877 2000

6.7% reduction




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• From LDCT screening in 55 yo smoker– 1-3 deaths from lung cancer / 10,000 persons screened

– 0.3 new cases of breast cancer / 10,000 persons screened

– Cumulative mortality reduction in NLST was 30 cases of lung cancer / 10,000 persons screened

– From American College of Radiology and Radiological Society of North America–Lifetime risk for fatal cancer from LDCT “very low” (1 per 10,000 to 1

per 100,000 persons

Risk of Radiation Exposure


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• Your 60 yo female patient with well-controlled HTN presents to you for her yearly physical exam– Asymptomatic and has run 3 miles 3 days/week for years

– Has a 30 pack-yr history of smoking but quit 10 years ago

• PE is normal

• She recently read an article (on her new Kindle that she received as a Christmas present) showing a benefit to screening for lung cancer with CT and asks you whether screening her is appropriate

• What do you tell her?

Adapted from Annals 2011:155:540

A Clinical Question


• This patient fits the high risk definition of NLST study

• Expect to decrease her risk of death from lung cancer

• Medicare and insurance companies presently do not reimburse patients for LDCT screening

• Smoking cessation program if patient is a current smoker

A Clinical Question – YES, maybe…


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• Need to discuss potential risks and limitations– NLST patients enrolled in urban tertiary hospital

– LDCT interpreted by chest radiologist with expertise in characterizing nodules and recommending appropriate follow up

– LDCT persons screened with LDCT (n=26,309), 27% had abnormal findings (n=7191)

– Most scans (96.4%) yield false-positive results

– May lead to additional transthoracic needle biopsy, unnecessary surgery, morbidity and mortality–16 patients died w/in 60 days after invasive procedure

–6 did NOT have lung cancer

– High volume of lung cancer surgery centers have nearly twice the5-yr survivorship of low-volume centers



• NLST study patients were younger– Only 8% in the oldest age group 70-74

– Generalizing the study results to this age group is suspect

– Average age of lung cancer diagnosis is 70 yo!

• How long do you screen if initial LDCT was negative?– Probably yearly for 3-5 years

– There were 367 additional lung cancer cases detected in LDCT group in the 5 yr follow-up

– More recommendations on length and frequency of screening to follow with forthcoming information



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• How about cost?

• Number needed to screen (NNS) to prevent one lung cancer death was 346 – NNS to prevent one breast cancer death (2,000 mammograms)

– To defer one cancer death, 900 CT scans and about 85 additional procedures

– Assuming the cost of each CT was $333 and the additional clinical procedure was $5000 in response to positive scans–900 x $333 = $300,000

–85 x $5000 = $425,000

– $725,000 total cost for screening to defer one death from lung cancer



• How about cost?

• On average, the duration of life lost to cancer is 15 years– Cost is $48,000 per year of life gained

– Most medical economist would put threshold for acceptability somewhere between $50,000-100,000 per year of life gained



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• Persons at high risk are more likely to benefit from screening

• Extending LDCT screening outside of the inclusion criteria at this time is not appropriate

• NLST results strongly advocate that physicians discuss CT screening with patients at high risk

• Only informed patients should be screened in a center with expertise in interpreting LDCT, evaluating lung nodules, and diagnosing and treating lung cancer

Conclusions


Thank you!

Documents

Lung Cancer Screening - Cleveland Clinic€¦ · 3 Men Women Total • Est. new cases 115,060 106,070 221,130 • Est. deaths 85,600 71,340 156,940 Lung cancer stats - 2011 5 DOS