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Lung Cancer Screening

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Title: Restless Leg Syndrome and Periodic Limb Movement Syndrome Author: David Koh Last modified by: Codee Champney Created Date: 2/22/2014 4:09:31 PM – PowerPoint PPT presentation

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Title: Lung Cancer Screening


1
Lung Cancer Screening
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David Koh, MD, FCCP March 1, 2014
2
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

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When did we know?
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Prevalence of Smoking
  • 1.3 billion smokers globally1.
  • 47 of men and 12 of women are smokers
    worldwide.
  • 45 Million adults in the US smoke2.
  • 23.5 males, 18.5 females.
  • There has been a decline in the percentage of
    smokers from 42 in 1965 to the 20.8 in 2006.

1. WHO Tobacco Free Initiative. 2004 2.CDC. MMWR
2005
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Cost of Smoking
  • 157 billion dollars

MMWR 2002
11
What is in Smoke?
  • A pack-a-day smoker puffs more than 70,000 times
    a year.
  • 92-95 of the total weight of mainstream smoke is
    present in the gas phase.
  • Nitrogen, oxygen, and carbon dioxide account for
    85 of smokes weight.

12
Selected Cigarette Smoke Constituents in
Particulate Phase
Substance Effects
Tar Carcinogen
Polynuclear aromatic hydrocarbons Carcinogen
Nicotine Neuro stimulant and depressant, addicting
Phenol Carcinogen and irritant
Cresol Carcinogen and irritant
b- Naphthylamine Carcinogen
N-Nitrosonornicotine Carcinogen
Benzo-pyrene Carcinogen
Trace metals (arsenic, polonium 210) Carcinogen
Indole Tumor accelerator
Carbazole Tumor accelerator
Catechol Carcinogen
13
Selected Cigarette Smoke Constituents in Gas Phase
Substance Effects
Carbon 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
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Mortality Rates
  • More than 399,000 US deaths annually are
    attributable to cigarette smoking.
  • Every 8 seconds, someone dies from tobacco use.
  • 40 of neoplasms are related to tobacco.
  • 22 of ischemic heart disease is caused by
    tobacco.
  • On average, male smokers lose 13.2 years and
    females lose 14.5 years of life expectancy

CDC. MMWR. 2005
16
CDC. MMWR. 2005
17
CDC. MMWR. 2005
18
Death Rates
  • Lung cancer accounts for 32 of all cancer deaths
    in men and for 25 of all cancer deaths in women
    making lung cancer the leading cause of cancer
    deaths.
  • For women, incidence rates dropped for cancers of
    the breast, colon/rectum, uterus, ovary, cervix,
    and oral cavity but increased for cancers of the
    lung, thyroid, pancreas, brain/nervous system,
    bladder, and kidney, as well as for leukemia,
    non-Hodgkin lymphoma, and melanoma.

CDC. MMWR. 2008
19
Death Rates
20
Top 12 States for New Lung Cancer Cases in 20121
  • California (18,060)
  • Florida (17,860)
  • Texas (14,810)
  • New York (13,620)
  • Pennsylvania (10,890)
  • Ohio (10,270)
  • Illinois (9,190)
  • Michigan (8,210)
  • North Carolina (7,950)
  • Georgia (6,570)
  • Tennessee (6,140)
  • New Jersey (5,990)

1. 2012, American Cancer Society, Inc.,
Surveillance Research
21
Local Lung Cancer
22
Local Lung Cancer Rate
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Reality Then
  • At present lung cancer is recognized late.
  • Opportunities to improve survival are through
    earlier detection, accurate diagnosis, accurate
    localization, and curative therapy.

Carbone, PPNIH Conference Annals of Internal
Medicine (1970) 731003
25
Reality Now
  • National Lung Screening Trial (NLST)
  • 8-year trial (2002 2010) compared low-dose ct
    screening to chest x-ray
  • 53,454 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 from
    lung cancer than those who received CXR.1
  • International Early Lung Cancer Action Program
    (I-ELCAP)
  • 31,567 current/former smokers, at high risk for
    lung cancer
  • 484 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 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 92.2
  • 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 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.
  • - Prof. John K Field, MA, PhD, BDS FRCPath,
    Chair of IASLC - June 29, 2011
  • Sources
  • NLST Research Team, N Engl J Med 365395-409,
    2011
  • IELCAP Investigators, N Engl J Med 3551763-1771,
    2006

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What was available
  • CT guided needle biopsy
  • Pneumothorax reates reported anywhere from 10-60
    with average of 25.
  • In Ohnos study, the lowest occurrences of PTX
    happened at a rate of 28.4 but a positive
    diagnosis in 77 when
  • FEV1 gt 70
  • Single puncture
  • Needle path lt 4 cm.

Ohno, Y et al. AJR, AM J Roentgenology, 2003
29
Ohno, Y et al. AJR, AM J Roentgenology, 2003
30
Newer Bronchoscopy Techniques
  • EBUS Endobronchial ultrasonography Preferred
    method for sampling lymph nodes without general
    anesthesia.
  • ENB Electromagnetic navigational bronchoscopy.
    Uses GPS to get to peripheral nodule.
  • Reconstruction guided bronchoscopy.

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Prior to Navigational Bronchoscopy
  • Difficult to get to peripheral nodules because we
    were looking at a 2-D image.
  • PTX rates were lower at 41.
  • Positive diagnosis 402 -603
  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

33
Now With Navagational Bronchoscopy
  • For difficult cases, the yield was 771.
  • Overall, the ENB has an accuracy rate of 89 and
    a negative predictive value of 792.
  1. Hogarth. Bronchol Intervent Pulmonal. 2011
  2. Minnich, DJ. Abstract at Society of Thoracic
    Surgeons Meeting. 2012

34
Electromagnetic Navigation Bronchoscopy
(ENB)Procedure Overview
CT-Scan
DICOM CD
Planning Software
Planned Pathway File
Navigation
Biopsy
Treatment
35
Lung Cancer Screening
  • Released in April 2012 Providing Guidance for
    Lung Cancer Screening The ALA Interim Report on
    Lung Cancer Screening
  • Key Points
  • Best way to prevent lung cancer is to never start
    or quit smoking
  • Low Dose CT (LDCT) should be recommended for
    those meeting NLST criteria
  • Current or former smoker, ages 55-74
  • Smoking history of at least 30 pack-years
  • Those that smoked in the last 15 years.
  • No history of lung cancer
  • Individuals should not receive a Chest X-ray
    (CXR) for lung cancer screeningFor hospitals
    offering screening
  • Ethical policies for advertising and promotion of
    screening should be set
  • Develop educational materials to assist patients
    in discussions on lung cancer screening
  • Provide screening services with access to a
    multidisciplinary team that can provide the
    needed follow-up evaluation of nodules

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What does the ACCT recommend?
37
Take Home Message
  • For smokers with a greater than 30 pack years.
  • Current smokers and former smokers that quit less
    than 15 years ago.
  • Age 55-74 years old.
  • Annual Screening with low-dose CT annually.

38
What about JAMA
  • Panel of experts from ACS, ACCP, ASCO and NCCN
    who reviewed 8 Randomized Clinical Trials and 13
    Cohort Studies
  • 20 in each round of screening had a positive
    result, requiring some degree of follow-up and
    approximately 1 had lung cancer
  • Screening must be done in a center that has the
    capabilities to evaluate and management findings
    with a multidisciplinary team
  • Low Dose CT (LDCT) screening appears promising,
    but is also considered to be in its infancy
  • Quality Improvements measures should be reviewed
    to determine the right group to screen, how
    often and for how long

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Risks of Second Hand Smoke
  • 3,423-8,866 deaths from lung cancer.
  • 22,700-69,600 deaths from cardiac causes.
  • SIDS 430 deaths.
  • Childhood asthma (new and exacerbations) 202,300.
  • Increases risk of COPD by 552.
  • Doubles the risk of CVA3.

CDC. Surgeon Generals Report. 2006. 2. Eisner,
MD. Eviron Health. 2005. 3. Goldstein, LB.
Stroke. 2006
42
Conclusions
  • Lung cancer can now be reduced by 20.
  • Cancer screening is the key to lowering deaths
    due to lung cancer by finding lung cancers at an
    early stage when lung cancer is still curable.
  • Who should be screened?
  • People from ages 55-74.
  • Greater than 30 pack years of smoking.
  • Smoked within 15 years.
  • No history of lung cancer.
  • Repeat CT for 3 consecutive years.
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