Lung Cancer: More prevalent than you think

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Lung Cancer More prevalent than you think

• Anthony D Weaver MD

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Disclosures

• Dr. Anthony Weaver has no relationships to
  disclose.

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Objectives

• 1. Analyze the current demographics of lung CA
• 2. Examine common presenting symptoms of lung
  cancer.
• 3. Discuss the pros and cons of screening for
  lung cancer in high risk individuals
• 4. Describe appropriate follow up care for
  primary care patients with findings suspicious of
  lung cancer.

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Remember

• The best way to treat lung cancer is to prevent
  it by not smoking.
• There is an overwhelming medical and scientific
  consensus that cigarette smoking causes lung
  cancer, heart disease, emphysema and other
  serious diseases in smokers. There is no safe
  cigarette . . . cigarette smoking is addictive,
  as that term is most commonly used today.
• Philip Morris tobacco company, 1999

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Objective 1

• Analyze the current demographics of lung CA

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History

• Early 1900s lung cancer was extremely rare
• End of 1900s prevalence second to prostate
  cancer in men, breast cancer in women.
• Lung cancer has passed heart disease as the
  leading cause of smoking-related mortality
• 159,480 deaths in 2013 (NCI lung cancer
  statistics)

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Top 5 Causes of Cancer Death for Men

1. Lung bronchus 28
2. Prostate 10
3. Colon rectum 8
4. Pancreas 7
5. Leukemia 5

Cancer Facts and Figures 2014 at www.cancer.org
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Top 5 Causes of Cancer Death for Women

• 1. Lung bronchus 26
• 2. Breast 15
• 3. Colon rectum 9
• 4. Pancreas 7
• 5. Ovary 5

Cancer Facts and Figures 2014 at www.cancer.org
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Kentucky Cancer Deathsper year 2006-2010

• Lung and Bronchus 3416
• Colon 881
• Breast 597
• Pancreas 507
• Prostate 392
• Leukemia 332
• Non-Hodgkin Lymphoma 320
• Ovary 212

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National Cancer Institute State Data
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5-year survival rates 2001-2007

• 65 for colon cancer
• 99 for prostate cancer
• 89 for breast cancer
• 16 for lung cancer

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Lung Cancer, 2004-2008
Region Incidence Rate Mortality Rate
US 62.0 52.5
Kentucky 100.8 75.1
The KY incidence is 62.6 HIGHER than the US The
KY mortality is 43.0 HIGHER than the US
Source SEERStat 7.0.4 SEER 17
Registries Source Kentucky Cancer Registry
Based on 2003-2007 rate
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Lung/Bronchus Cancer

• Leading cause of cancer death in the US and KY.
• All 120 counties death rate above the US
  average.
• The death rate varies from 59 in Larue and
  Cumberland counties to 124 in Gallatin County.
• The highest rates are in eastern KY and
  Ohio, Butler, and Muhlenberg counties.

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Smoking

• Up to 90 of lung cancer cases are related to
  smoking.
• 9-15 are related to occupational exposure to
  carcinogens.
• The strongest determinant of lung cancer is
  duration of cigarette smoking, and the risk
  becomes larger with more cigarettes smoked.
• Smoking causes lung cancer in both men and women.
  

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Prevalence of Current Smoking by Area
Development District, 2010
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Lung Cancer Incidence by Area Development
District, 2004-2008
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Lung Cancer Mortality by Area Development
District, 2004-2008
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Other Causes of lung cancer

• Asbestos exposure
• Radon exposure
• Halogen ether exposure
• Chronic interstitial pneumonitis
• Inorganic arsenic exposure
• Radioisotope exposure, ionizing radiation
• Atmospheric pollution
• Chromium, nickel exposure
• Vinyl chloride

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Lung Cancer Incidence by Area Development
District, 2004-2008
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Lung Cancer in the Mountains
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iLovemountains.org
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Objective 2

• Examine common presenting symptoms of lung
  cancer.

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Symptoms

• Cough 50-75
• Wt loss 8-68
• Hemoptysis 25-50
• Chest pain 27-49
• Dyspnea 37-58
• Hoarseness/stridor 2-18
• Paraneoplastic Synd 10-20
• Asymptomatic 7-10

http//emedicine.medscape.com/article/279960-clini
cal
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Objective 3

• Discuss the pros and cons of screening for lung
  cancer in high risk individuals

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Screening for Lung CancerScreening with Chest
XRAY/Sputum Cytology

• Mayo Lung Project
• 10,993 smokers 6 year program of CXR and sputum
  q 4 mos vs. annual CXR in the control group
• More cancers diagnosed in screened group but no
  mortality reduction at 20 yrs (actually higher in
  screened group
• PLCO Cancer Screening Trial ( due 2015, aborted)
• 15,4942 participants (51.6 current or former
  smokers)
• Single CXR at baseline and then annually x 3 yrs
  vs. usual care control group
• No difference in incidence or mortality
• Only 20 of cancers detected by screening

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Study Overview

• Persons undergoing three annual screening
  examinations with low-dose computed tomography
  had a 20 reduction in lung-cancer mortality
  compared with those screened with annual chest
  radiography.

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Study Design

• Participants
• Smokers/former smokers with a 30 pk-yr history
  aged 55-75 years
• Exclusions CT within 18 months of the study,
  hemoptysis or and unexplained weight loss
• 53,454 participants half assigned to CT group
  and CXR group

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Screening

• Three yearly screenings with either low dose CT
  or PA/Lat CXRs and followed for 5.5 years
• Scan included
• any non-calcified nodule or mass measuring 4mm
  or more
• Adenopathy or effusion
• If abnormalities were stable at 3rd screening,
  they were classified as minor abnormalities

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Outcome measures

• Primary lung cancer mortality between the two
  groups
• Secondary death rate from any cause and the
  incidence of lung cancer in the two groups
• Study 90 powered to detect a 21 decrease in
  mortality

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Resultsstopped 11/10 due to benefit

• Positive Result
• 24.2 CT group, 23.3 were false
• 6.9 CXR group, 6.5 were false
• False positive results
• 96.4 CT group, 94.5 CXR group
• gt90 of these resulted in further testing, most
  often further imaging

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Adverse events

• Procedural complications (all)
• 1.4 CT
• 1.6 CXR
• Major Complications (CT)
• .06 (non-lung cancer group)
• 11.2 (lung cancer group)
• Major Complications (CXR)
• 0.02 (non-lung cancer group)
• 8.2 (lung cancer group)

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Lung Cancer Diagnosis

• 1060 lung cancers in CT group (645/100,000)
• 941 lung cancers in CXR group (572/100,000)
• Rate ratio 1.13
• Stage 1A and B Disease
• 63 in CT group vs. 47.6 in CXR group
• Fewer Stage 4 lesions in CT group than CXR group
• Mortality
• 356 deaths from lung cancer in the CT group
• 443 deaths from lung cancer in the CXR group
• Signicant (20 reduction) in the CT group
  (P0.004)
• Reduced all-cause mortality by 6.7 ( P0.02).

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Cumulative Numbers of Lung Cancers and of Deaths
from Lung Cancer.
The National Lung Screening Trial Research Team.
N Engl J Med 2011365395-409
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Results of Three Rounds of Screening.
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Diagnostic Follow-up of Positive Screening
Results in the Three Screening Rounds.
The National Lung Screening Trial Research Team.
N Engl J Med 2011365395-409
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Stage and Histologic Type of Lung Cancers in the
Two Screening Groups, According to the Result of
Screening.
The National Lung Screening Trial Research Team.
N Engl J Med 2011365395-409
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Histologic Type of Lung Cancers in the Two
Screening Groups, According to Tumor Stage.
The National Lung Screening Trial Research Team.
N Engl J Med 2011365395-409
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Cause of Death on the Death Certificate,
According to Screening Group.
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USPSTF recommendation

• The USPSTF recommends annual screening for lung
  cancer with low-dose computed tomography (LDCT)
  in adults aged 55 to 80 years who have a 30
  pack-year smoking history and currently smoke or
  have quit within the past 15 years.
• Screening should be discontinued once a person
  has not smoked for 15 years or develops a health
  problem that substantially limits life expectancy
  or the ability or willingness to have curative
  lung surgery. (B recommendation)

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USPSTF recommendation

• The magnitude of benefit depends on that person's
  risk for lung cancer those who are at highest
  risk are most likely to benefit.
• The harms associated with LDCT screening include
  false-negative and false-positive results,
  incidental findings, overdiagnosis, and radiation
  exposure.
• False-positive LDCT results occur in a
  substantial proportion 95 of all positive
  results do not lead to a diagnosis of cancer. In
  a high-quality screening program, further imaging
  can resolve most false-positive results.

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USPSTF recommendation

• The USPSTF found insufficient evidence on the
  harms associated with incidental findings.
• A modeling study performed for the USPSTF
  estimated that 10 to 12 of screen-detected
  cancer cases are overdiagnosedthat is, they
  would not have been detected in the patient's
  lifetime without screening.
• Radiation harms, including cancer , vary
  depending on the age at the start of screening
  the number of scans received and the person's
  exposure to other sources of radiation.

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CMS Ruling

• Since 2009, the CMS has been permitted to add
  coverage for "additional preventive services" if
  they are recommended (grade B) or strongly
  recommended (grade A) by the USPSTF and meet
  other requirements.
• On February 10, 2014, the CMS opened a 30-day
  public comment period regarding coverage for lung
  cancer screening. The comments, coming primarily
  from healthcare providers, were overwhelmingly in
  favor.
• After the public comment period ended on
  March 12, the CMS will convene a meeting of the
  Medicare Evidence Development and Coverage
  Advisory Committee to review the available
  evidence on lung cancer screening.

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JAMA May 20, 2012, Vol 307, No. 22
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Radiation Exposure

• LDCT exposure estimated 1.5 mSv per scan
• Total exposure estimated 8 mSv per subject
• Radiation-induced cancer 10-20 years later
• Benefit greater than risk for NLST group
• Risk greater than benefit for age 42

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Conclusion

• Screening a population of individuals at a
  substantially elevated risk of lung cancer most
  likely could be performed in a manner such that
  the benefits that accrue to a few individuals
  outweigh the harms that many will experience.
• However, there are substantial uncertainties
  regarding how to translate that conclusion into
  clinical practice.

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N Engl J Med 3688 February 21, 2013
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Modified Logistic-Regression Prediction Model
(PLCOM2012) of Cancer Risk for 36,286 Control
Participants Who Had Ever Smoked.
Tammemägi MC et al. N Engl J Med 2013368728-736
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Tammemägi MC et al. N Engl J Med 2013368728-736
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N Engl J Med 3693 July 18, 2013
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NEJM July 18, 2013

• Only 1 of CT-prevented lung-cancer deaths
  occurred among the 20 at lowest risk
• 161 patients in the highest-risk quintile would
  need to be screened to prevent 1 lung cancer
  death.
• In the lowest-risk quintile, 5,276 would need to
  be screened to prevent 1 lung cancer death.

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Marty Driesler Project

• When compared to the NLST participants, MDLCP
  participants had
• higher smoking rates,
• lower income,
• lower education level and
• older age

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Can the US healthcare system afford this
screening what health services should be
eliminated to pay for this very expensive
endeavor (like childhood immunizations)?  
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Lung Cancer Why the Guilt Trip?

• Memorial Sloan-Kettering survey
• 2000 lung cancer patients
• 84 current non-smokers
• people who start smoking are generally 12 or
  13years old They were targeted.
• We are going to be faced with an epidemic of
  lung cancer for a decade or more if every single
  person stops smoking today.

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Cancer Research2012 (Federal dollars)

• 21,000 per breast cancer death
• 1400 per lung cancer death.

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Objective 4

• Describe appropriate follow up care for primary
  care patients with findings suspicious of lung
  cancer.

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Follow-up of pulmonary nodules

• Lesion Size Probability of Cancer
• lt 5 mm 0-1
• 5 -10 mm 6-28
• 11-20 mm 33-60
• 21-30 mm 64-82

Chest 2007 132 3 Suppl 94S-107S
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Characteristics of pulmonary nodules

• Benign disease

• Malignancy

• Triangular shape, abutting a fissure
• Central calcification

• Spiculated nodule
• Noncalcified
• Part solid

Chest 2007 132 3 Suppl 94S-107S
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Tammemägi MC et al. N Engl J Med 2013368728-736
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PET Scanning

• Average sensitivity 0.97 and specificity 0.78 for
  detecting a malignancy was reported
• Useful for searching for systemic spread
• More sensitive, specific, and accurate than CT
  scan for staging mediastinal disease
• PET scans may influence staging in up to 60 of
  cases

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Population-Based Risk for Complications After
Transthoracic Needle Lung Biopsy of a Pulmonary
Nodule An Analysis of Discharge Records

• Retrospective study of 15,856 adults who had a
  transthoracic needle biopsy of a pulmonary nodule
• 1.0 of biopsies complicated by hemorrhage
• 15 pneumothorax
• 6.6 of all biopsies pneumo chest tube
• Those with any complications had longer lengths
  of stay (Plt0.001) and were more likely to require
  mechanical ventilation (P 0.020)
• Soylemez Wiener, et al. Ann Int Med.2011
  155137-144

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Complications after the Most Invasive
Screening-Related Diagnostic Evaluation
Procedure, According to Lung-Cancer Status.
The National Lung Screening Trial Research Team.
N Engl J Med 2011365395-409
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Complications after the Most Invasive
Screening-Related Diagnostic Evaluation
Procedure, According to Lung-Cancer Status.
The National Lung Screening Trial Research Team.
N Engl J Med 2011365395-409
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Remember

• The best way to treat lung cancer is to prevent
  it by not smoking.
• There is an overwhelming medical and scientific
  consensus that cigarette smoking causes lung
  cancer, heart disease, emphysema and other
  serious diseases in smokers. There is no safe
  cigarette . . . cigarette smoking is addictive,
  as that term is most commonly used today.
• Philip Morris tobacco company, 1999