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GRACE Video

Lung Cancer Screening – Process and Potential Benefits

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GRACE Cancer Video Library - Lung

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Dr. Jed Gorden, Swedish Cancer Institute, reviews the lung cancer screening process, including low-dose CT scanning, smoking cessation, follow-up testing and counseling, and describes the potential benefits.

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Lung cancer screening is a very exciting advance in the field of lung cancer which has come about in the last several years. This is where low-dose CT scans, or “CAT” scans, very high resolution images of the lungs, are used to identify nodules and identify early cancers. The critical thing to know is that this is an advancement that has come about in the last several years due to a tremendous amount of government-funded research looking at the safety and the efficacy of using low-dose CT scans to identify high-risk patients who have lung cancer.

Let’s talk about that for a second: high-risk patients. Patients that qualify for lung cancer screening need to understand certain things, and you’re going to have to participate in a shared decision-making conversation with your team and caregivers. So who qualifies, who is high-risk? The high-risk criteria for lung cancer screening and people who should undergo low-dose CT imaging are patients who are 55 to 80 years old, who smoked for at least 30 pack-years which is one pack of cigarettes a day for 30 years, and are actively smoking or quit within the last 15 years. This is the minimum population who is at risk for lung cancer and meets the criteria to undergo low-dose CT screening.

It’s really important to understand that embarking on lung cancer screening and low-dose CT is a journey and a partnership with your team of professionals in the lung cancer screening center. The reason that I say this is because, number one: no single scan will prove that any individual doesn’t have lung cancer. It is through a partnership and continued surveillance based on specific criteria, and discussions with your team over time that will help minimize any risk of lung cancer.

Why would anyone want to embark on this journey? The data that we have and the reason we’re so excited about lung cancer screening now is that the data suggests that through low-dose CT screening of high-risk individuals that the mortality associated with lung cancer is decreased by 20% and the overall all-cause mortality is decreased by almost 7%. But it’s important to understand that this is done in the confines of a multidisciplinary team with counseling and active participation of patients who continue throughout the program and follow the guidelines that are established through screening.

So let’s talk about each one of these components. We’ve talked about the high-risk, which is the patient that’s involved — let’s talk a little bit more about high-risk. So we know that even within this risk profile are those that are at minimal risk for lung cancer, there are those that are at increased risk. We have an identified population of high-risk patients for lung cancer that we described: 55 to 80 years old, actively smoking or quit within the last 15 years, and smoked for at least 30 pack-years. We know that’s the minimum risk and it’s important for people to understand that at the minimum risk level for lung cancer, it takes almost 5,300 people screened to identify one single cancer. As the risk goes up, age goes up, increasing pack years of smoking goes up, we know that the number of people to screen goes down to about 160 to 170 people in the highest risk groups. Therefore it’s important that we adhere to these rigorous guidelines of only those patients who are at the highest risk, who meet the criteria that was described, to undergo lung cancer screening.

Number two: partnership. No single scan allows people to move forward without being continued in the program. It is a continuum that people need to engage in and a partnership with your professional team.

Number three: smoking cessation. Smoking cessation for those that are still smoking is critical to minimizing the risk for lung cancer. This is a teachable moment. This is an opportunity to partner with your team to identify the ability to quit, potential medications for helping you quit, triggers and counseling. I urge people to take advantage of this and to inquire with their team on how best to approach this process as you engage and move forward in the lung cancer screening arena.

The final thing is counseling. It is important to understand that many people who embark on the journey of lung cancer screening, both those that are in the highest risk group and those that are in the minimum risk group to qualify for lung cancer screening will oftentimes be found with an abnormality or what’s called a pulmonary nodule. A pulmonary nodule is a small abnormality seen on a CT scan. It can be described as a dot or a nodule or an abnormality, all descriptors of the same thing, but the critical thing to understand is that the overwhelming majority of the time, these are not cancer. They are benign, but we only know that through continued surveillance and strict adherence to guidelines on when to follow patients up, when to move to additional testing, and when to move on to invasive testing.

The confidence that you build with your professional team will allow you to move forward through this process with education and without fear, and allow you to move forward and minimize the risk of lung cancer in those patients who are high-risk.


GRACE Video

Trends in Lung Cancer Demographics and Changes in Histology

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Dr. Jared Weiss, UNC Lineberger Comprehensive Cancer Center, details the trends in lung cancer demographics and changes in histology by race and gender.

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I will speak to you today about trends in lung cancer demographics. So the incidence is probably the most important trend that we’ve had over the years, and this is somewhat different by men and women.

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Amongst men you can see that we’ve had a nice decline in cancers of the lung, perhaps not as great as we would like but a very real decline. In contrast, amongst women we had an increase in incidence over the years that has finally leveled off and is beginning to hopefully decline.

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There have been some trends in decreased incidence and [improved] survival — these are usually looked at by five year survival rates and unfortunately because of the high morbidity, high mortality, of lung cancer, these rates have not improved as much as some of the other cancers here, but you can see there has been a real, if small decline. This effect has been more pronounced among whites than amongst other minority groups.

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We have had a change in histology over time — histology is the type of lung cancer. When we’ve spoken in other podcasts about differences in efficacy of drugs by squamous or non-squamous, that’s the histology we’re talking about, the subtype of lung cancer. What we’ve seen over time is that there is a decline in incidence of squamous lung cancer and an increased incidence of adenocarcinoma. People have talked a lot about why this may be true — I think the dominant hypothesis is the advent of filters. Filters have not reduced lung cancer incidence but what they have done is bring the particulate matter further out to the periphery of the lung instead of larger particles that tend to settle more centrally in the lung. I think that’s probably what’s driving this change in incidence of squamous versus non-squamous histology.

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There are some marked racial differences in presentation overall of lung cancer and by histology. The gist of this is that in terms of incidence there is increased incidence amongst black patients as compared to caucasian patients.

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Presentation is also worse in black patients — there is a higher incidence of presentation at advanced stage, of course driving inferior outcomes and this is an important target for intervention.

Finally regardless of race, age and histology, I want to talk briefly about the thing that I hope will most change demographics in the years to come, and that’s screening.

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Screening has the potential to catch lung cancer at an earlier stage and hopefully improve our cure rates regardless of any of the other factors we’ve talked about: histology, stage — well hopefully it’ll migrate the stage — race or gender. I think that when we talk about this in five or ten years, we’re going to be talking about much more favorable changes based on the results of screening, and so I would encourage screening for appropriate populations. We’ve done a number of other presentations on screening on cancerGRACE.org, and I refer you to those for more information.

Thank you.


GRACE Video

Potential Advantages, Disadvantages and Limitations of Lung Cancer Screening

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Dr. Gerard Silvestri, Medical University of South Carolina, discusses the benefits and drawbacks of lung cancer screenings.

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Lung cancer screening is something that’s quite new in the United States. In 2010, the data was published on a 50,000 person trial where patients were either randomly allocated to get a CT (CAT) scan of their chest, a low dose radiation CT scan, or a chest x-ray, and the study showed a 20% reduction in lung cancer mortality in the patients who got screened for lung cancer with a CT.

There are a few things that you need to understand about that trial. One, it only included patients between the ages of 55 and 74; two, you had to have smoked at least 30 pack-years — that’s 30 years at a pack a day, or for example, 15 years at two packs a day. So you need to have a certain smoking history and be of a certain age to enter into that trial, and now patients in that age range with that smoking history are eligible to be screened for lung cancer with a yearly CT.

The advantage is that you hope to get the cancer when it’s quite small, and so it can be resected with a surgery, taken out, and that patient will have a better chance of being cured of their cancer because as we get to more advanced stages like when the cancer has spread outside of the chest, the hope for a complete cure is lessened. Early stage cancer, screen-detected cancer, has a better chance for cure.

There are some disadvantages to screening though that people need to be aware of. About one quarter of the time, patients who have a scan will have a spot on their lung, or a nodule, or a lesion it’s sometimes called — a quarter of the time those spots are there, and 96% of the time they’re benign spots, but they still need to be evaluated. Sometimes they’re evaluated just with following up with a CT scan, sometimes they’re evaluated with a biopsy, and even sometimes it requires surgery to get those out. That can cause a lot of anxiety in patients and certainly put them at risk for unnecessary procedures, particularly if you’re taking out something that was going to be benign all along. So that’s some of the disadvantage of being screened for lung cancer.

Also, as folks get older, so when you get up into that 75-77 age range, you also have other comorbidities, other things, other health issues that make it difficult for you to undergo surgery, and so some patients may not want to be screened if they have other health problems that may preclude a long life expectancy.

Overall, screening is being implemented in the United States the same way breast cancer screening was implemented years ago in the United States, and we’re doing it very carefully to make sure the patients are of the appropriate setting. The other thing we’re doing is making sure that if patients are smoking, that they get some smoking cessation as part of their screening endeavor.


Dr West

American Academy of Family Physicians Denies Utility of Chest CT Screening: A Harmful Slight to the Lung Cancer World

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This week, the American Academy of Family Physicians (AAFP) elected to not follow the lead of the more influential US Preventive Services Task Force (USPSTF), which previously reviewed the information on chest CT screening for high risk patients and recommended it, and said that there is insufficient evidence to support chest CT screening.

The specific arguments were that, when the evidence from the National Lung Screening Trial is combined with some other, less definitive studies, there wasn’t a clear enough signal of benefit to support chest CT screening, per Dr. Doug Campos-Outcalt, MD, MPA, the AAFP liaison to the USPSTF.

“People need to understand that their life expectancy could be extended by this, but on the other hand, their life expectancy could be shortened by it,” Dr. Campos-Outcalt said in a statement. “If they’re currently smoking, a better thing to do by far is to stop smoking.”

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Dr West

Can Lung Cancer be Clinically Insignificant? The Case for “Overdiagnosis” and “Overtreatment” of Lung Cancer

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For all too many people with lung cancer or caring for someone with it, the concept that lung cancer may not be threatening may seem sacrilegious.  It is, after all, by far the leading cause of cancer deaths in the US in both men and women, far ahead of both breast cancer and prostate cancer in its fatality rate, though breast cancers and prostate cancers are more commonly diagnosed in women and men respectively.  Yes, lung cancer is far more deadly than those two cancers, but both breast and prostate cancer are diagnosed in tens of thousands of people who aren’t truly threatened by it.   The world has been slow to recognize that lung cancer can also sometimes be minimally threatening, but it’s worth discussing that possibility.  And it shouldn’t lead us to minimize the danger of lung cancer any more than we should become complacent about handling deadly snakes just because there are some that are are perfectly safe.  In the real world, a far greater proportion of lung cancers than snakes are deadly, but the main idea is that we should consider each based on individual characteristics.  It is absolutely possible to “over-treat” a lung cancer.

This issue became newsworthy because of a new article in JAMA Internal Medicine that did a very complex calculated analysis (i.e., I didn’t understand it) of the lung cancers detected in the National Lung Screening Trial (NLST) and concluded that 18.5% of the lung cancers detected by chest CT screening and 22.5% of non-small cell lung cancers represented an “overdiagnosis” — a cancer that was detected but that would not be clinically relevant (as the numbers reflect, this is rarely a concern for small cell lung cancer).  For bronchioloalveolar carcinoma (BAC), which is often indolent (and especially likely when detected as a solitary lesion), up to nearly 80% of these lesions were potentially overdiagnosed cancer. 

As someone who sees the clinical behavior of hundreds of cases of lung cancer ever year, I’m here to tell you that this seems about right. This doesn’t mean that I don’t believe in CT screening for lung cancer: the NLST trial showed a 20% improvement in lung cancer-specific survival, which to me illustrates that screening for lung cancer is valuable. But it’s also worth knowing two things:

1) Not all lung cancers are life threatening.

2) There is a real risk of overtreating some lung cancers, causing more harm than benefit by treating it.

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