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GRACE Video

Lung Cancer Screening – Process and Potential Benefits

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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

ALK Rearrangements: What Are They, and Who Has Them?

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GCVL_LU-BA02_ALK_Rearrangements_What_Who

 

Dr. Ross Camidge, University of Colorado, describes ALK rearrangements and the characteristics of patients who most often have them.

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ALK stands for anaplastic lymphoma kinase. This is a gene which is involved in the development when we’re a little tiny embryo, and then it gets turned off when we become an adult. As an embryo, it’s involved in the development of the gut and the nervous system and a few other things. It’s silenced in most adult tissues, but it can be turned on again by what’s called a gene rearrangement. What that means is it brings in the front part of another gene which drives the expression of the previously silenced ALK, then it actually functions as something so powerful that it can actually turn a normal cell into a cancer cell.

The absolute frequency is running somewhere between 3% and 7% of lung cancer. The people who tend to have these more often tend to be people with a kind of lung cancer called adenocarcinoma of the lung — that’s what it looks like in the microscope, comes from glandular tissue. It tends to be more common in never smokers, it’s slightly more common in people who are younger than the average age of people who develop lung cancer, maybe a decade or so.

You also need to understand that all of these factors which are associated with it are not exclusive. So you can be older, you can have a history of smoking, you can have non-adenocarcinoma and still have an ALK rearrangement that may respond very well to an ALK inhibitor. So you have to understand the difference between an enrichment factor, and an absolute — “you should never test”, or “always test.” For me, I test everybody unless they have a 0% chance, and that’s a very small group that has a 0% chance. Essentially I test everybody with non-small cell lung cancer.


GRACE Video

Lung Cancer Risk Factors

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Dr. Jared Weiss, UNC Lineberger Comprehensive Cancer Center, discusses smoking, asbestos, radon and other risk factors for lung cancer.

 

 

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I’m going to speak to you today about lung cancer risk factors.

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Of course we cannot ignore that smoking is the dominant risk factor for lung cancer.

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Eighty-five percent or so of our patients have smoked at some point in their lives. However we cannot ignore as well that 15% of so of our patients have never smoked, and about 45% have long since quit.

What to do with this data? In my opinion, we need to really focus on smoking cessation.

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So at top left you see that smoking cessation at any time is worthwhile. Immediately upon quitting smoking, the lung cancer risk falls. This risk falls over time. Stated another way: it’s worth quitting cigarettes at any time point, but the sooner the better.

This effect on health is not just lung cancer. At the bottom left, you can see other cancer mortality declines because lung cancer is not the only smoking-related cancer. Cardiovascular disease competes with cancer for the leading cause for death in Americans — actually I think it edges it out, and you can see that risk declines with quitting smoking. Again, the sooner the better, and for total mortality, shown at the bottom right, the same effect holds.

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Lung cancer can affect anyone, regardless of age. On the far left of this table you can see that lung cancer can strike very young people — I’ve taken care of some of them. However you can also see in looking at the far right side of this curve that age is a legitimate risk factor. Our median age of presentation is about 71, and so this risk does go up with chronologic age.

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There are other risk factors for lung cancer and we need to spend some time particularly on those that are preventable. Asbestos is an important risk factor. This risk varies by fiber type, it also varies by the nature of the exposure. It turns out that occupational exposure, working in a factory on asbestos is a much greater risk factor than environmental exposure, meaning like having asbestos in the walls of the building you live in or something like that. It’s also worth noting that there’s a strong interaction factor here with smoking. Asbestos is bad, smoking is bad — put them together and you have something truly deadly.

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Radon is another major risk factor and also important because it is preventable. This one has a great difference in incidence by geography, shown here, and it’s important to talk about radon because you can do something about this risk.

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( www.epa.gov/radonwww.ncradon.org )

There are kits that can detect radon in your home, and if it’s found it can be mitigated.

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Cooking fumes are a major risk factor, particularly in developing countries and this risk varies by the type of coal used. It turns out that bituminous coal (I didn’t know that word before making this podcast) is the kind that makes a lot of smoke and this dramatically increases the lung cancer risk. In contrast, cleaner coals like anthracite coal seem to be a bit safer. European studies have shown that diesel exhaust contributes to lung cancer risk, but the relative risk increase is somewhat small.

The best data on radiation comes from Hodgkin’s disease and breast cancer, where radiation to the lung roughly triples the risk of later lung cancer.

In terms of pulmonary diseases like COPD, it’s a little hard to tease apart the component caused by smoking because smoking does cause both these diseases as well as lung cancer and the part caused by the actual pulmonary disease, but these pulmonary diseases are inflammatory and it makes common sense that they probably do increase the lung cancer risk a little bit.

Dietary factors are huge in the public consciousness. If you search the web, if you Google, you would think they were the only risk factor and that you can mitigate your lung cancer risk substantially by diet. In particular there was an idea out there that diets high in fruits and vegetables would lower the lung cancer risk. I wish this were true because this is the kind of diet that also prevents some other cancers and helps prevent cardiovascular morbidity and mortality, but the best data available points out that it’s probably just not true.  There’s also a big idea out there that beta carotene supplementation might decrease the lung cancer risk. The best data out there on this shows that not only does it not help, but it might actually increase the lung cancer risk. Again, these may not be the findings that we were looking for, it may not be consistent with all of the stuff in the popular press, but we have to go where the actual data leads us.

There’s real data out there that combined estrogen and progesterone hormones may increase the lung cancer risk a bit — for those more interested in this, Dr. West did an excellent post on this a few years ago that to my mind is still quite current.

The only other cancers that I treat other than lung cancer are cancers of the head and neck. In the tonsils and the base of the tongue, it is clear now that the human papillomavirus, the same one that can cause genital warts, and its high risk forms cause cervical cancer, can also cause cancers of the tonsil and base of tongue. These viruses can also be found in the upper respiratory passages, so there was an idea that perhaps they’re causing cancer there. It’s an interesting idea, it’s still undergoing further research, but to my mind the best available data on this don’t convince me that it’s actually true.

The final subject is genetics. We’re talking here about heritable genetics, the kind that you receive from your parents and that you can potentially pass on to your children, not the molecular changes that we talk about so often on GRACE. This is actually a rather rare risk factor. Lung cancer is one of the least heritable of the cancers, and if you want more information on this, this will be the subject of another podcast.

I thank you for your attention.


GRACE Video

Lung Cancer Demographics/Epidemiology

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GCVL_LU-A02_Lung_Cancer_Demographics_Epidemiology

 

Dr. Jared Weiss, UNC Lineberger Comprehensive Cancer Center, discusses the demographics and epidemiology of lung cancer.

 

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I’m going to speak to you today about lung cancer demographics.

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Lung cancer is just behind heart disease for the leading cause of death amongst Americans.

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Within cancer, lung cancer causes the overwhelming majority of the death.

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For both men and women, lung cancer is the second most incident cancer.

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However because of that highly deadly nature of lung cancer we talked about,

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it actually drives the highest death rate in both men and in women.

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Lung cancer can affect anyone: only 44% of our patients are current smokers, about the similar number have previously smoked and quit, and 10-15% are never smokers. However, given how deadly lung cancer is, this drives nonsmoking lung cancer to be one of the greatest causes of suffering and death amongst cancers.

So just to put this into perspective, I have five month old twin daughters. They will never smoke a day in their lives because they will know that I will kill them if they do. Assuming that’s true, that they never smoke a day in their lives, my daughters are far more likely to die of nonsmoking lung cancer than they are to die of breast cancer.

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Lung cancer can also affect anyone regardless of age. You can see here the spread of lung cancer — you can see that the bulk of presentation is at an older age, our median age of presentation is about 71 years, but you can see if you look at the left side of this table that it actually does have real incidence in younger patients. I have treated 20 and 30 year old patients for lung cancer. It is unfortunately quite real. I thank you for your kind attention.


GRACE Video

The Basics of a Lung Cancer Workup

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GCVL_LU-B00_Lung_Cancer_Workup_Basics

 

Dr. Gerard Silvestri, Medical University of South Carolina, describes the steps necessary to work up a lung cancer diagnosis, from initial scan to choice of treatment.

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What are the basics of working up a lung cancer? When I see a patient in my clinic, usually they haven’t had anything done yet. They’ve been referred to me with a “spot” or lesion, or a mass on their lungs, and again, the first thing I need to do is take a good history and physical. How long have you had your symptoms, have you had weight loss, do you have bone pain, have you had headaches, what are some of the things going on — what diagnostic workup have you had? Sometimes they’ll already have had a biopsy. My job though is to do these three steps, absolutely simultaneously and sometimes in order — what is it, where is it, what I can do about it — diagnosis, stage and treatment.

The first visit is almost always trying to review the imaging and decide whether you need more imaging, do a good physical exam, do a good smoking history, find out what other health issues the person may have like heart disease, that can give us a challenge in terms of how we’re going to treat the cancer. So that’s the first part.

Sometimes I have to say that some patients are — it’s thought they may have a lung cancer, and in fact it’s something else. It could be a fungal infection or something else going on in the lungs. So usually what happens over sort of the course of the next ten working days is, either some more imaging, or a biopsy, and then perhaps a PET scan to help us with the staging portion of this. So sometimes we get a PET scan that will help us both direct the biopsy, but also help us with the stage. Over the next ten days or so we’ll try to get those tests done.

In addition, we always present our new cases at a multidisciplinary tumor board. What’s that? A multidisciplinary tumor board is where all the different specialties get together to look over the imaging, the biopsy results, the pathologic results, and come up with a better treatment plan. So who’s in the room during the tumor board? A pulmonologist usually, a chest surgeon or a thoracic surgeon, a medical oncologist, a radiation therapist, a pathologist, sometimes you’ll have a dedicated chest radiologist who will help review the films, and then also people from other ancillary services that are extremely helpful like clinical trials staff, like palliative care nursing. So we have all those people in the room at the same time, and they’re either reviewing brand new cases, or difficult and challenging cases that are coming back to the tumor board for consideration.

So that kind of happens in that first ten days and for us, we know how anxious patients can get during that time period that they just want to get something started, but I would urge anyone listening to this to consider is, if you don’t get it right, if you don’t give the person the correct stage and the correct treatment options, you won’t get the best care. Yes, speed is important, but you’ve got to get it right — what is it, the diagnosis, where is it, the appropriate stage, and then what are your treatment options, which really differ depending on stage. For stage I it’s usually surgery, for stage II, surgery followed by chemotherapy, for stage III, chemotherapy and radiation, and for stage IV, chemotherapy alone or some of the targeted agents. So if you don’t get that right, you’re going to get the wrong treatment, so be patient with that and if your doctors need to biopsy in a different area, as long as they’re explaining it appropriately to you, you should try to stay with that program.

So that’s the general workup of a patient. I will say, every patient gives a little bit of a nuance and so sometimes a patient seemingly needs something that’s a bit unusual in terms of a biopsy or the location of a biopsy or how to best go about getting that biopsy, and I can also say that sometimes the tumor board is split. Sometimes there’s no right answer about whether we should do it via a needle biopsy through the chest wall, or a bronchoscopy, and sometimes talking that through with a patient, they can help us – you can help us as patients make a decision about which way we would go next. That’s the general workup of a lung cancer.


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