Lung Cancer Screening Trials. Edward Harris Respiratory Research Fellow Sir Charles Gairdner Hospital

Transcription

1 Lung Cancer Screening Trials Edward Harris Respiratory Research Fellow Sir Charles Gairdner Hospital

2 Lung Cancer Screening in Australia Not Funded except as part of a clinical trial Rationale PLCO, ELCAP NLST, NELSON, LSWA ILST ARP

3 Why do Lung Cancer Screening? More than 50% of patients with lung cancer have metastatic disease at time of diagnosis Diagnose early - more chance of cure Studies from 1960 s onwards CXR vs standard care CXR vs CXR and sputum cytology No reduction in mortality demonstrated

4 PLCO study Randomised 155,000 to 4 annual CXR vs standard care No reduction in mortality from lung cancer Similar stage at lung cancer diagnosis PLCO (2011). JAMA.

5 Early Lung Cancer Action Project (ELCAP) CXR and LDCT Single arm 1000 subjects, >60, >10 pack-years, no previous cancer & fit for surgery LDCT detected lung cancer at early stage Proved LDCT screening feasible Not powered to detect change in lung cancer mortality Henschke, Lancet, 1999

6 Randomised high risk individuals CXR vs Low Dose CT chest Annual screening for 3 yrs Primary outcome lung cancer mortality

7 20% Reduction in Lung Cancer Deaths

8 NLST overview For every 1,000 people screened over 3 years, 40 will have lung cancer (4%) Positive screen in 391 patients (39%), thus 351 false-positives Potential for harm: 365 in 1,000 false positive 24% had surgery with benign diagnosis Unknown harm from radiation (minimised by LDCT) Unknown rate of overdiagnosis NLST (2011). NEJM. Peirson et al (2015). CTFPHC. Black et al (2014). NEJM.

9 NELSON study (started 2003) Powered to detect change in mortality from lung cancer high risk smokers/ex smokers Randomised to LDCT at 1,2,4 & 6 years or no screening Different smoking criteria (15 cigs/25 yrs or 10 cig/30yrs quit<10yrs) Nearing Publication (2019)

10 Demonstrated feasibility in Australia 256 screened over three years 14 lung cancers Higher risk group screened older, heavier smokers, more asbestos

11 LungScreen WA Pilot trial screened 5 lung cancers found and treated 1 benign

12 Lungscreen WA Demonstrated Lung Cancer screening in WA feasible Community radiology and telephone based risk assessment GP recruitment Selection by risk rather than USPSTF/NCCN criteria possible in WA

13 International Lung Screen Trial Recruiting across WA, NSW, QLD, Vancouver Aim to recruit >4,000 participants Perth currently highest recruiter Fraser Brims at SCGH and Annette McWilliams at FSH are the primary investigators in WA Aim to recruit 500 participants from WA

14 International Lung Screen Trial Answer questions posed by NLST Best way to recruit? Risk based: >1.51% 6 year risk (based on PLCO study) USPSTF (30+PY <15yr, ex smoker) How to identify/classify/manage screen detected nodules?

15 Asbestos Review Program (ARP) est 1990 Asbestos exposed at increased lung cancer risk Especially if smokers (up to multiplicative risk) Screening asbestos exposed in WA with LDCT since 2012 Occupationally exposed (Wittenoom cohort and Mixed Fibre) 3 months full time exposure Or Pleural plaques on CXR/CT

16 Asbestos Review Program (ARP) 1% have lung cancer after 5 years follow up (17/1760) Despite 1/3 of cohort being never smokers Lung cancer screening criteria USPSTF no allowance for occupational exposure NCCN make arbitrary reduction to 20 PY NCCN - National Comprehensive Cancer Network USPSTF - US Preventative Services Task Force

17 Take Home Message Lung Cancer Screening not recommended or funded ILST aims to answer the remaining questions SCGH and FSH heavily involved in lung ca screening research Federal Government watching for further evidence

18 Questions? ARP still recruiting ILST Recruiting