Robert J. McKenna M.D. Chief, Thoracic Surgery Cedars Sinai Medical Center

Transcription

1 You Smoke, You Get Lung Cancer, You Die: Can Screening Change this Paradigm? Robert J. McKenna M.D. Chief, Thoracic Surgery Cedars Sinai Medical Center AATS Saturday 4/28/2012

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3 Cancer Screening Cancer Breast Prostate Colon lung Screening Test Mammography BRCA PSA Rectal exam Stool guaic Colonoscopy NONE

4 Detectable preclinical phase of disease Preclinical phase of disease Clinical phase Lead time A B Dx Cp S D Biologic onset of disease Disease detectable via screening Preclinical disease detected via Critical point Symptoms develop Death

5 Prevalence of Lung Cancer by Stage 18% IV? III I + II 18% 25% 39%

6 Prevalence of Stage 1 Lung Cancer Stage 1 In US 20% With CXR screening 40% With CT screening 80+%

7 Lung Cancer Screening: who to screen Ages 55 to 74 years 30-pack-year history of smoking

8 Lung Cancer Latency after Smoking Cessation N= 626 patients with lung cancer 11.3% current smokers 77% smoking history 59.8% stopped smoking years earlier (39% 20+ years) Mung, McKenna, JCO 2011

9 years years years years years years Length of Smoking Cessation at the time of Lung Cancer Diagnosis (years) 1.9 Former Smokers 39% 20+ years after smoking cessation

10 Lung Cancer Screening ELCAP 31,567 patients screened 27,4576 with follow up CT scans 484 lung cancers detected 412 (85%) stage 1 10 yr survival of resected lung cancers 88%

11 Lung Cancer Screening ELCAP 7 mm adenocarcinoma

12 ELCAP Recommendations for masses identified 5-14 mm: follow up CT scan in 3months >15 mm: biopsy + PET: biopsy -PET: CT in 3 months

13 Lung Cancer Screening ELCAP (NSCL) Size of tumors T1N0 <15 mm 91% 16 to 25 mm 83% 26 to 35 mm 68% >36 mm 55% Arch Intern Med. 2006;166:

14 Lung Cancer Screening ELCAP (small cell) Size of tumors T1N0 < 25 mm 67% >25 mm 23% Arch Intern Med. 2006;166:

15 Lung Cancer Screening 8 cancers detected and not resected 5 yr survival = 0 How does lead time bias explain that?

16 National Lung Screening Trial (ELCAP) 1 lung-cancer-related death prevented for every 320 high-risk individuals screened 200,000 deaths from lung cancer/ year Screening would save 40,000 lives

17 National Lung Screening Trial (NLST) 20% reduction in deaths from lung cancer among current and former heavy smokers screened with helical low-dose CT, compared with those screened with chest radiograph. N Engl J Med. 2011;365:

18 National Lung Screening Trial (NLST) 53,454 patients screened Test # patients Positive test False positive CT 26, % 96.4% CXR 26, % 94.5% N Engl J Med. 2011;365:

19 National Lung Screening Trial (NLST) 53,454 patients screened Test # patients Lung cancer Cancer deaths CT 26, CXR 26, N Engl J Med. 2011;365:

20 Results NLST CT screening reduced lung cancer mortality by 20.0% (95% CI, 6.8 to 26.7; P=0.004) N Engl J Med. 2011;365:

21 National Lung Screening Trial (NLST) Lung Cancer Deaths CXR 247 /100,000 Low dose CT 309/100,000 95% confidence interval, 6.8 to 26.7

22 National Lung Screening Trial (NLST) 96% of all nodules found by CT were not cancer "burden" of following up with patients with nodules is "not trivial" high-risk individuals consists of adults 55 to 74 years of age with a 30-pack-year or more history of smoking N Engl J Med. 2011;365:

23 National Lung Screening Trial (Recommendations) Follow up CT depends on the size and status: Solid vs nonsolid vs part-solid ground-glass, ground-glass opacity PET with CT for nodules >8 mm Biopsy or excision of nodules that are suspicious for lung cancer, on PET /CT N Engl J Med. 2011;365:

24 National Comprehensive Cancer Network (NCCN) Strongly recommend low-dose helical computed tomography (CT) screening for select individuals at high risk for lung cancer Journal of the National Comprehensive Cancer Network (2012;10: )

25 Radiologic Management of Small Pulmonary Nodule Size (mm) 4 Nodules on CT (Fleischner Society Statement Radiology 2005; 237: ) Low-risk Patient No Follow-up > 4 6 Follow-up: 6 12 months > 6 8 Follow Follow-up: 6 12 mo. Then months Follow High-risk Patient Follow-up 12 months Follow-up: 6 12 mo. Then: mo. Follow-up: 3 6 mo. Then: 9 12 mo. Then: 24 mo. > 8 Follow Follow-up: 3, 9, 24 mos. PET/Dynamic CT and/or biopsy Same

26 Over-diagnosis Bias Renal cell cancer: 1% incidence by clinical and radiologic data; years of age. 22% incidence at autopsy unrelated to death. Lung Cancer: 1% incidence at autopsy

27 ELCAP Clinical Stage I Lung 88% Estimated 10- year survival (Kaplan-Meier curves) 302 Stage I Lung resected within 1 mo after diagnosis 92% 10-year survival (Kaplan-Meier curves) 8 Stage I Lung Cancer without Rx All died within 5 years

28 Negative Effects of Screening Discovery of Pseudo-disease Radiation exposure Cost

29 Health Care Costs USA Total spending $2.3 trillion 2007 (16% of GDP) $7,500 / U.S. resident In 1970 U.S. spending $75 billion ($356 /U.S. resident Health Care Cost rising 2.4 % faster than the GDP since 1970

30 Cost of Imaging 5% ($12 billion) of total health care dollar 23% of Out-patient cost (largest component of out-patient health care) Fastest growing component of health care

31 Screening Financial Issues Cost & Benefit Breast and Colon Cancer: $30 50K/Life-year Saved

32 Environmental Radiation Exposure Rads/yr msv/year L.A Denver Alps 2 20 Himalayas Ave. Background (US) Airplane Travel Rad/hour msv/hour Radiologist 5 50

33 Radiation Exposure Medical Entrance Dose Chest X-ray AP Lumbar 0.2 Spine Fluoroscopy 0.01 R/film 0.1 msv/film R/minute 20 msv/m Mammogram (max California <0.2 R/film) Digital: 0.14 R/f; Analog: 0.15 R/f (< 2.0 msv/film) Dig: 1.4; Ana: 1.5 MDCT

34 Cancer Risk Secondary to Radiation Exposure in Diagnostic Radiology U.S. and Canada T.B. Sanitariums min Fluoroscopy / exam Up to 100 rads/min exams / yr rads/ yr 250% increased incidence of breast cancer 60% increased breast cancer related deaths

35 Length-Time Bias CT Screening is most-sensitive for the detection of peripheral lung cancer. Most peripheral lung cancers are adenocarcinoma. Peripheral lung cancers are less likely to have positive lymph nodes.