Joint Session with ACOFP and Cancer Treatment Centers of America (CTCA): Cancer Screening: Consensus & Controversies. Ashish Sangal, M.D.

Transcription

1 Joint Session with ACOFP and Cancer Treatment Centers of America (CTCA): Cancer Screening: Consensus & Controversies Ashish Sangal, M.D.

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3 Cancer Screening: Consensus & Controversies Ashish Sangal, MD Director, Medical Education Medical/Thoracic Oncology Cancer Treatment Centers of America OMED 2016 Anaheim, California September 20, 2016 Lung Cancer Screening: CT Screening Current Status 2 1

4 Disclosures No conflict of interest! 3 Lung Cancer Facts Cause of cancer-related death in the United States Only 15% of lung cancer patients are diagnosed at an early, localized stage 4 CA Cancer J Clin Jan;63(1):

5 Lung Cancer Facts 5 Lung Cancer Facts - 228,190 cases yearly in the US % of all new cancer cases % of all cancer deaths - Estimated deaths: 159,

6 Screening for Lung Cancer The ideal screening test: Scientifically validated Relative safety Accessible Reproducible Low cost Improve outcome 7 NCCN Guidelines Version Screening for Lung Cancer Historical Review: Chest X-ray/Sputum Cytology Northwest London Mass Radiography Service [55k male ; bi-annual CXR for 3 yr] Memorial-Sloan Kettering study The Johns Hopkins study Czechoslovakian study [6364 males ; bi-annual CXR + sputum cytology for 3 yrs] Mayo Lung Project [10,993 male ; CXR + sputum cytology every 4 mon up to 20 yr] The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial [154,942 M+F; annual CXR for 3 yr] N=20k; annual CXR + sputum cytology 8 4

7 Screening for Lung Cancer Historical Review: Chest X-ray/Sputum Cytology None of the randomized trial shown mortality benefit!!! 9 Screening with Chest CT National Lung Screening Trial (NLST) 20% fewer lung cancer deaths among 53,000 participants screened with low-dose helical (spiral) CT compared to those screened with chest X-rays. 10 5

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9 Downside with CT Screening High false positive rate False negative Radiation risk Risk to patient with workup Cost of screening per life saved? 13 United States Preventive Task Force (USPSTF) Recommendation Age Able and willing to receive treatment Smokers and formal smokers who have not quit in the past 15 yrs > 30 pack yr smoking history 14 7

10 National Cancer Comprehensive Network (NCCN) Guidelines Who should be screened? 15 Lung CT Scan Follow Up: Next steps if no nodules Next LDCT in 1 yr At least for 2 yrs After 2 yrs clinician may continue yrly screening 16 8

11 Lung CT Scan Follow Up: Next steps if solid or part solid nodule 17 Lung CT Scan Follow Up: Timing of 2 nd Screening Test 18 9

12 Fleischner Society Guidelines 19 MacMahon H, Austin JH, Gamsu G et al. Radiology 2005; 237: Caveats Surveillance after lung cancer surgery Not in Europe 20 10

13 Lung Screening Programs Requirements 21 Lung Screening Programs Benefits vs. Dangers 22 11

14 Summary Lung cancer screening involves a multidisciplinary approach and includes several specialties Management of downstream testing and follow-up requires administrative processes Individuals at high risk of lung cancer should participate in an informed and shared decision making process 23 Colorectal Cancer Screening 2015 Updated Guidelines 24 12

15 Colorectal Cancer Screening Guidelines Updated December 2015 American Cancer Society (ACS), US Multi-Society Task Force on Colorectal Cancer, and American College of Radiology American College of Physicians (ACP) American College of Gastroenterology (ACG) National Comprehensive Cancer Network (NCCN) 25 Colorectal Cancer Screening Guidelines All guidelines recommend routine screening for colorectal cancer and adenomatous polyps in asymptomatic adults Start at age

16 American Cancer Society (ACS), US Multi- Society Task Force on Colorectal Cancer, and American College of Radiology Screening begins at age 50 years for asymptomatic men and women Screening begins at 40 years for asymptomatic African American men and women 27 High risk patients Earlier age Family history of colorectal cancer or polyps Family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC) Personal history of colorectal cancer Personal history of inflammatory bowel disease (UC or Crohn s disease) 28 14

17 American Cancer Society (ACS), US Multi- Society Task Force on Colorectal Cancer, and American College of Radiology Screening options for average risk adults consist of tests that detect adenomatous polyps and cancer. Tests that detect cancer and adenomatous polyps Flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Double-contrast barium enema every 5 years Computed tomographic (CT) colonography every 5 years 29 American Cancer Society (ACS), US Multi- Society Task Force on Colorectal Cancer, and American College of Radiology Tests that primarily detect cancer: Annual guaiac-based fecal occult blood test with high sensitivity for cancer Annual fecal immunochemical test (FIT) with high test sensitivity for cancer Stool DNA test with high sensitivity for cancer, interval uncertain 30 15

18 American College of Gastroenterology (ACG) Prevention vs. Detection Screening Tests The ACG guidelines make a distinction between screening tests for cancer prevention and cancer detection Tests that prevent cancer are preferred over those that only detect cancer 31 ACG Preferred screening options The preferred colorectal cancer prevention test is colonoscopy Every 10 years, beginning at age 50 years, but at age 45 years in African Americans For patients who decline colonoscopy or another cancer prevention test, the preferred cancer detection test is FIT annually 32 16

19 ACG Alternative screening options Alternative cancer detection tests recommended in the ACG guidelines: Flexible sigmoidoscopy every 5-10 years CT colonography every 5 years, which replaces double contrast barium enema as the radiographic screening alternative for patients who decline colonoscopy Annual Hemoccult Sensa Fecal DNA testing every 3 years 33 ACG Family History impacts Screening Recommendation For patients with a single first-degree relative diagnosed with colorectal cancer or advanced adenoma before age 60 years, or those with two first-degree relatives with colorectal cancer or advanced adenoma, the guideline recommends colonoscopy every 5 years, beginning at age 40 years or at 10 years younger than the age at diagnosis of the youngest relative 34 17

20 ACG Additional information For screening purposes, patients with one firstdegree relative diagnosed with colorectal cancer or advanced adenoma at age 60 years or older are considered at average risk The ACG recommends that all colorectal cancer patients be checked for Lynch syndromes, by testing for microsatellite instability (MSI) 35 The National Comprehensive Cancer Network (NCCN) Guidelines Separate guidelines for average-risk and high-risk individuals For average individuals, the recommendations are nearly identical of those of the ACS, and the ACR 36 18

21 NCCN High Risk Patients For high-risk individuals, the guidelines specify recommendations for each risk factor Lynch syndrome Familial adenomatous polyposis (FAP) Attenuated familial adenomatous polyposis (AFAP) MUTYH-associated polyposis (MAP) Peutz-Jeghers syndrome (PJS) Juvenile polyposis syndrome (JPS) 37 Post polypectomy Surveillance The ACG has guidelines for surveillance of patients who have had adenomas detected and removed at colonoscopy Colonoscopy findings and recommended scheduling of follow-up colonoscopy are as follows: No polyps 10 years Small (<10 mm) hyperplastic polyps in rectum or sigmoid 10 years 1-2 small (<10 mm) tubular adenomas 5-10 years 38 19

22 Post polypectomy Surveillance 3-10 tubular adenomas 3 years 10 adenomas - < 3 years One or more tubular adenomas > or = to 10 mm 3 years One or more villous adenomas 3 years Adenoma with high grade dysplasia 3 years 39 Post polypectomy Surveillance For serrated lesions, the following recommendations are made: Sessile serrated polyp < 10 mm with no dysplasia 5 years Sessile serrated polyp > or = to 10 mm with no dysplasia 3 years 40 20

23 Post polypectomy Surveillance Sessile serrated poly with dysplasia 1 year Traditional serrated adenoma 1 year Serrated polyposis syndrome 1 year 41 Additional References: Levin B, Lieberman DA, McFarland B, Smith RA, Brooks D, Andrews KS, et al. J Clin May-Jun. 58 (3): Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, et al. Am J Gastroenterol Mar. 104 (3): National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Colon Cancer Version

24 Questions? Advancements in Cancer Managements for Primary Care COMING SOON! Philadelphia Tulsa Chicago Phoenix Atlanta Dallas/Fort Worth Detroit Grand Rapids 44 22