Lung Cancer Screening: To screen or not to screen?

Transcription

1 Lung Cancer Screening: To screen or not to screen? Dan J. Raz, M.D. Co Director, Lung Cancer Screening Program Co Director, LungCancer and Thoracic OncologyProgram Assistant Professor, Thoracic Surgery City of Hope

2 Consultant, Cireca LLC, Grant Funding, Merck Disclosures

3 Outline Update on lung cancer screening Who should be screened Guidelines New ideas Barriers to lung cancer screening

4 Annual U.S. Lung Cancer Deaths

5 Stage of Lung Cancer at Diagnosis Stage IV 40% Stage I 20% Stage II 10% Stage IIIb 15% Stage IIIa 15%

6 Lung cancer screening Early LungCancer Action Program (ELCAP) Low dose CT scan of the chest 80% of lung cancers detected stage I 85% of stage I patients treated cured Decrease lung cancer deaths by about t60% Save 82,000 lives/year 224 lives every day Mammography: 15% reduction in breast cancer deaths

7 Lung Cancer Screening RCT, n= 53,454 : LD CT vs CXR x 3 years NLST criteria: Age >30py smoker or former smoker Quit <15 yrs ago if former smoker Nosymptoms oflung cancer

8 NLST: Lung cancer CT screening Baseline + 2 yearly screens 20% relative reduction in lung cancer mortality 7% all cause mortality reduction 367/1060 lung cancers detected diagnosed after screening phase

9 NLST: Lung cancer CT screening

10 NLST: costs 24% positive (4mm nodule cutoff) 16% with 5mm 96% false positive Definition of positive vs indeterminate Invasive testing amongpositives: 2% needle biopsy 4% bronchsocopy 4% surgical procedure Adverse events 16 patients died with 90d of invasive procedure (<0.1%) 10 had lung cancer (of 1060 lung cancers) Radiation related deaths or morbidity

11 ELCAP: False positives reduced dby raising ii nodule threshold. No cancers missed by raising from 4mm to 6mm. Henschke, Ann Intern Med 2013

12 ACR Lung RADS

13 Other benefits of LDCT Tobacco cessation Coronary calcification Emphysema Aortic aneurysm

14 Potential Harms Cost False positives Unnecessary invasive i testingti Anxiety Radiation Overdiagnosis License to smoke

15 Lung cancer screening IS COST EFFECTIVE Milliman 2012, Health Affairs: Cost per year of life saved =$19,000 Cost for mammography=$30 50, Cost for screening population=$0.76 per member/month Cost for mammography=$3.16 per member/month

16 Cost analysis: NLST Included cost of treating radiation induced lung cancer Black et al. NEJM 2014

17 Effective radiation dose Chest xray Mammogram 01mSv msv Low dose CT 1 msv IV Contrast CT 8 msv CTA (PE) PET/CT 15 msv 25 msv 3 msv= background x1yr

18 False positives: anxiety NLST: No difference in anxiety/hrqol at 1 or 6 months in positive vs negative NELSON: Anxiety in both groups, higher at 2 months in those with positives No information i on diverse populations, sex differences, mental illness

19 Overdiagnosis: Natural history of Stage I NSCLC Raz DJ, et al. Chest 2008

20 Lung cancer screening LDCT SCREENING SAVES LIVES CXR screening does not save lives Mayo lung, PLCO USPTF draft: Recommended (B) CMS approved ELCAP, DANTE (Italy), NELSON, Danish

21 CMS Requirements Written order during a LCS counseling and shared decision meeting. Eligibility Shared decision meeting using decision aid to include benefits, harms, followup diagnostic testing, overdiagnosis, false positive rate, and radiation exposure Tobacco cessation counseling Nodule management protocol Participated in LCS trial or ACR certified Dose <1.5mSv Collect and submit data to CMS approved registry of LCS ACR

22 LCS Criteria (CMS) Age >30 pack-years If f k it ithi 15 If former smoker, quit within 15 years

23 LCS Criteria NCCN 3 AATS 7 Organizations LCS criteria for screening USPSTF 1 CMS 4 6 using 2 Primary Secondary NLST derived criteria Primary Secondary Age (years) Smoking History (pack year) Quit time (years) none none Additional risk factor or Other criteria Additional risk factor Lung cancer survivors USPSTF = US preventative Services Task Force; CMS = Center for Medicare and Medicaid Services; NCCN = National Comprehensive Cancer Network; NLST = National Lung Screening Trial; AATS = American Association for Thoracic Surgery [1] Organizations including the American Cancer Society (ACS), American College of Chest Physicians (ACCP), American Society of Clinical Oncology (ASCO), American Lung Association (ALA) [1] History of personal cancer, lung disease, family member with lung cancer, radon exposure, occupational exposure, COPD or pulmonary fibrosis. [1] Resulting in cumulative lung cancer risk 5% in 5 years (ie. COPD with FEV1<70%, environmental/occupational exposure, prior cancer/radiation therapy, genetic/family history) [1] After 4 yrs negative surveillance

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25 Blood screening

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27 Barriers to Lung Cancer Screening

28 Physician Barriers COH Primary Care Physician Study Lung Cancer Research Foundation Surveyed PCPs in LA County (n=250)

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30 Efficacy

31 Efficacy

32 Utilization

33 Barriers

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35 System Barriers

36 Tobacco Cessation: Opportunity for LCS? Tobacco cessation programs Kaiser Permanente State and National Quitlines CVS minute clinics

37 Kaiser Permanente Study 1. SurveyStudyof Study tobacco cessation participants 2. Educational intervention in a group tobacco cessation program 3. Randomized dintervention i study Effect on LCS adherence Effect on tobacco abstinence

38 Conclusion Lung Cancer Screening with LDCT recommended for those who meet CMS criteria More research on bet criteria Overcoming barriers