The Maine Lung Cancer Coalition. Working Together to Reduce Lung Cancer in Maine

Transcription

1 The Maine Lung Cancer Coalition Working Together to Reduce Lung Cancer in Maine

2 funding

3 Maine Lung Cancer Coalition (MLCC) Webinar Lung Cancer Screening: Following Up On Abnormal Low Dose CT Scans with Gary Hochheiser, MD June 26, pm

4 Webinar Logistics for Zoom Audio lines for non-presenters are currently muted Please use the chat box for questions or comments throughout the presentation If you are requesting CME for this webinar and did not sign into zoom through a direct link - or you are watching as part of a group - please MLCC@mainequalitycounts.org during or immediately after the webinar so we can track your participation 4

5 QC Staff is Working to Improve the Health of Everyone in Maine

6 Connect With Us list: mainequalitycounts.org

7 Speaker Disclosure and CME Certificates: CME disclosure: The speaker today does not have any relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. A CME evaluation survey will sent after the learning session via . Please complete the survey via Survey Monkey within 1 week A CME certificate will be ed within 1 month of completion of the survey

8 Today s Presenter: Gary Hochheiser, MD Surgical Oncology, Thoracic and Cardiac Surgery, Maine Medical Partners As the Director of Thoracic Surgery and Thoracic Oncology and Medical Director for the Lung Screening Program at Maine Medical Center, I specialize in minimally invasive procedures in the treatment of thoracic diseases, including both benign and malignant diseases of the lung, esophagus, and pleura, along with the surgical treatment of lung and esophageal cancer as well as lung-sparing cancer surgery. As a past instructor of minimally thoracic procedures, I also have an interest in both benign and malignant diseases of the esophagus including reflux, hiatal hernia and esophageal motility disorders. Education & Credentials Board Certifications Surgical Oncology Thoracic and Cardiac Surgery, 2007 Fellowships Vanderbilt University Medical Center, Thoracic Surgery, 2004 Residencies Maine Medical Center, General Surgery, 2001 Medical Education University of Vermont College of Medicine, M.D., 1996

9 Lung Cancer Screening Following Up on Abnormal Low Dose CT Scans Gary Hochheiser, MD Director, Thoracic Surgery and Lung Cancer Screening Program Maine Medical Center Cancer Institute

10 Aim of LDCT Screening Program Early Diagnosis Early Treatment Increased Probability of Cure 10

11 National Lung Cancer Screening Trial (NLST) Multi-institutional (33 sites), randomized CT scan annually vs. CXR Reported NEJM ,454 patients High Risk Age 55-74, 30 pack year history or greater, quit within last 15 years, Asymptomatic 3 annual screening Low Dose CT (2002-4) $200,000,000 11

12 Relative mortality reduction of 20% in screened group (3 lung cancer deaths prevented per 1000 screened) 6.7% reduction in all cause mortality 24.2% scans positive nodule found 4mm or larger 95% false positive Cancer found 1% NLST 12

13 Lung imaging Reporting and Data System Similar to Fleischner but specifically designed for screening population Categories based on size Solid/part solid/non solid (GGN) New vs. baseline (initial image) ACR Lung-RADS 13

14 ACR Lung-RADS Threshold adjustment - Minimal size for solid nodule 6mm (vs. 4mm) - Minimal size for GGN 20mm Decrease the rate of false positives - 5.3% vs. 21.8% (NLST) - Decreased sensitivity 78.6% vs. 93.8% 14

15 Major concern for screening is rate of false positives May lead to unnecessary procedures that add risk - Biopsy, surgery ACR Lung-RADS Goal to limit the number of procedures for false positive findings Overdiagnosis finding slow growing malignancy that would not affect prognosis 15

16 Nodule Evaluation Imaging - PET/CT: False positives, incidental findings, resolution - Follow up CT scans looking for growth» May miss cancer at a treatable stage (progression) 16

17 Nodule Evaluation CT guided Transthoracic Needle biopsy - Pneumothorax, bleeding, non-diagnostic (false negative) - Added radiation Bronchoscopy - Respiratory complications, pneumothorax, bleeding - Requires sedation airway risk - Image guided systems available Surgical - Anesthetic and perioperative risks 17

18 ACR Guidelines

19 No nodules or definitely benign nodules Lung nodules with specific calcifications - Complete, central, popcorn, concentric rings, fat containing nodules Probability of malignancy <1% Recommendation continue annual low dose CT screening Prevalence 90% Category 1- negative 19

20 Category 2 benign appearance or behavior Solid <6mm, new <4mm Part-solid <6mm Non-solid <20mm or >20mm stable or slow growth Any category 3 or 4 that is stable over 3 or more months Recommendation continue annual screening Probability of malignancy <1% Prevalence 90% 20

21 Solid 6mm - <8mm, new 4mm - <6mm Part solid 6mm or larger with solid component <6mm or new <6mm Non-solid 20mm or larger Recommendation follow up CT 6 months Probability of malignancy 1-2% Prevalence 5% Category 3 Probably benign 21

22 Findings for which additional diagnostic testing and/or tissue sampling is recommended. 4A - Solid 8mm - <15mm, <8mm and growing, new 6mm <8mm - Part-solid 6mm or larger with solid component 6mm - <8mm, new or growing <4mm solid component - Endobronchial nodule Category 4 - Suspicious Recommendation 3 month follow up CT - PET may be used if >8mm solid component 22

23 Category 4 - Suspicious 4A - Probability of malignancy 5-15% - Prevalence 2% 23

24 4B 4X - Solid 15mm or larger, new or growing 8mm or larger - Part Solid 8mm or greater solid component, new or growing 4mm or greater solid component - Category 3 or 4 nodules with additional features or imaging findings that increase the suspicion of malignancy Recommendations Chest CT with contrast, PET/CT, tissue sampling Probability of malignancy - >15% Prevalence 2% Category 4 - Suspicious 24

25 Additional Findings S category significant other findings not related to lung cancer C category designates patient with prior lung cancer 25

26 How to handle category 4 Highest variability but significant risk for malignancy Most will still be benign Options: - Repeat imaging with interval (3 months) - PET/CT if 8mm or larger - Biopsy Patient factors - Pulmonary reserve, comorbidities, functional status 26

27 Multidisciplinary Nodule Evaluation Nodule experts from differing specialties - Pulmonology particularly with bronchoscopy and endobroncial ultrasound experience - Radiology screening specific radiologists and interventional expertise - Thoracic Surgery particularly with minimally invasive training 27

28 Nodule review Multidisciplinary Evaluation Obtain as much patient data as possible Team discussion and decision on follow, repeat or further imaging, vs. tissue sampling and which procedure likely to be highest yield Also allows for directing referral to appropriate physician for evaluation and management 28

29 Multidisciplinary Evaluation Mitigates specialty bias Expertise in all areas of nodule evaluation and biopsy Allows for more efficient navigation of care 29

30 Multidisciplinary Evaluation Virtual nodule clinic Multispecialty evaluation/team available via electronic means Video link telemedicine Present cases, discuss findings and recommendations for follow up Avoid patient travel for evaluation Rural communities 30

31 Questions

32 Insurance Coverage for Low Dose CT Lung Screenings with Angela Criswell, Senior Manager of Medical Outreach, Kentucky LEADS at Lung Cancer Alliance And Barbara Wiggin, MBA, CNMT, CBDT July 18, :00 pm- 1:00 pm

33 Thank You mainelungcancercoalition.org