COPD: early detection, screening and case-finding: what is the evidence? Prof. Jan-Willem Lammers, Md PhD Department of Respiratory Diseases
«If you test one smoker with cough every day You will diagnose one patient with COPD a week» Page 2 - IPCRG 2012
. Should we screen ALL smokers for COPD? Page 3 - IPCRG 2012
Global Strategy for Diagnosis, Management and Prevention of COPD. Diagnosis of COPD A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV 1 /FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD. Page 4 - IPCRG 2012
Does screening for disease save lives in asymptomatic adults? N. Saquib et al. Int J Epidemiol 2015, 1-14 Cancer, Heart and Vascular Diseases, type 2 Diabetes & COPD 48 RCT s and 9 meta-analyses: disease specific or all-cause mortality Reductions in disease-specific mortality were uncommon and reductions in all-case mortality were very uncommon No data on COPD reported
Early diagnosis in COPD: PRO Patients with undiagnosed COPD have more health problems a High prevalence of co-morbidities b Diabetes, heart- en vascular diseases, osteoporosis, depression COPD is progressive and irreversibel c Deterioration of lung fucntion can not be restored Accelerated decrease in lung function must be stopped Largest decrease in lung function and changes in lung parenchyma in early stages of COPD d a Mapel D, et al. Value Health 2008; b Decramer M, et al. COPD 2008; c Hogg J, Lancet 2004; d Decramer M, et al. Lancet 2009
The challenge of early detection Pulmonary damage Intermittent symptoms Breathlessness Obstruction Page 7 - IPCRG 2012
Screenings bias
Who to screen? With active screening you will find a lot of smokers with COPD, earlier unrecognised COPD 27% of the smokers, 40-55 years, had COPD 85% of those had mild COPD Mild COPD Moderate COPD Severe COPD Stratelis G et al. Br J Gen Pract 2004; 54:201-6 Page 10 - IPCRG 2012
Screening for Chronic Obstructive Pulmonary Disease Using Spirometry: Summary of the Evidence for the U.S. Preventive Services Task Force Ann Intern Med. 2008;148(7):535-543
Screening for Chronic Obstructive Pulmonary Disease Using Spirometry: Summary of the Evidence for the U.S. Preventive Services Task Force Ann Intern Med. 2008;148(7):535-543 Conclusion: Screening for COPD using spirometry is likely to identify a predominance of patients with mild to moderate airflow obstruction who would not experience additional health benefits if labeled as having COPD. Hundreds of patients would need to undergo spirometry to defer a single exacerbation.
COPD detected with screening: impact on patient management and prognosis Frail elderly > 65 yrs Dyspnea or exercise intolerance 386 screened: 84 = 21,8 % new diagnosis of COPD Changes in drug prescriptions were infrequent during 12-mo follow-up Hospitalisations: overall 25.9 %, 32,1 % in screendetected COPD COPD detected with screening: impact on patient management and prognosis Loes Bertens, Eur Resp J, 2014
COPD detected with screening: impact on patient management and prognosis COPD detected with screening: impact on patient management and prognosis Loes Bertens, Eur Resp J, 2014
How to screen: Lung Cancer and COPD: sharing the same risk factor New Engl J Med; 2006
Dutch-Belgian Lung Cancer Screening Trial: NELSON NELSON trial Dutch-Belgian lung cancer screening trial University Medical Centers of Utrecht, Groningen and Leuven (Belgium) and Haarlem Hospital Inclusion criteria >50 years of age >20 pack years smoking <10 years quit smoking Walking 2 flights of stairs
Dutch-Belgian Lung Cancer Screening Trial: NELSON NELSON trial Dutch-Belgian lung cancer screening trial University Medical Centers of Utrecht, Groningen and Leuven (Belgium) and Haarlem Hospital Inclusion criteria >50 years of age >20 pack years smoking <10 years quit smoking Walking 2 flights of stairs Study design NELSON 7907
Pulmonary Function Tests Random sub-selection of subjects underwent repeat spirometry (n=2,254) age: 59.8 5.3 yrs (mean SD) FEV 1 /FVC baseline: 72.2 9.4% follow-up: 69.3 9.9% <70% at baseline: 32.9%
Identification of Chronic Obstructive Pulmonary Disease in Lung Cancer Screening Computed Tomographic Scans 1140 male participants of the NELSON-study Heavy (former) smokers, 50-75 years Inspiratory and Expiratory CT-scans Assessment of emphysema, airway wall thickening, air-trapping Pulmonary Function Tests: FEV1, FEV1/FVC Mets et al. (2011). JAMA 306(16):1775-1781
Identification of Chronic Obstructive Pulmonary Disease in Lung Cancer Screening Computed Tomographic Scans COPD patients can be detected with only inspiratory CT scans (sensitivity 63 %, specificity 88% as compared to PFT) CT emphysema CT-airtrapping CT-airway wall thickening Contribute to COPD detection on lowdose CT - scans Mets et al. (2011). JAMA 306(16):1775-1781
Conclusions CT and screening Screening for lung cancer with CT-scans appears to be highly effective. Automatic quantification of emphysema, air-trapping and airway wall thickening on low-dose CT-scans is feasible. Additional findings related to chronic obstructive pulmonary disease and cardiovascular disease are common in lung cancer screening and may provide an opportunity to increase screening benefits at minimal cost in the future.
Case-finding in general practice Netherlands a Spirometry in smokers In every 5-6 smokers, 1 smoker with airway obstruction Poland b Spirometry in patients >40 years (smokers and non-smokers) 9% airway obstruction (19 % known with COPD) Poland c Spirometrie in smokers (>10 pack years, >40 years) 24% unknown airway obstruction a van Schayck C, et al. BMJ 2002; b Bednarek M, et al. Thorax 2008; c Zielinksi J, et al. Chest 2001
Case-finding: NICE and IPCRG National Institute of Clinical Excellence (NICE) (Ex-)smokers >35 years Chronic respiratory complaints International Primary Care Respiratory Group (IPCRG) b Smokers >35 years Chronic respiratory complaints High risk COPD according to IPCRG questionnaire (>17) a NICE. Management of COPD in adults in primary and secondary care. London. 2010 ; b Price, et al. Prim Car Respir J 2009
Unrecognized Heart Failure and Chronic Obstructive Pulmonary Disease (COPD) in Frail Elderly Detected Through a Near-Home Targeted Screening Strategy Frail elderly Questionaires > assessment Diagnosis confirmed by expert panel 395/ 570 (69 %): dyspnoea or reduced exercise tolerance New Heart Failure: 127 (33,5 %) Unrecognised COPD: 65 (16,8 %) Yvonne van Mourik, J Am Board Fam Med November-December 2014 27:811-821
Unrecognized Heart Failure and Chronic Obstructive Pulmonary Disease (COPD) in Frail Elderly Detected Through a Near-Home Targeted Screening Strategy Yvonne van Mourik, J Am Board Fam Med November-December 2014 27:811-821
NHG: case-finding COPD SYMPTOMS (chronic) Cough Sputum Dyspnoea, wheezing Wait loss RISK FACTORS Smoking Age > 40 yrs Occupation è SPIROMETRY
Take home message There is significant underdiagnosis of COPD Spirometry may be used to reduce underdiagnosis of COPD, but CT may be better for smoking induced diseases Case-finding of COPD is to be preferred above screening