Lung Cancer Screening Preston Wright, DO University of Kansas School of Medicine- Wichita Family Medicine Residency at Via Christi Hospitals 1
Objectives Identify patients who need screened for lung cancer Explain benefits and risks of lung cancer screening Summarize treatment recommendations 2
Case 68 year old male with a history of tobacco use disorder and CAD comes to the office for smoking cessation counseling Patient states that he has a friend with lung cancer who used to smoke and he wonders if he is at risk and what he can do to prevent lung cancer You discuss smoking cessation and through his history you note that he has an on and off history of 36 pack years and is currently smoking Besides sometimes having a cough he denies ever having other concerning symptoms such as hemoptysis, chest pain, or dyspnea Otherwise he is in generally good health 3
Why Screen Lung Cancer Leading cause of cancer deaths [1] 1.6 million deaths worldwide annually [2] 250,000 new U.S. cases each year Treating early more beneficial [3] 4
Who to Screen By the book: USPSTF 2013 Systematic Review [4] 55-80yo 30 pack years of smoking Currently smoking or quite not longer than 15years ago Generally good health Others National Comprehensive Cancer Network [5] 55-74yo Medicare [6] 55-77yo 5
Screening Basis NLST (National Lung Cancer Screening Trial) [4] RCT 53,000 patients; CT vs. CXR 55-74yo Followed annually for 6.5yrs Positive= non-calcified nodule >4mm Positive Results: NN to screen 1:320 Cancer mortality benefit 20% All cause mortality benefit 6.7% 6
Benefits of Screening Stats Cancer mortality [4] All-cause mortality [4] Earlier detection [3] Best smoking cessation [3] 7
Harms of Screening False Positives Patient Distress Unnecessary Interventions Incidental Findings Radiation 8
Harms of Screening False Positives NLST: 24.2% positive LDCT [4] 96% were false positive 11% of positive led to invasive study Veterans home: 59.7% Positive [7] 1.5% truly had cancer. 1:17 may have had it, 1:42 actually had it 40% positive screen require follow up imaging Patient distress 9
Harms of Screening Radiation exposure [8] LDCT 1.4mSv vs. Standard CT 7-8mSv Cumulative13.0mSv For every 108 cancers discovered one was induced Overdiagnosis [9] 13-27% per observational studies 10
Evaluating the Data Who is it most effective in? [10] Current smokers in their 60 s Cost per quality life year [10] Modeling Cost Effectiveness Study; NEJM 2014 $52,000 per life year $81,000 per quality adjusted life year gain 60-69yo: most cost effective Cost of CT affect cost quality 11
Coding ICD-10 [6] Z87.891 - Personal Hx of nicotine dependence CPT codes G0296 - Counseling visit to discuss need for lung cancer screening using low dose CT scan G0297 Low-dose CT scan for lung cancer screening Age 55-77yo [6] 12
Case Revisited 68 year old male with a history of tobacco use disorder and CAD comes to the office for smoking cessation counseling Patient states that he has a friend with lung cancer who used to smoke and he wonders if he is at risk and what he can do to prevent lung cancer You discuss smoking cessation and through his history you note that he has an on and off history of 36 pack years and is currently smoking Besides sometimes having a cough he denies ever having other symptoms hemoptysis, chest pain, or dyspnea Otherwise he is in generally good health 13
References 1. Siegel RL, Miller KD, Jemel A. Cancer statistics, 2017, CA Camcer J Clin 2017; 67: 7 2. Stewart B, Wild CP. World Cancer Report 2014, 2014. 3. van der Aalst CM, van der Bergh Kaa, Willemsen MC, et al. Lung cancer screening and smoking abstinence: 2 year follow up data from the Dutch Belgian randomized controlled Lung Cancer Screening Trial. Thorax 2010; 65: 600. 4. National Lung Screening Trial Research Team, Aberle BR, Adams AM, et al. Reduced lung-cancer mortality with low dose computed tomographic screening N Engl J Med 2011, 365: 395. 5. Wood DE, National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Lunc Cancer Screening. Thoracic Surg Clin 2015; 25: 185. 6. Hughes, Cindy. How to Document and Code Medicare Preventative Services. Family Practice Management. 2016 Jul-Aug;23(4):9-12. 7. Kisinger LS, Anderson c. Kim J, et al. Implementation of lung cancer screening in the Veterans Health Administration. JAMA Intern Med 2017; 177: 399. 8. Larke FJ, Kruger RL, Cagnon CH, et al. Estimated radiation dose associated with low dose chet CT of averagesize participants in the National Lung Screening Trial. AJR Ana J Roentgenol. 2011; 197: 1165. 9. Reich JM. A critical appraisal of overdiagnosis: estimates of its magnitude and implications of lunc cancer screening. Thorax 2008; 63: 377. 10. Black WC, Gareen IF, Soneji SS, et al. Cost-effectiveness of CT screening in the National Lung Screening Trial. N Engl J Med 2014; 371: 1793. Other: Essential Evidence Plus. POEM of the Week. 14
Thank you. ANY QUESTIONS? 15