Lung cancer Screening Family Physicians and CancerControl 2018 Alain Tremblay Division of Respiratory Medicine University of Calgary
Disclosures BD Inc - Consultant / Medical Device development Olympus Respiratory America - Consultant / Medical Device development Olympus Canada Honoraria for bronchoscopy CME courses BD Inc. Patent licensed to BD Inc for device to treat pleural diseases Investigator led clinical trials (Alberta Lung Cancer Screening)
Objectives To understand recent recommendations on lung cancer screening To review pros and cons of lung cancer screening To examine the availability of lung cancer screening in the Province and across the country
Overview Lung Cancer & Smoking trends LDCT screening Who to screen? How to manage nodules? How to avoid drowning in IFs? Costs and opportunistic / ad-hoc screening Implementation of screening in Alberta / Canada
Intro & Background - Smoking
Lung Cancer Rates vs. Cases Alberta 2000-2030 By Vincent Van Gogh 1885 The number of lung cancer cases will continue to rise in Alberta
Reducing Lung Cancer Incidence and Mortality Prevention Smoking Cessation! Early Detection and treatment 5 year survival for early stage lung cancers is 70% Advances in treatment
Alberta's Cancer Plan to 2030 VISION: By 2030, Alberta will be a place where most cancers are prevented, more cases of cancer are cured Strategies (10): Transform Alberta s approach to cancer by creating a comprehensive and coordinated system of prevention, screening Find cancer early by using robust data and appropriate screening activities. Lung cancer by far the most common cause of cancer deaths in Alberta. 2.3x Colon ca, 3.75x Breast ca, 3.9x Prostate ca Absolute number of lung cancer cases to RISE in AB to 2030 Achieving this vision impossible without lung cancer screening
Annual PA CXR x3
NEJM 2011 53,464 high risk individuals CXR vs. CT annual x3 High risk eligibility criteria: Ages 55 74 30 pack year smoking history If quit, <15 years 48% current smokers Fewer Deaths in LDCT arm 20% Lung cancer specific mortality reduction (3/1000) 6.7% all cause mortality reduction (5/1000) Number needed to screen: 320 / lung cancer death 200 / any cause death
NNS 5276 531 415 171 161
Use of lung cancer risk prediction model more sensitive than NLST criteria Applied model vs. NLST criteria to 37,332 PLCO smokers / 678 lung cancers 14,144 eligible as per NLST criteria Corresponds to a 1.3455% risk threshold (PLCO M2012 ) Sensitivity NLST 71.1% 62.7% Model 83.0% 62.9% Specificity Model identifies 12% more cancers than NLST crit
Pan-Canadian Early Detection Study Risk Model Based Recruitment N=2537 Minimum risk 2%/6 years (PLCO m2007 or PanCan model) Median follow-up 5.5 yrs 164 cancers (6.5%) detected NLST 4% after 6.5 years NELSON 2.6% after 8.16 years NEJM 2013;369:920-31 Lancet Oncology 2014;15:1342-50
Lung Cancer Screening: Participant Selection by Risk Model the Pan-Canadian Study Lancet Oncol. 2017 Nov;18(11):1523-1531 PanCan (N=152) NLST (N=1080) Ontario (2007-2009 N=11,261, age 50-75y) p<0.001 PanCan vs NLST or Ontario Early (I-II) vs. Late stage (III-IV) Other advances since NLST: Improve specificity of +screen definitions; improved understanding of indolent lung cancers; Integration of smoking cessation activities; optimal screening intervals
High nodules (>10%) at baseline in the Alberta Lung Cancer Screening Study 6 5 P=0.076 4 % 3 2 1 0 Both RPM&NLST (n=304) RPM > 1.5% only (n=114) NLST (n=82)
Optimal Selection Criteria for LDCT Lung Cancer Screening WCLC 2017 Study Site British Columbia Alberta London Total No. Screened 318 688 648 1654 Age (yrs±sd) 65+6.3 63.5+6.3 66+4.2 64.8+5.7 %Current(CS)/Former 43%CS:57%EX 50%CS:50%EX 73%CS:27%EX 58%CS:42%EX Smoker(EX) Pack Years (mean±sd) 47.3+22 42.4+15.8 47.7+22.3 45.3+19.8 Median Follow-up (mths) 7.5 9.7 12.6 9.9 No. of lung cancers 7 6 21 34 34 lung cancers 100% met the PLCO m2012 selection criteria 67% met NLST- like criteria. No lung cancer found in participants who met NLST-like criteria alone.
Bach et al. JAMA. 2012;307(22):doi:10.1001/jama.2012.5521
Screening Positivity Rate in NLST Positive Screen = nodule 4mm or other findings potentially related to lung cancer 39% of NLST CT participants had at least 1 positive scan 72% of positive scans had diagnostic workup (mostly CTs )
Bach et al. JAMA. 2012;307(22):doi:10.1001/jama.2012.5521
False Positives 7% of patients with false positive / 2% overall will have invasive procedure Ann Int Med 2010; 152:505-512 Surgical procedure for benign disease not infrequent VATS or thoracotomy for benign disease Mayo BCCA PLuSS DANTE LCSS NLST 0.70% 1% 1% 1% 0.5% 0.6%
ACR LungRADS Size Nodule character Adopted in US programs
Comparison of the PanCan model, Lung-RADS and NCCN guidelines Danish Lung Cancer Screening dataset PanCan performed superiorly to Lung-RADS and NCCN (AUC 0.874 vs. 0.813, p = 0.003; 0.874 vs. 0.836, p = 0.010)
Probabilistic approach to guide clinical decisions using the Pan Canadian model Martin C Tammemagi, and Stephen Lam BMJ 2014;348:bmj.g2253 2014 by British Medical Journal Publishing Group
Baseline nodules ALCSP (N=649) 12 month f/u 9.2% positive screen / require other than annual scan 5.7% have a nodule with >=10 risk Lung-RADS >=3 (10.6%) 3 month f/u Clinical assessment
Cancer diagnosis Participant Nod risk Path Stage Treatment Comment 88JW_A 0.522 adenoca Ib VATS wedge Outside NLST (age) Herder: 93.3%
Under investigation Risk Type/size Location Follow-up Plan 326JG_A 0.31 Solid 10mm LUL PETCT-Resolving Return to annual
Incidental findings Thyroid nodules Adrenal nodules Coronary calcifications Breast lesions Interstitial lung disease Pleural effusions Pericardial effusions Renal lesions Mediastinal adenopathy Anterior mediastinal lesions
Incidentals Other Cancers 191MP_A: Invasive ductal carcinoma left breast. 87GS_A: Invasive ductal carcinoma left breast. 610AS_A: Mesothelioma 666KL_A: Esophageal cancer 1332DG_A:?Ovarian cancer
75% of participants at least 1 IF Only 8.5% possibly clinically relevant 6% underwent addition evaluation 1% determined to have IF with clinical implication Findings were located most frequently in liver (n=76, 53%) kidneys (n=53, 37%) less common in: thyroid, mediastinum, adrenals, breast, colon, and spine
Incidental Liver Mass < 0.5 cm 0.5cm Suspicious imaging features Benign imaging features 0.5-1.5 cm 1.5 cm One or more liver lesions (<0.5 cm) are detected as described above. No further work-up is required unless risk factors are present (prior malignancy, cirrhosis, or other hepatic risk factors) in which case follow-up imaging (CT, U/S or MRI) is recommended in 6 months. Benign, No follow-up One or more liver lesions (0.5-1.5cm) are detected as described above. Follow-up imaging (CT, U/S or MRI) is recommended in 6 months. One or more liver lesions (>1.5cm) are detected as described above. Further evaluation is required with MRI or biopsy according to patient risk factors (prior malignancy, cirrhosis, or other hepatic risk factors). Risk = average, unless known malignancy, hepatic dysfunction, abnormal liver function tests or hepatic malignancy risk factors (hepatitis, chronic active hepatitis, sclerosing cholangitis, primary biliary cirrhosis, hemochromatosis, hemosiderosis, oral contraceptive use, anabolic steroid use) or symptoms attributable to the liver. Benign imaging features: Typical hemangioma eg sharply marginated, homogenous low attenuation (up to 20 HU). May have sharp, but irregular margins. Suspicious imaging features: Ill defined margins, enhancement (more than 20 HU), heterogeneous, enlargement. To evaluate--> prefer multiphasic MRI.
Part 1 http://www.screencast.com/t/j60ttvb4 Part 2 http://www.screencast.com/t/kkecifqsiqa Part 3 http://www.screencast.com/t/6fpxiv1nfll Screening Management Platform
Is lung cancer screening cost-effective Data from NLST (US system) $81,000 per quality-adjusted lifeyear. (N Engl J Med Volume 371(19):1793) Canadian Modeling $52 000/QALY, $C24 000/QALY with effective smoking cessation (J Thorac Oncol. 2014 Oct;9(10):1449) PANCAN high hisk screening model $C20,724 per QALY gained (J Thorac Oncol. 2017 Aug;12(8):1210) screening may even offer cost savings if noncurative treatment costs for advanced cancer continue to rise
Opportunistic vs. Organized Screening (CPAC) Opportunitsic screening will very likely be more costly and less costeffective than organized screening If indirect costs and costs of harms were included, opportunistic screening would be even less costeffective than projected
Access to CT Services 90.4% of Alberta s population lives within a 60 minute drive of a CT Scanner
Stage Distribution: Impact to Surgery/Oncology in AB
Funding for Lung Cancer Screening No Provincial funding to date in Canada 10,000 participant pilot initiated in Ontario BC/Vancouver cohort (private donor) In AB study funded to 800 participants (enrolment complete) Request submitted to expand to 3,000 and propose a full scale program to AH/AHS DECLINED! Discussions ongoing USA Under Affordable Care Act, private insurers must cover USPSTF grade B recommendations Medicare coverage in place Discordance in Canada between CTFPHC and Provincial funding for programs
Current AHS Policy on lung cancer screening October 2017 memo we will not presently offer LDCT examinations for Lung Cancer Screening at AHS facilities. Would not recommend obtaining CT outside of a formal program Outside criteria for screening Likely full dose even contrast No systematic reporting of findings Variable management approaches
Why bother? More than 50% of new lung cancers diagnosed today are in either ex-smokers or never-smokers Screening programs can incorporate smoking cessation support for those who still smoke A large number of common health conditions we face today are at least in part heavily impacted by individual behaviors or habits, be it smoking, alcohol, diet or inactivity. This is not a reason to shun interventions that may help these individuals, in particular for such a devastating disease as lung cancer. While smoking remains an individual choice, the majority of smokers are hooked at a young age, often before age 18 Society must share the responsibility for their addiction and associated consequence to a legal product in the past heavily marketed to our population, and for which we all draw (through our governments) substantial revenue even today (1 billion $/year AB). Never-smokers would also benefit from a reduction in death and suffering from our deadliest cancer in their parents, grand-parents, sisters, brothers, spouses and other loved ones.
Conclusions LDCT screening reduces mortality from #1 cancer killer Several organizations have recommended screening (NLST criteria) Well defined programs should proceed, preferably with close monitoring and research components to ensure proper inclusion and management, as well as increase knowledge Inclusion criteria, definition & management of positive tests, incidental findings, cost, integration of smoking cessation activities, quality metrics Potential for ineffective and costly opportunistic screening in the absence of an organized program
Thank you! alain.tremblay@ucalgary.ca