The Case for Lung

Cancer ScreeningKimberly Ann Luse, Ed.D, RT(R)

My Background

Born and raised in Newport, Kentucky

Began smoking in high school

Stopped smoking when I became pregnant with my first of four

children in 1984

Became a Radiologic Technologist in 1985

Had a partial lung resection in 2000 after discovering a mass that was

thought to be malignant

Dense Material Ahead!

Background

Lung Cancer is the leading killer of all cancers combined

There has been evidence of the connection between smoking and lung

cancer than goes back four decades

Smoking cessation programs and efforts have increased

Lung Cancer screening needs to catch up to the evidence

Raising Awareness

February: Go Red For Women

October: Go Pink For Women

November: No Shave November

What month represents Lung Cancer Awareness?

November!

The High Fatality Rate is Staggering

The Center for Disease Control and Prevention lists the following on

their cancer statistics webpage, referencing 2010:

201,144 people in the United States were diagnosed with lung cancer,

including 107,164 men and 93,980 women

158,248 people in the United States died from lung cancer, including

87,698 men and 70,550 women

LOTS and LOTS of Acronyms Ahead!

More Context

The surgeon general first exposed the link between smoking and lung

cancer in a report that was released in 1964

Lung cancer is prevalent not only in the United States, but worldwide,

with particular elevations in third world countries

The International Agency for Research on Cancer estimated 1.6 million

new diagnoses in 2008 of lung cancer worldwide which translates into

12.7% of new manifestations of all cancers worldwide

Until a former smoker is past fifteen years smoke-free, they are

considered to be at approximately the same risk factor as patients

who are currently smoking

NCCN and USPSTF

The National Comprehensive Cancer Network (NCCN) is a

collaboration of twenty-five highly regarded cancer centers

They routinely issue consensus-based clinical practice guidelines on

how to most effectively diagnose and treat various forms of cancer

NCCN has recommended screening for high risk individuals but only

recently has any momentum begun

The United States Preventative Services Task Force (USPSTF) helped

move the fight forward in July 2013, endorsing low-dose CT screening

for those at the highest risk of developing lung cancer

ELCAP

The Early Lung Cancer Action Program (ELCAP) is an organization formed in

1992, consisting of a group of physicians from Cornell University Medical

Center and other specialists to establish research parameters to positively

impact lung cancer detection

This design utilized both chest radiography and low-dose chest CT

Baseline scanning was established followed by repeat annual screening

This research forged the way for others to build upon

ELCAP was scrutinized for not randomizing the trial

NCI and NLST

The National Cancer Institute (NCI) funded a randomized trial in 2002

The National Lung Screening Trial (NLST) enrolled 53,454 patients

identified to be high risk for lung cancer between 2002-2004

Clinical trial participants were randomly assigned to undergo three

annual screening with either low-dose chest CT (26,722) or single-

view PA chest radiography (26,732)

Data was collected through 2009

Researchers found a 20% reduction in deaths from lung cancer among

current or former heavy smokers who were screened with low-dose

helical CT vs. chest X-rays

Significance of the NLST

20% decrease in mortality from lung cancer was documented in the

low-dose chest CT group when compared with the group that received

only chest X-Rays

Official endorsement for low dose CT screening for lung cancer by:

The National Comprehensive Cancer Network, The International

Association for the Study of Lung Cancer, The American Cancer

Society, The American Lung Association, The American Thoracic

Society, The American College of Chest Physicians and The American

Society of Clinical Oncology occurred as a result

I Mustache You a Question

True or False?

True

As early as 2007, data

demonstrated less than 7% of lung

cancer was cured in patients

In Stage I, survival rates are

greater than 90% for patients,

especially if the tumors are equal

to or greater than 10%

The combined mortality rate for all

stages of lung disease is 90%

False Contact with radon is not an

indication for early screening

A history of other types of cancer does not influence a patient’s likelihood of developing lung cancer

Research groups have come to consensus on what constitutes risk factors for inclusion in low dose CT screening for detection of lung cancer

Recommended Risk Factors Include:

Tobacco smoking

Contact with radon

Contact with asbestos or other cancer-causing agents

History of other cancer(s)

Family history of lung cancer/other lung diseases

Contact with second hand smoke

Patients greater than 50 years old and greater than 20 pack years

Regular exposure to second hand smoke

Pack Years?

“Pack Years” is defined by the number of packs of

cigarettes smoked times the number of years the patient

has smoked, for example having smoked more than one

pack of cigarettes a day for thirty years, or two packs of

cigarettes a day for fifteen years would be translated as

“30 pack years”

Five Points for Consideration

Confounding Factors

Participants are still impacted by the stigma associated with lung

cancer due to smoking

Patients in the lower socio-economic ranks may not have access to the

education necessary to participate or the monetary ability to do so

Lack of consensus about what inclusion criteria to follow has fueled

the argument against the screening with low-dose CT

Participants who develop a secondary illness are disqualified

High rate of false positives leading to unnecessary follow up

procedures

Major Progress from the Centers for Medicare

and Medicaid Services February, 2015

Decision Memo for Screening for Lung Cancer with Low-Dose CT

CMS Criterion

Age 55-77 years

Asymptomatic

Tobacco smoking history of at least 30 pack years

Current smoker or someone who has quit within the last 15 years

Receives a written order for LDCT lung cancer screening

Indirect Benefits of Screening

Lung cancer screening programs serve as an entry point to other

services that generate revenue for the hospital system

Patients with a positive lung screening will require further evaluation

in the form of more imaging or surgical services for biopsy

Patients diagnosed with lung cancer will additionally require some

combination of surgical, oncology, and radiation oncology services

depending on the stage of the cancer

Screening programs can assist the health system in building strong

relationships within their neighborhoods

What is Your Why?

REFERENCES

1. Lung Cancer Alliance; www.lungcanceralliance.org.

2. Humphrey LL, Deffebach M, Pappas M, Baumann C, Atis K, Mitchell JP, Zaker

B, Rogwei F, Slator, CG. Screening for lung cancer with low-dose computed

tomography. Annals of Internal Medicine. July 2013; www.annals.org.

3. Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen

IF, Gatsonis C, Marcus PM, Sicks JD. Reduced lung-cancer mortality with low-

dose computed tomographic screening. New England Journal of Medicine.

2011; 365: 395-409.

4. Moyer VA. Benefits and harms of computed tomography lung cancer

screening strategies. Annals of Internal Medicine. December 2013;

www.annals.org.

5. Henschke CI, Yankelevitz DF, Smith JP, Miettinen OS, ELCAP GROUP.

Screening for lung cancer: The early lung cancer action approach. Lung

Cancer. 2002; 35(2): 143-148.

6. Henschke CI, Yankelevitz DF. CT screening for lung cancer: Update 2007.

The Oncologist. 2008; 13: 65-78.

7. Tavernise S. Task force urges scans for smokers at high risk. The New York

Times. July 29, 2013.

8. Sox HC. Better evidence about screening for lung cancer. The New England

Journal of Medicine. 2011; 365: 455-457.

9. Henschke CI, Altorki N, Farooqi A, Hess J, Libby D, McCauley DI, Pasmantier

MW, Reeves AP, Smith JP, Vazquez M, Yankelevitz DF, Yip R, Zhang L, Agnello

K, Ostroff J, Miettinen OS. Computed tomographic screening for lung cancer:

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