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Lung Cancer Screening
David Koh, MD, FCCP
March 1, 2014
Objectives
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Define the historical aspects of smoking and its
relation to lung cancer
Describe the current process of lung cancer
screening
State the newly recommended guidelines for
lung cancer screening
Describe the new technology for the screening
of lung cancer
When did we know?
Prevalence of Smoking

1.3 billion smokers globally1.

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47% of men and 12% of women are smokers
worldwide.
45 Million adults in the US smoke2.
23.5% males, 18.5% females.
 There has been a decline in the percentage of
smokers from 42% in 1965 to the 20.8% in 2006.

1. WHO Tobacco Free Initiative. 2004 2.CDC. MMWR 2005
Cost of Smoking
157 billion dollars
MMWR 2002
What is in Smoke?
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A pack-a-day smoker puffs more than 70,000
times a year.
92-95% of the total weight of mainstream
smoke is present in the gas phase.
Nitrogen, oxygen, and carbon dioxide account
for 85% of smoke’s weight.
Selected Cigarette Smoke
Constituents in Particulate Phase
Substance
Effects
Tar
Carcinogen
Polynuclear aromatic hydrocarbons
Carcinogen
Nicotine
Neuro stimulant and depressant, addicting
Phenol
Carcinogen and irritant
Cresol
Carcinogen and irritant
b- Naphthylamine
Carcinogen
N-Nitrosonornicotine
Carcinogen
Benzo-pyrene
Carcinogen
Trace metals (arsenic, polonium 210)
Carcinogen
Indole
Tumor accelerator
Carbazole
Tumor accelerator
Catechol
Carcinogen
Selected Cigarette Smoke
Constituents in Gas Phase
Substance
Effects
Carbon Monoxide
Impairs oxygen transport
Hydrocyanic acid
Ciliotoxin and irritant
Acetaldehyde
Ciliotoxin and irritant
Acrolein
Ciliotoxin and irritant
Ammonia
Ciliotoxin and irritant
Formaldehyde
Ciliotoxin and irritant
Oxides of nitrogen
Ciliotoxin and irritant
Nitrosamines
Carcinogen
Hydrazine
Carcinogen
Vinyl Chloride
Carcinogen
Mortality Rates
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More than 399,000 US deaths annually are
attributable to cigarette smoking.
Every 8 seconds, someone dies from tobacco
use.
40% of neoplasms are related to tobacco.
22% of ischemic heart disease is caused by
tobacco.
On average, male smokers lose 13.2 years and
females lose 14.5 years of life expectancy
CDC. MMWR. 2005
CDC. MMWR. 2005
CDC. MMWR. 2005
Death Rates
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Lung cancer accounts for 32% of all cancer deaths
in men and for 25 % of all cancer deaths in women
making lung cancer the leading cause of cancer
deaths.
For women, incidence rates dropped for cancers of
the breast, colon/rectum, uterus, ovary, cervix, and
oral cavity but increased for cancers of the lung,
thyroid, pancreas, brain/nervous system, bladder,
and kidney, as well as for leukemia, non-Hodgkin
lymphoma, and melanoma.
CDC. MMWR. 2008
Death Rates
Top 12 States for New Lung
Cancer Cases in 20121
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
California (18,060)
Florida (17,860)
Texas (14,810)
New York (13,620)
Pennsylvania (10,890)
Ohio (10,270)
Illinois (9,190)
Michigan (8,210)
North Carolina (7,950)
Georgia (6,570)
Tennessee (6,140)
New Jersey (5,990)
1.
2012, American Cancer Society, Inc., Surveillance Research
Local Lung Cancer
Mortality Rate per 100,000
54
53
52
51
Rate per 100,000
50
49
48
47
National
Illinois
McLean County
Local Lung Cancer Rate
Lung Cancer Survival Rate
18.00%
16.00%
14.00%
12.00%
10.00%
Survival Rate
8.00%
6.00%
4.00%
2.00%
0.00%
NCDB
ABMC
Reality Then
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At present lung cancer is recognized late.
Opportunities to improve survival are through
earlier detection, accurate diagnosis, accurate
localization, and curative therapy.
Carbone, PPNIH Conference
Annals of Internal Medicine (1970) 73:1003
Reality Now
National Lung Screening Trial (NLST):
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8-year trial (2002 – 2010) compared low-dose ct screening to chest x-ray
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53,454 current/former smokers, at high risk for lung cancer
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Results Released in November 2010: Those who received LDCT had a 20% lower risk of dying
from lung cancer than those who received CXR.1
International Early Lung Cancer Action Program (I-ELCAP):
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31,567 current/former smokers, at high risk for lung cancer
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484 were diagnosed with lung cancer, 412 at Stage I
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Results Published in October 2006: Over 80% of patients who have a lung cancer detected by
CT screening can be cured. When the lung cancer is found early, and the patient receives surgical
removal right away, the cure rate rises to 92%.2
International Association for the Study of Lung Cancer (IASLC):
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“The publication of the NLST trial is a major turning point in lung cancer, which demonstrates the
enormous potential of CT screening as an early detection tool, which, in combination with smoking
cessation programs, is likely to have a major impact on lung cancer.”
- Prof. John K Field, MA, PhD, BDS FRCPath, Chair of IASLC - June 29, 2011
Sources:
1.NLST Research Team, N Engl J Med 365:395-409, 2011
2.IELCAP Investigators, N Engl J Med 355:1763-1771, 2006
What was available
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CT guided needle biopsy:
Pneumothorax reates reported anywhere from 1060% with average of 25%.
 In Ohno’s study, the lowest occurrences of PTX
happened at a rate of 28.4% but a positive diagnosis
in 77% when:
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FEV1 > 70%
 Single puncture
 Needle path < 4 cm.
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Ohno, Y et al. AJR, AM J
Roentgenology, 2003
Ohno, Y et al. AJR, AM J
Roentgenology, 2003
Newer Bronchoscopy Techniques
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EBUS: Endobronchial ultrasonography:
Preferred method for sampling lymph nodes
without general anesthesia.
ENB: Electromagnetic navigational
bronchoscopy. Uses GPS to get to peripheral
nodule.
Reconstruction guided bronchoscopy.
Prior to Navigational
Bronchoscopy
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Difficult to get to peripheral nodules because we
were looking at a 2-D image.
PTX rates were lower at 4%1.
Positive diagnosis 402 -603 %
1. Eberhardt, R et al. Am J Resp Critical Care Medicine. 2007
2. Schenk et al. Chest. 2003
3. Schreiber, G et al. Chest. 2003
Now With Navagational
Bronchoscopy
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For difficult cases, the yield was 77%1.
Overall, the ENB has an accuracy rate of 89%
and a negative predictive value of 79%2.
1. Hogarth. Bronchol Intervent Pulmonal. 2011
2. Minnich, DJ. Abstract at Society of Thoracic Surgeon’s
Meeting. 2012
Electromagnetic Navigation Bronchoscopy
(ENB)
Procedure Overview
CT-Scan
DICOM CD
Planning Software
Planned Pathway File
Navigation
Biopsy
Treatment
Lung Cancer Screening
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Released in April 2012: “Providing Guidance for Lung Cancer Screening: The
ALA Interim Report on Lung Cancer Screening”
Key Points:
Best way to prevent lung cancer is to never start or quit smoking
Low Dose CT (LDCT) should be recommended for those meeting NLST criteria:
• Current or former smoker, ages 55-74
• Smoking history of at least 30 pack-years
• Those that smoked in the last 15 years.
• No history of lung cancer
Individuals should not receive a Chest X-ray (CXR) for lung cancer screening
For hospitals offering screening:
• Ethical policies for advertising and promotion of screening should be set
• Develop educational materials to assist patients in discussions on lung cancer
screening
• Provide screening services with access to a multidisciplinary team that can
provide the needed follow-up evaluation of nodules
What does the ACCT recommend?
Take Home Message
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For smokers with a greater than 30 pack years.
Current smokers and former smokers that quit
less than 15 years ago.
Age 55-74 years old.
Annual Screening with low-dose CT annually.
What about JAMA
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Panel of experts from ACS, ACCP, ASCO and NCCN who
reviewed 8 Randomized Clinical Trials and 13 Cohort Studies
20% in each round of screening had a positive result, requiring
some degree of follow-up and approximately 1% had lung cancer
Screening must be done in a center that has the capabilities to
evaluate and management findings with a multidisciplinary team
Low Dose CT (LDCT) screening appears promising, but is also
considered to be in it’s infancy
Quality Improvements measures should be reviewed to
determine the “right” group to screen, how often and for how
long
Risks of Second Hand Smoke
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3,423-8,866 deaths from lung cancer.
22,700-69,600 deaths from cardiac causes.
SIDS 430 deaths.
Childhood asthma (new and exacerbations)
202,300.
Increases risk of COPD by 55%2.
Doubles the risk of CVA3.
CDC. Surgeon General’s Report. 2006. 2. Eisner, MD. Eviron Health. 2005. 3.
Goldstein, LB. Stroke. 2006
Conclusions
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Lung cancer can now be reduced by 20%.
Cancer screening is the key to lowering deaths due
to lung cancer by finding lung cancers at an early
stage when lung cancer is still curable.
Who should be screened?
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People from ages 55-74.
Greater than 30 pack years of smoking.
Smoked within 15 years.
No history of lung cancer.
Repeat CT for 3 consecutive years.