Download Lu ng Cancer

The heart and science of medicine.
UVMHealth.org/MedCenter
Lu ng Cancer
Garth W. Garrison, MD
Assistant Professor of Med icine
Co-Director, Lu ng Cancer Screening Program
Director, Lu ng Cancer Mu ltid iscip linary Clinic
University of Verm ont Med ical Center
UVMHealth.org/MedCenter
Lu ng cancer basics
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Lu ng cancer rate is d ecreasing bu t…
120
100
80
60
Men
Women
40
20
0
SEER Cancer Statistics Review, 1975-2011, National Cancer Institute
Lu ng cancer rem ains the lead ing cau se of cancer
related d eath
• 224,000 new lung
cancer cases,
159,000 deaths in
2013
• As many deaths per
year as breast,
prostate, colorectal,
pancreatic cancers
COMBINED
CA: A Cancer Journal for Clinicians Volume 64, Issue 1, pages 9-29,
Lu ng cancer in Verm ont
• Cancer is the leading cause of death in Vermont causing 1,322 deaths
per year.
• Lung cancer, which causes 388 deaths per year in VT, is the leading
cause of cancer death.
Age Adjusted Lung Cancer Death Rates
(per 100,000)
61.6
61.3
U.S.
VT
Male
38.5
45.5
Female
Data Source: Vermont Vital Statistics 2007-2011
Lu ng cancer research lags behind other cancers
Lu ng cancer
• Cancer originating from
lung or airway tissue
• Several types based on
tissue of origin within the
lung:
– Small cell carcinoma (1015%)
– Non-small cell carcinoma
(85%)
– Carcinoid tumor (1-5%)
Lu ng cancer stage
I
N2
N3
N1
II
III
IV
Stage at presentation pred icts su rvival
Chest. 2009;136(1):260-271.
Stage at presentation: UVM Med ical Center
35%
50% Alive
@ 5 Years
65%
2% Alive
@ 5 Years
1138 Cases / 2008-2012
Basic lu ng cancer staging treatm ent
N2
N3
N1
I
Surgery*
II
Surgery* then
chemo
III XRT AND chemo
IV Chemo**,
palliative XRT
*if surgical excision is not feasible,
XRT is considered
Are you at risk for lu ng cancer?
• Smoking cigarettes
– Single biggest risk factor for lung cancer
– 85% of lung cancers can be tied to cigarette
smoking
• Environmental/Occupational exposures
• Personal history of cancer
– Head/neck cancer or prior lung cancer
– Radiation treatment to the chest
• Family history of lung cancer
• Personal history of lung disease
– COPD
– Pulmonary fibrosis
Asbestos
Radon
Arsenic
Beryllium
Cadmium
Chromium
Coal smoke
Diesel Fumes
Nickel
Silica
Soot
• Age
12
Stopping sm oking – the best w ay to d ecrease risk
of d ying from lu ng cancer*
*lung cancer risk remains elevated vs
never-smokers
Over 50% of patients with lung cancer
at UVM are FORMER smokers
Halpern J Natl Cancer Inst. 1993; 85:457–464.
802Quits Resources
Vermont
Quitline
1-800-QUIT-NOW
(1-800-784-8669)
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•
•
Group Classes
Tobacco Treatment
Specialist
Link in
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Free Nicotine Replacement Therapy for Vermont
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14
Estim ating you r lu ng cancer risk?
www.shouldiscreen.com
15
UVMHealth.org/MedCenter
Catching lu ng cancer early
16
Screening rationale
• Lung cancer is common
• Lung cancer will continue to be common in the
foreseeable future
• Early stage lung cancer often is asymptomatic
• Diagnosis of lung cancer in higher stages (III/IV) is
typical
• Diagnosis of lung cancer in higher stages is associated
with poor prognosis
• Screening of asymptomatic high risk patients could lead
to increase in diagnosis of cancer in early stages and
improve mortality
N ational lung screening trial (N LST)
• Sponsored by National Cancer Institute (NCI)
• Estimated total cost of $250,000,000
• Randomized trial of annual low-dose chest CT with
annual chest x-ray
• 53,454 patients at 33 medical centers
•
•
•
•
CXR = 26,730 / CT = 26,722
59% men
48% current smokers
91% white
• 3 years annual screening + 4 years observation
• 2002 - 2009
N Engl J Med 2011; 365:395-409
N LST eligibility criteria
N Engl J Med 2011; 365:395-409
N LST key findings – 20% reduction in lung
cancer death rate
CATEGORY
Lung cancer number
Lung cancer rate / 10^5 person-years
Lung Cancer related deaths
Cancer death rate / 10^5 person-years
Death from all causes
LDCT
1,060
645
CXR
941
572
346
247
425
309
1,877 2,000
N Engl J Med 2011; 365:395-409
The screening low -d ose chest CT (LDCT)
• Chest CT delivering <10% of the radiation of a standard
chest CT
Full dose
Low
dose
Screening w it h annual low -dose CT is
now recommended by :
•
•
•
•
•
•
American Cancer Society
American Lung
Association
American Society for
Clinical Oncology
American Thoracic
Society
Association of Thoracic
Surgeons
American College of
Chest Physicians
• US Preventive Services
Task Force
• Centers for Medicare &
Medicaid Services
Recommended screening population:
Age 55-80 (55-77 for Medicare)
Cumulative 30 pack-year smoking
history
Active smoking OR quit within the last
15 years
Healthy enough to undergo treatment
for lung cancer
UVMHealth.org/MedCenter
Controversies
Issu es to d iscu ss before screening
• Overall, a minority of those screened will have some
benefit
– 1 lung cancer death averted for every 320 screened
• High false positive rate
– In the NLST trial, 39% of patients had a positive result within the
3 years
• 4% of positive results were truly positive  96% false positive rate
• Many detected cancers may be “overdiagnosed
• Radiation exposure
• Cost
Ultim ately, how shou ld w e d iscu ss risks w ith
patients?
Odds of preventing lung cancer
death
Probability of false positive test result
NPR.org
Closing thou ghts
• Lung cancer remains common
• Smoking is the biggest risk factor for lung cancer but
other risk factors also exist
• Stopping smoking is the only way to prevent lung cancer
• Lung cancer screening may catch lung cancer earlier
when it is easier to treat
• Individualized discussion of risks and benefits of
screening should be done before entering the program