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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 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1978 1979 1980 1975 1976 1977 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) 802Quits Quit Online Quit in Person • • Group Classes Tobacco Treatment Specialist Link in 802quits.org Free Nicotine Replacement Therapy for Vermont Residents 802Quits.org 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