Early lung cancer screening an update of the current evidence l.jpg
Sponsored Links
This presentation is the property of its rightful owner.
1 / 51

Early Lung Cancer Screening: An Update of the Current Evidence PowerPoint PPT Presentation


  • 154 Views
  • Uploaded on
  • Presentation posted in: General

Early Lung Cancer Screening: An Update of the Current Evidence. Simon Martel, MD IUCPQ Quebec , Canada. No conflict of interest. Lung Cancer Epidemiology. Most frequent cause of cancer death In 2020 = 5 th cause of death

Download Presentation

Early Lung Cancer Screening: An Update of the Current Evidence

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Early Lung Cancer Screening:An Update of the Current Evidence

Simon Martel, MD

IUCPQ

Quebec, Canada


No conflict of interest


Lung Cancer Epidemiology

  • Most frequent cause of cancer death

  • In 2020 = 5th cause of death

  • In 2010 (Canada) = 11200 deaths in men and 9400 deaths in women (27% of all cancer deaths)

  • Overall survival at 5 years around 15%

  • 90% of cases attributable to smoking and 50% of new cases in former smokers


Fundamentals of Screening

  • The purpose of screening is to detect a disease at a stage when cure or control is possible

  • At risk population for a specific disease is submitted to a test to identify asymptomatic persons having the disease

  • Persons with a positive result will then be evaluated to determine whether they actually have the disease


Fundamentals of Screening

  • Characteristics of a good screening test and program:

    • Reasonable sensitivity and specificity

    • Accessible with a low cost

    • Low associated morbidity

  • There should be an effective treatment at an early stage of the disease


Screening Bias

Patz EF et al. New Eng J Med 2000


Screening Bias

Patz EF et al. New Eng J Med 2000


Screening Bias

Black WC. Cancer 2007


Fundamentals of Screening

  • A good lung cancer screening program should reduce lung cancer mortality and overall mortality in the screened group compared to the unscreened group


1950-1990

  • Randomised and non randomised controlled trials:

    • John Hopkins Lung Project

    • Memorial Sloan Kettering Lung Project

    • Mayo Lung Project

    • Czechoslovakian Study

    • North London Cancer Study

    • Erfurt County Study

    • Kaiser Permanente Study

  • Chest radiograph ± sputum cytology every 4 to 12 months compared to less frequent or no screening over 3 to 16 years

  • 52000 subjects in intervention groups and 48000 in control groups


1950-1990

  • Intervention groups:

    • More lung cancers

    • More early stage lung cancers

    • More resectable lung cancers

  • No reduction in lung cancer mortality


Recommendations

Bach BP et al. Chest 2007


Are we done with chest X-ray

in lung cancer screening?

J Natl Cancer Inst 2005


Radiation

« Persons at risk for repeated radiation exposure, such as workers in health care and the nuclear industry, are typically monitored and restricted to effective doses of 100 mSv every 5 years (i.e. 20 mSv per year), with a maximum of 50 mSv allowed in any given year. »

Fazel R et al. New Eng J Med 2009


Radiation


Radiation

  • Low dose CT

Baldwin DR et al. Thorax 2011


CT lung cancer screening

Black WC. Cancer 2007


CT lung cancer screening

Black WC. Cancer 2007


CT lung cancer screening

Black WC. Cancer 2007


CT lung cancer screening

  • What have we learned from these studies?

    • Management of small pulmonary nodules

    • CT can detect early stage lung cancer

    • Excellent survival in a majority of screened cases

    • More epidemiology

    • More and more adenocarcinomas…

    • Overdiagnosis? Slow growing tumors?


Follow-up of nodules

MacMahon H et al. Radiology 2005


Thorax 2011


Early stage detection

New Eng J Med 2006


Overdiagnosis?


Growth Model of Lung Cancer

Bach BP et al. Chest 2007


CT Randomised Controlled Trials

  • DEPISCAN (France)

  • ITALUNG trial (Italy)

    • 3 206 participants

    • Active and former smokers 55-69 years old

    • Chest CT annually for 4 years vs no screening

  • NELSON Trial (Dutch-Belgian)

    • 15 248 participants (2004-2006)

    • Chest CT at 0, 1 and 3 years vs no screening

    • Active and former smokers 50-75 years old


CT Randomised Controlled Trials

  • DANTE Trial (Italy)

    • 2472 participants, male, 60-75 years old (2001-2006)

    • Chest X-ray and sputum cytology at baseline (all)

    • Chest CT at 0, 1, 2, 3 and 4 years vs annual medical visit

    • Active and former smokers of at least 20 pack-years


DANTE trial

Infante M et al. Am J Respir Crit Care Med 2009


CT Randomised Controlled Trials

  • NLST (USA)

    • 53 456 participants (2002-2004)

    • Chest CT vs radiograph at 0, 1 and 2 years

    • Active and former smokers 55 to 74 years-old

  • Results

    • 20.3% reduction in lung cancer mortality (354 deaths vs 442 deaths)

    • All-cause mortality lower by 7% in the CT group


NLST Participants


Pan-Canadian Early Detection of Lung Cancer Study

  • Validate a lowcostriskmodeling to select a population with a higherrisk of lung cancer

  • Evaluate the add-on impact of spirometry, bloodbiomarkers and AFB in a screening strategy

  • Evaluate the impact of the screening modalities on the quality of life

  • Evaluate the cost of implementing a lung cancer screening in Canada


Pan-Canadian Early Detection of Lung Cancer Study

Enrolled N=2533

AFB = 1252

66 lung cancers confirmed


478 Normal CT Scans at Baseline (20%)


Pan-Canadian Early Detection of Lung Cancer Study

  • Nodules of course

  • Other findings:

    • Kydney cyst or mass

    • Adrenal nodule

    • Interstitial lung disease

    • Coronary calcifications

    • Thoracic aorta aneurism

    • Thyroid nodule


Conclusions

  • We are not ready for lung cancer screening

  • Low dose CT might be an interesting tool but many questions to answer

    • Lung cancer mortality reduction?

    • Overall mortality reduction?

    • Magnitude of overdiagnosis?

    • Morbidity associated with screening?

    • Cost of this type of screening?

  • SMOKING CESSATION is still a priority!


Screening Bias

Black WC. Cancer 2007


1950-1990

Manser RL et al. Thorax 2003


1950-1990

Manser RL et al. Thorax 2003


1950-1990

Manser RL et al. Thorax 2003


Radiation

Brenner DJ et al. New Eng J Med 2006


Radiation

Brenner DJ et al. New Eng J Med 2006


New Engl J Med 2009


Coûts-Bénéfices?

Am J Respir Crit Care Med 2008


Coûts-Bénéfices?

  • Étude PLuSS

    • 3 642 sujets avec TDM de base

    • 3 423 sujets avec TDM répété à 1 an

    • 1 477 sujets avec nodules au TDM initial

    • 821 sujets ont eu une ou des études supplémentaires (TDM et/ou TEP) avant le TDM à 1 an


Coûts-Bénéfices?

Wilson DO et al. Am J Respir Crit Care Med 2008


Coûts-Bénéfices?

Bach PB et al. Chest 2007


Overdiagnosis?


Follow-up of nodules


Lung Cancer Risk Assessment Model

  • Age

  • Smoking history

  • History of COPD (self-reported)

  • Chest X-ray in last 3 years

  • Family history

  • Education

  • Body mass index

M Tammemagi & PLCO Study Group


66 Confirmed Cancers

*Normal at baseline


  • Login