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Benjamin Besse, Philippe Girard

1ers MACA – Ajaccio – 10 mai 2012. Benjamin Besse, Philippe Girard. Cancer Incidence and Mortality (world). LUNG CANCER Incidence = 1,600,000/yr Mortality = 1,370,000/yr  Lethality ≈ 85%. Screening: why ?. Goal: cancer mortality reduction Detect asymptomatic cancers

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Benjamin Besse, Philippe Girard

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  1. 1ers MACA – Ajaccio – 10 mai 2012 Benjamin Besse,Philippe Girard

  2. Cancer Incidence and Mortality (world) LUNG CANCER Incidence = 1,600,000/yr Mortality = 1,370,000/yr  Lethality ≈ 85%

  3. Screening: why ? Goal: cancer mortalityreduction Detect asymptomatic cancers Asymptomatic cancers = better prognosis (?)

  4. 7% Stade II 31% Stade III 24% Stade I 38% Stade IV Clinical Stages and Survival/Prognosis Fry, Cancer 1999;86:1867-76 Groome, IASLC Lung Cancer staging project, JTO 2007;2:694-705

  5. Screening for Lung CancerWhat Tools ? • Sputum cytology • Chest X-ray • Chest CT • Autofluorescence bronchoscopy • Markers (serum, exhaled air, urine…)

  6. Lung Cancer Screening Tools • Sputum Cytology • Chest X-ray Bach, ACCP guidelines, Chest 2007;132:69S-77S

  7. The PLCO (Prostate, Lung, Colorectal and Ovarian) trial • 3 annual chest X-rays (n=77445) vs usual care(n=77456) • 55-74 yrs, 45% never smokers Number of lung cancers 1696 vs 1620 Oken, JAMA 2011;306(17):1865-1873

  8. The PLCO (Prostate, Lung, Colorectal and Ovarian) trial • 3 annual chest X-rays(n=77445) vs usual care(n=77456) • 55-74 yrs, 45% never smokers Deaths from lung cancer 1213 vs 1230 Oken, JAMA. 2011;306(17):1865-1873

  9. Screening for Lung CancerWhat Tools ? • Sputum cytology • Chest X-ray • Chest CT • Autofluorescence bronchoscopy • Markers (serum, exhaled air, urine…)

  10. Lung Cancer Screening with CT Screening « window » Bach, ACCP guidelines, Chest 2007;132:69S-77S

  11. Computed Tomography (CT) of the Chest Routine Low-dose 938mGy/cm 15.9 mSv 88mGy/cm 1.5 mSv Smith-Bindman, N Engl J Med 2010;10.1056

  12. Screening with Low-dose CT • It works ? • 31,567 subjects • (1993-2005) • 481 lung cancers • detected • 85% stage I • (n=412) ELCAP, NEJM 2006;355:1763-71

  13. 40,000PLCO Scanner low dose FumeursAnciensfumeurs ≥ 30 PAAge 55-74 Radiographie 10,000ACRIN 0 1 2 Years National Lung CancerScreening Trial (NLST) RANDOM I S A T I ON NLST, NEJM 2011; 365(5):395-409

  14. NLST: Trial discontinuation in oct. 2010 ! • 55 to 74 yrs, > 30P-Y, active or stop<15 yrs NNS to prevent 1 lung cancer death = 320… NLST, NEJM 2011; 365(5):395-409

  15. NLST: Highly selected population • Probably healthier vs. base population • < 65 years • 73% vs 65% in the base population • Less current smokers • 48% vs 57% • Better educated • 6% with less than a high school education vs 21% NLST, JNCI 2010

  16. 155 ponctions, 206 fibros, 297 chirurgies 270 cancers ! (4%)

  17. NLST: Magic Compliance • NLST : Compliance > 90% • Women adherence to mammography screening higher if • Younger • Higher education • Lived in an area with a higher percentage of mammography facilities Philips KA, Health Serv Res. 1998 Apr;33(1):29-53.

  18. Cause of Death (CT group) NLST, NEJM 2011; 365(5):395-409

  19. NLST: Trial discontinuation in oct. 2010 ! Deaths from lung cancer but… « NCI is not yet recommending such screening » NLST, NEJM 2011; 365(5):395-409

  20. Unanswered Questions • How to diminish the false positive rate ?

  21. The NELSON trial(Nederlands-Leuvens Longkanker Screenings Onderzoek) • Automated volumetric measurment for non-calcified nodules • NPV of diagnostic strategy at 1 yr = 99.9% 4,147mm3 van Klaveren, NEJM 2009, 361:123

  22. Unanswered Questions • How to diminish false positive rate? • Should the ongoing trials go on?...

  23. European Screening Trials Overview de Koning, ECCO-ESMO meeting, Sept. 2011

  24. PISA position Statement (March 2011) • 6 ongoing European trials have enrolled 32,000 subjects with about 150,000 person-years of follow-up (approx. half of NLST) • European trials continuation ! • Concrete plan for interim analyses and/or pooling • Discouragement of opportunistic screening outside clinical trials ! de Koning, ECCO-ESMO meeting, Sept. 2011

  25. Unanswered Questions • How to diminish false positive rate? • Should the ongoing trials go on?... • How many screen rounds?

  26. How many screen rounds? • Lung cancer was diagnosed frequently after the third low-dose CT screening • This observation suggests that continuing to screen high-risk individuals annually will provide a net benefit.

  27. Unanswered Questions • How to diminish false positive rate? • Should the ongoing trials go on?... • How many screen rounds? • False reassurance (license to smoke)?...

  28. Screening with Low-dose CT • It works ? • 31,567 subjects • (1993-2005) • 481 lung cancers • detected • 85% stage I • (n=412) Negative CT ? Keep smoking ! Positive CT ? Keep smoking ! (we can cure your cancer) IELCAPI, NEJM 2006;355:1763-71

  29. Screening routine nightmare McMullan and Cohen NEJM 2006, 354 (4): 397

  30. Unanswered Questions • How to diminish false positive rate? • Should the ongoing trials go on?... • How many screen rounds? • False reassurance (license to smoke)?... • Where to go ?

  31. Blood is the issue NSLT collected >100 000 blood samples

  32. Effects of Smoking Cessation on the Risk of Lung Cancer • Quit at age 50: • risk reduction about 66% Peto, BMJ 2000,321:323

  33. Deal ? 1 CT scan (138 €) = 27 packs of cigarettes = 1 month of tobacco consumption = 2.5 months of nicotine substitutes

  34. Séminaire de réflexion sur la littérature récente concernant le dépistage scanographique du Cancer broncho-pulmonaire. 17-18 février 2012 – GOLF et IFCT • Dépistage à l’échelon individuel • Après information sur les bénéfices et risques encourus • Sujets âgés de 55 à 74ans et ont fumés plus de 30PA • Information sur sevrage tabagique impératif • GOLF : • Fabrice Barlési • Etienne Lemarié • GOLF : • Fabrice Barlési • Etienne Lemarié

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