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Lung Cancer / Lung Cancer Screening

Lung Cancer and the NLST impact on screening
by

Zack Smith

on 16 November 2012

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Transcript of Lung Cancer / Lung Cancer Screening

However - If NO SCREENING was Done:

$0 would be spent on screening
$10.4M would be spent on diagnostic tests
$220M would be spent on treatment. Lung Cancer Screening Goals:
At the end of this lecture you will:

Gain knowledge about the impact of lung cancer on the US and world.

Have an understanding about the NLST's results and how these are related to the new NCCN guidelines.

Understand the impact false positives and 'lead time bias' on outcomes.

Review concerns on expense vs benefit to insurance carriers.

Gain insight on how lung screening protocols will become part of standard procedures. The Lung Cancer Burden
Cancer is the LEADING cause of death worldwide.
7.6M in 2008 and may climb to 11M by 2030.
Lung Cancer accounts for nearly 1 in 5 cancer deaths. New NCCN Guidelines for Lung Cancer Screening in the United States Challenges to Diagnosing Lung Cancer Only 15% of Lung Cancers are Diagnosed
at an early stage. Who Gets Lung Cancer? Survival Rates Historically Problematic
some studies showed great benefit
some showed no benefit Tools of the first screenings (1970s):
Sputum
Pulmonary Function Testing
Plain Chest Radiograph So What Changed the Game? What about the most important issues? Improved outcomes? Cost Challenges
Patient Selection
Technology Limitations
Leveraging New Technologies The NLST was a randomized national trial involving current and former heavy smokers Total Enrolled: 53,456
Age: 55 to 74.
Must have at least 30 pack-years of smoking
NED at enrollment
Cost est~$250M Participants were randomized to 3 annual screenings:

- Standard Chest X-ray
- Low-dose Spiral Chest CT w/single breath hold Results:

The Good News:
- CT better than CXR at detecting abnormalities.
- 20% decrease in mortality in screened group. The Bad News:
- CT scans were "Positive" in 24.2% of participants
- 96.4% were FALSE positives
- 26 patients patients died from invasive procedures:
16 from CT positives (6 did not have cancer)
10 from CXR positives (All had cancer) Summary of Screening before NLST:

- No Standard Screening Model
- No Proven Effective Treatment
- Conflicting Studies Zachary Smith - Director
Radiation Oncology
Baton Rouge General Pennington Cancer Center Cost Studies have shown:
If 100,000 'high-risk' individuals were screened:

Nearly 3,000 undiagnosed lung cancers would be found
Early detection would result in 6.3 - 5.7 Life Years (LY).
CT cost $30M and trigger $50M in diagnostic costs.
$229M would be spent on treatment. Summary:

NLST demonstrated a true benefit in mortality.
NCCN Screening protocols have been developed*
Chest CT protocols will play a role in any program.
Those that can't afford it may not get it. Patient Selection
In Light of the lack of facts, how will MDs determine the "High Risk"







From the "Worried Well"? The Screening Debate for Lung Cancer What Lung Cancer Looks Like In the NON-Smoker http://radiology.rsna.org/cgi/content/abstract/radiol.10091808 More Bad News

- Many left 'out in the cold'
Smokers with less than 30 pack-years
Those exposed to 2nd-hand smokers
Non-smokers
Everyone under 55 years of age. Questions? Increasing the Specificity of Screening $$$$$ . Even More Issues
No cost assumptions done.
50% of cancers found after study closed. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Here in the USA, as a result of:

Aging of the population
Success in preventing and treating Cardiovascular Disease

Cancer is the LEADING cause of death under for those under 85. The Lancet vol 12. Issue 10, Sept/Oct 2011. www.thelancet.com/oncology While Smoking is the
SINGLE largest factor,
it is not the ONLY factor
to consider. 85% of Lung Cancer Patients
present with late-stage disease World Health Organization 2008 data. Reproduced from Oncimmune - www.oncimmune.com, Last accessed June 2011 Reproduced from Oncimmune LLC, www.oncimmune.com, Last accessed June 2011 Overall, 10-15% of lung cancers occur in non-smokers. (Another 50% occur in former smokers.)

Two-thirds of the non-smokers who get lung cancer are women, and 20% of lung cancers in women occur in individuals who have never smoked.

This percentage is significantly higher in Asian women. PI: Claudia Henschke, PhD, MD
New York, New York PI: Claudia Henschke, PhD, MD
New York, New York Reproduced from Oncimmune LLC, www.oncimmune.com, Last accessed June 2011 Reproduced from Oncimmune LLC, www.oncimmune.com, Last accessed June 2011 Goals:
At the end of this lecture you will:

Gain knowledge about the impact of lung cancer on the US and world.

Have an understanding about the NLST's results and how these are related to the new NCCN guidelines.

Understand the impact false positives and 'lead time bias' on outcomes.

Review concerns on expense vs benefit to insurance carriers.

Gain insight on how lung screening protocols will become part of standard procedures. Etiology of Lung Cancer There are ~94 Million Current and Former Smokers in the United States. Patient 1:
- 55y Male
- 30pk/yr hx
- Screened and Early Lung Ca FoundThis is a World-Wide Trend!Patient 1:
- 55y Male
- 30pk/yr hx
- Screened and Early Lung Ca FoundPatient 1:
- 55y Male
- 30pk/yr hx
- Screened and Early Lung Ca FoundPatient 1:
- 55y Male
- 30pk/yr hx
- Screened and Early Lung Ca Found [For those doing the math $79M less] Lead-time Bias Patient 1:
- 55y Male
- 30pk/yr hx
- Screened and Early Lung Ca Found - Treated and NED for 5 years - Recurrent Lung Ca at year 6 and dies in 2 years. Patient 2:
- 55y Male
- 30pk/yr hx
- Not screened but does have Lung Ca
- Becomes symptomatic at 61 and dies at 63 7 year survival
with Early Detection 2 year survival
without Early Detection
Full transcript