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Lung Cancer: More prevalent than you think

Lung Cancer: More prevalent than you think. Anthony D Weaver MD. Disclosures. Dr. Anthony Weaver has no relationships to disclose. Objectives. 1 . Analyze the current demographics of lung CA 2. Examine common presenting symptoms of lung cancer.

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Lung Cancer: More prevalent than you think

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  1. Lung Cancer: More prevalent than you think Anthony D Weaver MD

  2. Disclosures • Dr. Anthony Weaver has no relationships to disclose.

  3. Objectives 1. Analyze the current demographics of lung CA 2. Examine common presenting symptoms of lung cancer. 3. Discuss the pros and cons of screening for lung cancer in high risk individuals 4. Describe appropriate follow up care for primary care patients with findings suspicious of lung cancer.

  4. Remember… • The best way to treat lung cancer is to prevent it by not smoking. “There is an overwhelming medical and scientific consensus that cigarette smoking causes lung cancer, heart disease, emphysema and other serious diseases in smokers. There is no safe cigarette . . . cigarette smoking is addictive, as that term is most commonly used today.” Philip Morris tobacco company, 1999

  5. Objective 1 Analyze the current demographics of lung CA

  6. History • Early 1900s: lung cancer was extremely rare • End of 1900s: prevalence second to prostate cancer in men, breast cancer in women. • Lung cancer has passed heart disease as the leading cause of smoking-related mortality • 159,480 deaths in 2013 (NCI lung cancer statistics)

  7. Top 5 Causes of Cancer Death for Men Lung & bronchus 28% Prostate 10% Colon & rectum 8% Pancreas 7% Leukemia 5% Cancer Facts and Figures 2014 at www.cancer.org

  8. Top 5 Causes of Cancer Death for Women 1. Lung & bronchus 26% 2. Breast 15% 3. Colon & rectum 9% 4. Pancreas 7% 5. Ovary 5% Cancer Facts and Figures 2014 at www.cancer.org

  9. Kentucky Cancer Deathsper year 2006-2010 • Lung and Bronchus 3416 • Colon 881 • Breast 597 • Pancreas 507 • Prostate 392 • Leukemia 332 • Non-Hodgkin Lymphoma 320 • Ovary 212

  10. National Cancer Institute State Data

  11. 5-year survival rates 2001-2007 • 65% for colon cancer • 99% for prostate cancer • 89% for breast cancer • 16% for lung cancer

  12. Lung Cancer, 2004-2008 The KY incidence is 62.6% HIGHERthan the US The KY mortality is 43.0 % HIGHER than the US *Source: SEER*Stat 7.0.4 SEER 17 Registries **Source: Kentucky Cancer Registry #: Based on 2003-2007 rate

  13. Lung/Bronchus Cancer • Leading cause of cancer death in the US and KY. • All 120 counties’ death rate above the US average. • The death rate varies from 59 in Larue and Cumberland counties to 124 in Gallatin County. • The highest rates are in eastern KY and Ohio, Butler, and Muhlenberg counties.

  14. Smoking • Up to 90% of lung cancer cases are related to smoking. • 9-15% are related to occupational exposure to carcinogens. • The strongest determinant of lung cancer is duration of cigarette smoking, and the risk becomes larger with more cigarettes smoked. • Smoking causes lung cancer in both men and women.

  15. Prevalence of Current Smoking by Area Development District, 2010

  16. Lung Cancer Incidence by Area Development District, 2004-2008

  17. Lung Cancer Mortality by Area Development District, 2004-2008

  18. Other Causes of lung cancer • Asbestos exposure • Radon exposure • Halogen ether exposure • Chronic interstitial pneumonitis • Inorganic arsenic exposure • Radioisotope exposure, ionizing radiation • Atmospheric pollution • Chromium, nickel exposure • Vinyl chloride

  19. Lung Cancer Incidence by Area Development District, 2004-2008

  20. Lung Cancer in the Mountains

  21. iLovemountains.org

  22. Objective 2 Examine common presenting symptoms of lung cancer.

  23. Symptoms • Cough 50-75% • Wt loss 8-68% • Hemoptysis 25-50% • Chest pain 27-49% • Dyspnea 37-58% • Hoarseness/stridor 2-18% • Paraneoplastic Synd 10-20% • Asymptomatic 7-10% http://emedicine.medscape.com/article/279960-clinical

  24. Objective 3 Discuss the pros and cons of screening for lung cancer in high risk individuals

  25. Screening for Lung CancerScreening with Chest XRAY/Sputum Cytology Mayo Lung Project • 10,993 smokers: 6 year program of CXR and sputum q 4 mos vs. annual CXR in the control group • More cancers diagnosed in screened group but no mortality reduction at 20 yrs (actually higher in screened group PLCO Cancer Screening Trial ( due 2015, aborted) • 15,4942 participants (51.6 % current or former smokers) • Single CXR at baseline and then annually x 3 yrs vs. “usual care” control group • No difference in incidence or mortality • Only 20% of cancers detected by screening

  26. Study Overview • Persons undergoing three annual screening examinations with low-dose computed tomography had a 20% reduction in lung-cancer mortality compared with those screened with annual chest radiography.

  27. Study Design Participants: • Smokers/former smokers with a 30 pk-yr history aged 55-75 years • Exclusions: CT within 18 months of the study, hemoptysis or and unexplained weight loss • 53,454 participants: half assigned to CT group and CXR group

  28. Screening • Three yearly screenings with either low dose CT or PA/Lat CXRs and followed for 5.5 years • + Scan included: • any non-calcified nodule or mass measuring 4mm or more • Adenopathy or effusion • If abnormalities were stable at 3rd screening, they were classified as minor abnormalities

  29. Outcome measures • Primary: lung cancer mortality between the two groups • Secondary: death rate from any cause and the incidence of lung cancer in the two groups Study 90% powered to detect a 21% decrease in mortality

  30. Results—stopped 11/10 due to benefit • Positive Result: • 24.2 % CT group, 23.3% were false + • 6.9 % CXR group, 6.5% were false + • False positive results: • 96.4% CT group, 94.5% CXR group • >90% of these resulted in further testing, most often further imaging

  31. Adverse events Procedural complications (all) • 1.4% CT • 1.6% CXR Major Complications (CT) • .06% (non-lung cancer group) • 11.2% (lung cancer group) Major Complications (CXR) • 0.02% (non-lung cancer group) • 8.2% (lung cancer group)

  32. Lung Cancer Diagnosis • 1060 lung cancers in CT group (645/100,000) • 941 lung cancers in CXR group (572/100,000) • Rate ratio = 1.13 Stage 1A and B Disease • 63% in CT group vs. 47.6% in CXR group • Fewer Stage 4 lesions in CT group than CXR group Mortality • 356 deaths from lung cancer in the CT group • 443 deaths from lung cancer in the CXR group • Signicant (20% reduction) in the CT group (P=0.004) • Reduced all-cause mortality by 6.7% ( P=0.02).

  33. Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer. The National Lung Screening Trial Research Team. N Engl J Med 2011;365:395-409

  34. Results of Three Rounds of Screening.

  35. Diagnostic Follow-up of Positive Screening Results in the Three Screening Rounds. The National Lung Screening Trial Research Team. N Engl J Med 2011;365:395-409

  36. Stage and Histologic Type of Lung Cancers in the Two Screening Groups, According to the Result of Screening. The National Lung Screening Trial Research Team. N Engl J Med 2011;365:395-409

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