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Early Lung Cancer Screening: An Update of the Current Evidence

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

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Early Lung Cancer Screening: An Update of the Current Evidence

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  1. Early Lung Cancer Screening:An Update of the Current Evidence Simon Martel, MD IUCPQ Quebec, Canada

  2. No conflict of interest

  3. 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

  4. 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

  5. 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

  6. Screening Bias Patz EF et al. New Eng J Med 2000

  7. Screening Bias Patz EF et al. New Eng J Med 2000

  8. Screening Bias Black WC. Cancer 2007

  9. 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

  10. 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

  11. 1950-1990 • Intervention groups: • More lung cancers • More early stage lung cancers • More resectable lung cancers • No reduction in lung cancer mortality

  12. Recommendations Bach BP et al. Chest 2007

  13. Are we done with chest X-ray in lung cancer screening? J Natl Cancer Inst 2005

  14. 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

  15. Radiation

  16. Radiation • Low dose CT Baldwin DR et al. Thorax 2011

  17. CT lung cancer screening Black WC. Cancer 2007

  18. CT lung cancer screening Black WC. Cancer 2007

  19. CT lung cancer screening Black WC. Cancer 2007

  20. 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?

  21. Follow-up of nodules MacMahon H et al. Radiology 2005

  22. Thorax 2011

  23. Early stage detection New Eng J Med 2006

  24. Overdiagnosis?

  25. Growth Model of Lung Cancer Bach BP et al. Chest 2007

  26. 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

  27. 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

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

  29. 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

  30. NLST Participants

  31. 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

  32. Pan-Canadian Early Detection of Lung Cancer Study Enrolled N=2533 AFB = 1252 66 lung cancers confirmed

  33. 478 Normal CT Scans at Baseline (20%)

  34. 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 • …

  35. 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!

  36. Screening Bias Black WC. Cancer 2007

  37. 1950-1990 Manser RL et al. Thorax 2003

  38. 1950-1990 Manser RL et al. Thorax 2003

  39. 1950-1990 Manser RL et al. Thorax 2003

  40. Radiation Brenner DJ et al. New Eng J Med 2006

  41. Radiation Brenner DJ et al. New Eng J Med 2006

  42. New Engl J Med 2009

  43. Coûts-Bénéfices? Am J Respir Crit Care Med 2008

  44. 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

  45. Coûts-Bénéfices? Wilson DO et al. Am J Respir Crit Care Med 2008

  46. Coûts-Bénéfices? Bach PB et al. Chest 2007

  47. Overdiagnosis?

  48. Follow-up of nodules

  49. 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

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