Lung Cancer Screening and Pulmonary Nodule Evaluation

1. Lung Cancer Screening andPulmonary Nodule Evaluation Todd C. Hoopman, MD Lung Nodule and Lung Cancer Screening Clinic Medical Director Kootenai Health Coeur d’Alene, ID

2. Lung Cancer • Accounts for more deaths than any other cancer in both men and women in the U.S. and worldwide1 • 175,000 new cases each year • 27% of cancer deaths in 2015 (160,000 deaths) • 1 in 14 men and 1 in 17 women will be diagnosed with lung cancer during their lifetime2 • 433 deaths per day (Every 3.3 minutes) • 69% diagnoses are made in patients 65 and older • Lung Cancer Deaths3 Colon Breast Prostate 1 American Cancer Society Facts and Figures 2015 2 Cancer J Clin. 2015;65:5–29 3 Cancer J Clin. 2011; 61: 69-90

3. Lung CancerSurvival1 • Lowest 5-year survival rate1: 18% • Breast 90%, Prostate 99%, Colorectal 65% • Half of women diagnosed with lung cancer will survive only one year • Only 1 in 5 women will survive 5 years • If detected before spread, 5-year survival can improve to 55% • Low-dose CT screening can reduce mortality in high-risk populations by up to 20% 1 http://seer.cancer.gov/statfacts.html.lungb.html

4. Regional Lung CancerStatistics • Northern Counties: Kootenai, Benewah, Bonner, Boundary, Shoshone • Other Idaho Counties: Clearwater, Idaho,Lewis, Nez Perce • 2016 Volume: 267 cases • 2021 Projected Volume: 306 cases (14.6% increase) • 2026 Projected Volume: 337 cases (26.0% increase) • Low Dose Lung Cancer Screening Chest CT Program • Incidental Nodule Management Program

5. 5-Year Lung CancerSurvival 1990-20101 1 Cancer. 2018; 1-16.

6. 5-Year Cancer Stage 1 Survival Comparison (2007-2013)1 *NSLCL and Small Cell 1 SEER.cancer.gov

7. National Lung Cancer Screening Trial1 • Previous attempts to screen for lung cancer • CXR trials • Sputum cytology studies • Foreign and Domestic studies • NEJM August 4, 2011 • Sentinel trial • Randomized, multicenter trial • “Would LDCT reduce mortality from lung cancer in high-risk • individuals compared with CXR screening?” 1 NEJM 2011; 365: 395-409.

8. National Lung Cancer Screening Trial1 • Total Enrollment: 53,454 ( approx. 26,700 in each group) • Ages 55 - 77 • 30-pack year tobacco history • Active smoker or quit < 15 years prior to enrollment • Excluded: prior lung cancer, CT<18 months, hemoptysis, weight loss • The Protocol • Three annual screenings (LDCT vs. CXR) • LDCT: 1.5 mSV Standard Chest CT: 8 mSV • Standardized reading protocols: nodules > 4mm were “suspicious for” • Primary end-point: Lung-cancer mortality between the two groups 1 NEJM 2011; 365: 395-409.

9. Lung CancerScreening • Symptoms that do NOT exclude from screening eligibility: • Tobacco abuse/dependence • COPD • Chronic, stable Shortness of Breath • Chronic, stable Cough • Hypoxia

10. National Lung Cancer Screening Trial1 • High false-positive rate: approximately 95% in both groups • 90% of positive screening tests in round 1 led to a diagnostic evaluation • Majority of follow-up evaluations were imaging • Higher rate of positive screenings in LDCT group • Participants with at least one positive screening result: • 39.1% LDCT • 16.0% CXR • Limitations: • More advanced scanners (higher detection rate) • Variable institutional expertise (interpretation, testing, surgery) • Overdiagnosis: detect cancers that never would have been symptomatic

11. NLST Results • LDCT: 20% relative reduction in rate of death from lung cancer • LDCT: 6.7% reduction in death from any cause • Number needed to Screen with LDCT to prevent one death: 320 • Adherence to follow-up exams • 95% in the LDCT group • 93% in the CXR group • Local Adherence Rate: 15-20% • Limitations: • More advanced scanners (higher detection rate) • Variable institutional expertise (interpretation, testing, surgery) • Overdiagnosis: detect cancers that never would have been symptomatic

12. Low Dose Chest CT Facts1 • Radiation Dose: • 1.5 mSV (millisieverts) • Comparative: • 3 mSV/year from natural radiation (radon, atmosphere/outer space) • LDCT “similar” radiation dose to mammography • Cancer risk from a standard CT is 1:2000 • Lifetime risk of cancer for everyone is 1:5 • Much higher chance of dying from a smoking related cancer than from the radiation exposure 1 http://cancer.gov

13. Lung-RADS Guidelines1 1 https://www.acr.org/Quality-Safety/Resources/LungRADS

15. LDCT Local Stats • Screening LDCTs: • 2015: 32 • 2016: 180 • 2017: 337 • 2018: 530

16. LDCT Local Stats • 2016: 6 cancers detected • 3 - Stage 1 • 3 - Stage 4 • CDR 33.3 : 1000 screened • 2017: 7 cancers detected • 3 - Stage 1a • 1 - Stage 2b • 3 - Stage 4 • CDR 20.8 : 1000 screened • 2018: 5 cancers detected • 1 - Stage 4 • 3 - Staging pending • CDR 14.9: 1000 screened National CDR 1.48 : 1000 Screened

17. Incidental Pulmonary Nodules

18. Pulmonary Nodules • Definition: Round, <30 mm, surrounded by lung tissue1 • Solid vs. Sub-solid (“ground glass”) nodules • 0.09%-0.20% of all Chest X-rays1 • Incidence of malignancy: 10-70% • Chest CT Nodule incidence (2006-2012)3 • 4.8 million chest CTs performed: 1.57 million nodules detected • Prediction Models • Mayo Clinic: https://reference.medscape.com/calculator/solitary-pulmonary-nodule-risk4 • TREAT Model: https://treat.mc.vanderbilt.edu/calculator2.05 • 1 Inter CardVasc Thor Surg. 2005; 4:18-20. • 2 AJRCCM. 2015; 10: 1149-50. • 3 AJRCCM. 2015; 10 1208-1214. • 4 www.reference.medscape.com • 5 www.treat.mc.vanderbilt.edu

19. Incidental Pulmonary Nodules • Non-Malignant Etiologies of a Pulmonary Nodule: • Infections: bacterial, fungal, mycobacterial • Inflammation: Rheumatoid arthritis, sarcoidosis, vasculitis • Benign Tumors: Hamartoma, hemangiomas, fibromas • AV malformations, amyloidosis, pulmonary infarction • Fleischner Guidelines2005 (updated 2013, 2017)1 • 51% of smokers > 50 y.o. will have a nodule2 • 96.4% of these nodules are benign • Size determines malignancy risk3: • 0-1% if <5 mm • 6-28% if 5-10 mm • 64-82% if >20 mm • 1 J Radiol. 2017; 4: 228-43. • 2 Inter Card Thor Surg. 2005; 4:18-20. • 3 J Can Res Pract. 2018; 5:13-19.

22. Cancer Risk Factors

23. My Patient has an Incidental Pulmonary Nodule…What’s next? • Discuss the results with the patient • Determine their willingness to proceed with diagnostic testing • Important factors to consider: age, comorbidities, functional status • Consider referral to Lung Cancer Screening and Incidental Nodule Clinic • Wednesday afternoons at KH Cancer Center in CdA • Consultation to review patient history and study patient images together • Formulate a plan: • Diagnostic Intervention vs. Further Imaging vs. Observation • Bronchoscopy typically performed the following morning • Referral can be made directly to the Lung Cancer Screening and Incidental Nodule Clinic: (208) 625-LUNG

24. Diagnostic Strategies • Bronchoscopy vs. CT-Guided biopsy for Peripheral Nodules • Conventional bronchoscopy: 25% yield • CT-guided biopsy: 80-90% yield with a pneumothorax rate 15-30% 1 • Navigational Bronchoscopy: 65-89% yield 2-6 with a pneumothorax rate 3.5-6% 7 • PET Scan • Utilized for evaluation of solid nodules • Low sensitivity for nodules < 1 cm in diameter • Can prove difficult to receive authorization without a cancer diagnosis 1 AJR AM J Roentgenol 2010; 194(3): 809-914. 2 Respiration. 2014; 87 (2): 165-76. 3 Crit Care Med 2006; 174: 982-989. 4 J Bronchol 2005, 12: 9-13. 5 J Bronchol 2007, 14 (4): 227-332. 6 Lung 2009, 1877: 55-59. 7 Ir Med J. 2012; 105(2): 50-2.

25. Diagnostic Strategies: CT-Guided Needle Biopsy • CT-Guided Needle Biopsy • Peripheral lesions, adjacent to pleural surface • Apical lesions • Limited adjacent emphysema

26. Diagnostic Strategies

27. Diagnostic Strategies: Electromagnetic Navigational Bronchoscopy • Safely, precisely and accurately obtain diagnostic tissue • Older patients / comorbidities • Severe emphysema • Smaller nodules (8 mm) and semi-solid • Combines conventional and virtual bronchoscopy • Extends the reach of bronchoscopy to the pleural surface • Reduce the need for “Watchful Waiting” of small nodules • ACCP guidelines: ENB recommended for peripheral lesions1 • Since 2016: 289 Navigational Bronchoscopy procedures at KH 1 CHEST. 2013; 143 (5 Suppl): 7S-37S.

28. Additional Elements of Care • Pulmonary Function Testing • Thoracic Tumor Board Review • Direct Referrals to Medical Oncology, Radiation Oncology, Thoracic Surgery • Ongoing patient support • Treatment side effects • Management of disease progression • Goals of Care and Palliative Care discussions • Survivorship Care

29. The Way We Should ALLWant it Work… • 61 y.o. woman, active smoker. Visit with PCP for annual check up. LDCT program discussed and patient agrees to an exam • LDCT: 2 pulmonary nodules (bilateral) detected • Navigational Bronchoscopy: • RUL nodule: Adenocarcinoma • LLL nodule: “suspicious” for malignancy • August 2018: RUL VATS wedge resection • September 2018: LLL Robotic Superior Segmentectomy • Two separate Stage 1a tumors: 5 year survival > 90%

30. LDCT Program The Impact

31. Stage Shift 8.5% decline 7.5% increase

32. What Does this Mean for People of N. Idaho? • In the past two years: 60 N. Idahoans with lung cancer now have a better chance of being alive in 5 years because we detected their lung cancer at Stage 1 • 80% chance of being alive vs. 5.5% chanceof being alive