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Early Detection of Lung Cancer & Beyond

Early Detection of Lung Cancer & Beyond. GUIA ELENA IMELDA R. LADRERA, MD Lung Center of the Philippines. Objectives. Present available statistics on Lung Cancer. Present data on the early detection of lung cancer. Present the LCP Algorithm in the approach to lung cancer suspect.

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Early Detection of Lung Cancer & Beyond

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  1. Early Detection ofLung Cancer & Beyond GUIA ELENA IMELDA R. LADRERA, MD Lung Center of the Philippines

  2. Objectives • Present available statistics on Lung Cancer. • Present data on the early detection of lung cancer. • Present the LCP Algorithm in the approach to lung cancer suspect. • Present LCP research results in the treatment & prevention of Lung Cancer.

  3. Incidence of Lung Cancer • Lung Cancer is the most common cause of cancer related death worldwide • Overall 5 year survival - < 15% CANCER Principles and Practice of Oncology DeVita et al 8th Edition p896 • Philippines - 15,881 deaths are expected this year - Median survival of 6 months - Five-year survival of 5.28% & a 10-year survival of 2.68% 2005 Philippine Cancer Facts & Estimates

  4. Estimated Five Leading Cancer Sites in 2005, Both Sexes2005 Philippine Cancer Facts & Estimates Number of Cases

  5. Five Leading Causes of Cancer Deaths in 2005, Both Sexes2005 Philippine Cancer Facts & Estimates

  6. Lung Center of the Philippines Tumor Registry 2000 - 2004

  7. Patients with Diagnosis of Bronchogenic Cancer at the Lung Center of the Philippines 2000 - 2004 * Adeno-Squamous CA +Neuroendocrine CA

  8. Number of Patients with Lung Cancer (NSCLC & SCLC)2000 – 2004Lung Center of the Philippines Tumor Registry

  9. Histopathologic Types of NSCLCLung Center of the Philippines Tumor Registry

  10. Distribution of Patients with Lung Cancer 2000 – 2004 Lung Center of the Philippines Tumor Registry

  11. Distribution of NSCLC According to Stage of the DiseaseLung Center of the Philippines Tumor Registry

  12. Survival of Patients with Lung Cancer Lung Center Tumor Registry

  13. Lung Center of the Philippines Bronchogenic Carcinoma (152 cases) 1986 - 1991 1 Year Survival by Stage Stage 1 (T1-2 N0 M0) 96.8% Stage II (T1-2 N1 M0) 94% Stage IIIA (T1-2 N2 M0) 88.9% LCP Tumor Registry 1994

  14. Lung Center of the Philippines Bronchogenic Carcinoma (152 cases) 1986 - 1991 Average 1 Year Survival for all Types 93.2% LCP Tumor Registry 1994

  15. Overall 5 year survival is LESS THAN 15% Philippines - 15,881 deaths are expected this year - Median survival of 6 months - Five-year survival of 5.28% & a 10-year survival of 2.68% 2005 Philippine Cancer Facts & Estimates

  16. Diagnostic Algorithm for Lung CancerLung Center of the Philippines 2008

  17. CLINICAL PRESENTATION Pulmonary mass A ** Negative for malignancy or Non-specific diagnosis TTNAB/ Sputum cytology (1) Peripheral lesion Inconclusive Cough or dyspnea CXR Follow-up evaluation Establish diagnosis Negative * * * Bronchoscopy with Biopsy / Sputum cytology Do staging Confirm diagnosis Central lesion Abnormal ENT examination Refer to ENT Repeat biopsy Increase in mass size Treat other diseases as indicated or follow up visit every 1 mo. Go to B Low suspicion/ risk * (2) CXR and ENT Exam No change in mass size Hemoptysis No further testing B Normal ENT examination with negative or positive CXR Negative Follow-up High suspicion/ risk Exploratory thoracoscopy other invasive procedures Appropriate treatment Positive (3) Go to B Positive for pulmonary mass Positive B Bronchoscopy with cytology and biopsy Further testing: TTNA/TBNA EBUS-NA VATS Unresolved pneumonia of >1 month with abnormal CXR or asymptomatic with abnormal CXR * CT of chest/MRI High risk Negative or low suspicion of neoplasm Negative * Low risk Follow-up every 3 months SPECIAL SITUATIONS * * * Presence of extrapulmonary lymph node Biopsy of lymph node, if accessible Definition: *Low risk – age < 40 years old, non-smoker with (-) family History. *High risk – age > 40 years old, smoker/ passive (+) family History. Diagnostic thoracentesis Pleural fluid cytology or pleural biopsy Thoracoscopy Pleural effusion Video-assisted Thoracic Surgery (VATS) Open lung biopsy CT guided biopsy Multiple pulmonary nodules Atelectasis Fiberoptic bronchoscopy (FOB) RAD/jbl06 ALGORITHM IN THE GENERAL APPROACH IN THE DIAGNOSIS OF SUSPECTED LUNG CANCER

  18. Treatment of Lung Cancer Lung Center of the Philippines

  19. Lung Center of the Philippines Bronchogenic Carcinoma 1986 - 1991 Total no. Of cases - 3,338 Total no. Of 0perations - 152 (4.55%) LCP Tumor Registry 1994

  20. Lung Center of the Philippines Bronchogenic Carcinoma Resection Rate of Operated cases 1982 – 1986 68.6% 1986 – 1991 92.7% LCP Tumor Registry 1994

  21. Percentage of Patients with Early Stage NSCCA who Underwent Surgery 2000 – 2004 Lung Center of the Philippines Tumor Registry

  22. Lung Center of the Philippines Early Lung Cancer Detection ProgramLung Center OF THE Philippines Program, R. Montevirgen, MD • Study period: 1991 -1996 • Subjects 120 initial participants enrolled • High risk individuals • Q 6 months CXR until age 75 • Results - 3/120 (+) to have lung cancer. - 2 patients presented with late stage disease upon enrolment. - 1 patient detected with early disease (0.83%)

  23. Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum CytologyL.L. Humphrey MD et al Ann Intern Med 2004;140:740-753

  24. Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum CytologyL.L. Humphrey MD et al Ann Intern Med 2004;140:740-753

  25. Summary • Two RCTs (JHLP & MSKLP) which used sputum cytology for screening. No mortality benefit was found. • MLP used CXR & sputum cytology compared to usual care. No mortality benefit was found. • CLP used q 6m CXR for 3 years, then yearly CXR for 3 years compared to annual CXR. No mortality benefit was found.

  26. Cohort Trials of Low Dose CT ScreeningCANCER Principles and Practice of Oncology DeVita et al 8th Edition p 685 Table III

  27. Cohort Trials of Low Dose CT ScreeningCANCER Principles and Practice of Oncology DeVita et al 8th Edition p 685 Table III

  28. Summary • The lung cancer prevalence rate depends on risk characteristics. • The ratio of baseline to annual cancers is much higher for CT scan than it was for CXR. Or sputum cytology. • High proportion of finding Stage I disease.

  29. No major medical professional organization currently recommends screening for lung cancer

  30. Alternatives to Lung Cancer Screening ?????

  31. National Smoking Prevalence StudyResearch & Development, Lung Center of the PhilippinesPhil. Journal Int. Medicine 27: 133 – 156, May – June 1989 Adult population - 46.52% smokers Urban population – 40.92% Rural population – 49.94% Young Population - 22.70% Urban population – 18.98% Rural population – 26.20%

  32. Manila, PhilippinesPrevalence of ever smoking in population1 ages >40 by sex 1 Unweighted data for the sample of responders Overall = 55% Philippine BOLD Study . AS Buist et al, The Lancet 2007, Vol 370 pp 741 - 50 21 February 2008

  33. Cigarette Smoking Among Hospitalized Patients in Metro ManilaJCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp65 - 73 • Results : 1. 34% current smokers 43% former smokers 2. Of all current smokers <30y, 65% NEVER thought of attempting to quit. For those >30y, 66% attempted to quit 3. Of those who attempted to quit, 52% had 5-10x attempts.

  34. Attitudes & Beliefs of Smokers More than half of population thought seriously about quitting. 2.5-3x serious attempts to quit – Urban group 1 serious attempt to quit - Rural group Cigarette Smoking Among Hospitalized Patients in Metro ManilaJCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp65 - 73

  35. Young People as Smokers • Overall – 22.70% - Urban : 18.98% - Rural : 26.20% • Mean age for starting is 11 – 12 y • Major reason for starting – Peer group pressure Cigarette Smoking Among Hospitalized Patients in Metro ManilaJCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp65 - 73

  36. Teaching Lung Cancer Prevention to the Filipinos: an Inter-Agency CollaborationDepartment of Research & Development, Lung Center of the PhilippinesScientific Proceedings 1995 Vol 3 pp47- 52 • Aim is to develop a curriculum material on both elementary and HS levels on Lung Cancer prevention. • Modules are designed to develop awareness among students of the health hazards of smoking and its direct link to lung cancer.

  37. SUMMARY • Lung cancer is the leading cause of cancer diagnosis and deaths worldwide and locally. • Lung cancer screening is currently not advocated even for high risk population. • Standardization of diagnostic evaluation for patients with suspected lung cancer is recommended. • Prevention of smoking through education, implementation of tobacco regulation law may help curb the incidence of lung cancer.

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