Why Aren’t Never Smokers Screened for Lung Cancer with LDCT?

Posted on September 24, 2014 by Gray Connections | 5 Comments

As you’ve probably heard, 25% of lung cancer patients worldwide are never smokers. Like all lung cancer patients, the majority of never smoker LC patients are diagnosed with metastatic lung cancer, even though they often have no real symptoms. How come lung cancer screening guidelines don’t suggest never smokers get screened for lung cancer?

Well, it’s all a matter of risk reduction.

Medical practitioners (and those who pay for their services) do not like to run a medical test when the patient might be put at risk for little benefit. This is a concern if a test is not 100% accurate and follow-up procedures for a positive result are potentially invasive. This is the situation with LDCT screening. With today’s technology, a lung cancer diagnosis can only be confirmed with a biopsy, which is invasive and does carry some risk. And, lung biopsies are not guaranteed to detect a cancer, even if one is present. Lung cancer screening with low dose CT might generate a false positive (meaning the test says the patient has lung cancer when they really don’t). False positives could result in unnecessary invasive follow-up procedures with some risk to the patient.

For this reason, LDCT screening is only recommended for those who are at HIGH RISK for lung cancer. At this time, “high risk for lung cancer” means current or past heavy smoking history and age 55 to 75. These risk factors were not chosen due to stigma or discrimination. To date, these are the only two risk factor scientifically demonstrated to have a HIGH correlation with lung cancer in several studies. A very large clinical trial (the National Lung Screening Trial, or NLST) showed people who had these risk factors were likely to benefit from lung cancer screening with LDCT despite the risks of false positives.

For these patients at high risk for lung cancer, the benefits of screening outweigh the risks. LDCT screening reduced their lung cancer deaths by 20% compared to screening with x-rays, simply by detecting the lung cancer before it spread and getting it treated early. By the way, NO deaths due to LDCT screening occurred in the 53,000+ participants enrolled in the NLST.

Since lung cancer occurs in a low percentage of the never smoker population, the risk of screening doesn’t make sense for never smokers unless they have another high risk factor.

We know of other risk factors associated with lung cancer–radon gas in homes, air pollution, previous cancer treatments (especially radiation treatment to the lungs), exposure to certain hazardous materials, even an inherited gene. However, analysis to date hasn’t shown any of these factors have as strong a correlation with lung cancer, possibly because it’s harder to track those risk factors in a controlled study. As we learn more about how lung cancers get started, and how they differ from each other, we are likely to discover more HIGH risk factors that can be validated by objective analysis.

This definition of “high risk” and this method of screening are just the first steps in early detection for lung cancer. As more high risk factors (like the inherited version of the T790M gene) are validated by objective studies, people who have those risk factors should also be included in covered lung cancer screening, whether or not they have a smoking history.

As more accurate and less expensive lung cancer screening technologies become available, testing will become more accessible to everyone. Someday–hopefully in our lifetimes–accurate lung cancer screening will be as easy as a blood test or spitting into a test tube, without the need for a biopsy.

So keep supporting more research! We need accurate, affordable early detection of lung cancer in never smokers.

Guest Post: Does Cancer Screening Cause “Overdiagnosis”?

Posted on March 3, 2014 by Gray Connections | 3 Comments

The guest post below is written in response to Dr. Scot Aberegg’s blog post. His and other recent blog posts and articles have claimed “overdiagnosis” of breast cancer and lung cancer due to screening. Andrea Borondy Kitts, a former engineer and fellow Lung Cancer Social Media tweeter whose husband died of lung cancer last year, addresses Dr. Aberegg’s claims in her letter.

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Dr. Aberegg, thank you for your interesting post on overdiagnosis problems with breast and lung cancer screening. I would like to comment on many of your points.

Background:

I am a mechanical engineer. I have a Master’s degree in Management and retired after a 32 year career in aerospace, 10 years as an executive. I am back in school getting a 2nd Masters degree, this time in Public Health. I advocate for lung cancer as a volunteer for the American Lung Association, for the National Lung Cancer Partnership, on twitter as @findlungcancer, and for several Hartford CT area hospitals with their lung cancer screening programs. I lost my husband, Dan, to lung cancer on April 12th, 2013 after an 18 month hard fought battle. Dan had all the risk factors for lung cancer. He was 69 years old at the time of his diagnosis, he had quit smoking 11 years prior to his diagnosis, he had an 80 pack year smoking history, his sister had died of lung cancer at age 62 and Dan had COPD. Unfortunately, at the time of his diagnosis, lung cancer screening was not recommended.

Comments on the BMJ paper about the Canadian National Breast Screening Trial:

We had a 3 hour discussion in my UConn Chronic Disease Control class last week about the recent British Medical Journal (BMJ) paper on the 25 year follow up to the Canadian National Breast Screening Study. In attendance were 2 cancer epidemiologists, one a breast cancer expert, and an oncologist with breast cancer expertise. In conclusion, the consensus among the experts was the study did not provide enough credible evidence to change the recommendation for breast cancer screening in the US.

Key concerns raised with this study:

In the mammography group 2/3 of the breast cancers found were palpable. This is not consistent with clinical breast screening experience where most breast cancers found with mammography are too small to feel.
Screening was only for 5 years. Most breast cancers are slow growing so may not have screened long enough to capture the difference in mortality. The risk for breast cancer increases with age, so each passing year after the screening stopped the women had a higher risk of getting breast cancer. The number of breast cancers found in the mammography and non mammography arms were the same after the 5 year screening period was stopped.
Although mortality did not differ between the 2 groups, the cancers found in the mammography group were smaller and less were lymph node positive.
The study is predicated on universal access to adjuvant therapy. Canada has a National Health System so all women have access to care. This is not the case in the US.

Other discussion points:

There are 22 million women in the US between the ages of 40 – 49. Not screening this population would save a lot of money.
Need to have better genetic markers for who will develop breast cancer to risk stratify the population to screen

My “take-aways” from the discussion

Large screening clinical trials/studies are hard to do right especially with decades of follow-up; often new technology and new treatments can overtake results
Policy can be influenced by strong advocacy sometimes resulting in non-evidence based recommendations
Even the experts don’t fully understand the results and don’t know how to apply to population recommendations

Comments on lung cancer screening:

The most important point to consider when comparing lung cancer screening to Mammography or PSA screening is that lung cancer screening is different. Screening is limited to the high risk population and the gold standard randomized trial, the National Lung Screening Trial (NLST), showed a 20% mortality reduction with LDCT screening versus chest x-ray.

I don’t understand the derivation of your NNS of 950. The original paper published in the NEJM calculates the NNS as 320 for the NLST study population.

One of your discussion points focused on all-cause mortality being biased lower in the LDCT group, not because of incidental findings, but because of changed behavior in the LDCT group with false positives; for example smoking cessation. I do not think this biases the results. The results are a real, albeit, an unintended benefit for LDCT screening. The public health and medical communities have been continuously searching for ways to influence people to adopt healthy behaviors. It’s wonderful, if in fact, LDCT screening provides a “teachable moment” resulting in healthier behaviors and improved outcomes.

Your discussion about telling folks to quit smoking as a better alternative to lung cancer screening is flawed in that, more than 50% of lung cancer diagnoses are in former smokers. These are people who have already quit smoking. Their only hope for improved survival is for secondary prevention in the form of early diagnosis with LDCT screening.

Your discussion about older people not being screened due to overdiagnosis because of mortality due to other causes is disturbing. You seem to be advocating that when people reach a certain age, we should give up on any type of screening because they will probably die soon anyway. I was particularly shocked with your statement “What if, in essence, we save a lot of people from lung cancer who then die from a heart attack 6 months later?” This would imply we should not treat any disease with a 6 month or less prognosis; let’s just save the money, 6 months is not worth the expense to society. WOW. You criticize the USPSTF final recommendation to screen to age 80 as too old. However, you neglect to mention the USPSTF modifier that “screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery”.

And finally you discuss how a physician patient discussion on lung cancer screening might go. I would like to add a few more scenarios to your hypothetical discussion.

There is now a recommended screening test for lung cancer for a high risk population. I think you might be in the recommended to screen group. I wanted to review your risk factors with you and discuss if screening might be right for you.
It’s great that you stopped smoking 11 years ago. However, your risk level is still elevated. Your heavy 80 pack year smoking history puts you at increased risk. We know there is a strong dose response relationship with smoking and lung cancer. In addition, knowing that your sister died at age 62 from lung cancer, puts you at increased risk as well. You also have COPD another known risk factor. I have a risk calculator I use to help me stratify risk for my patients. http://www.brocku.ca/lung-cancer-risk-calculator
There is a 25% chance you will have a finding from your screening. 95% of the time it will not be lung cancer. Most of the time, the follow up to the finding is another LDCT. There is a small possibility you would have a more invasive procedure. However, the benefit of finding lung cancer at an early stage is improved survival. At stage 1a there is an 85% chance you will be alive after 5 years. At stage 4 that is less than 10%.
Based on your risk profile, I think you should consider LDCT lung cancer screening.

The point is that each patient is unique and the discussion with the patient should be tailored to the risk profile for the patient. The discussion you portray would not be appropriate for my hypothetical patient, who yes, happens to fit the profile of my husband who died in April 2013 from lung cancer.

Lung cancer is the leading cause of cancer deaths in men and women in the US and worldwide. It is the second leading cause of all deaths in the US after cardiovascular disease. More people die of lung cancer than breast, colon, and prostate cancer combined. Five year survival at 16% is essentially unchanged since 1975. We finally have a screening test for lung cancer and if everybody would stop trying to discredit the test and just get out of the way we will save lives!

December 19 #LCSM Chat: “Lung Cancer Screening – The Good, The Bad and the Indolent”

Posted on December 16, 2013 by Gray Connections | 3 Comments

[This is a reblog of a post on the #LCSM Chat website, shared with permission (it’s really easy to give myself permission to reblog something I wrote).]

The next #LCSM Chat will occur on December 19 at 5 PM Pacific Time (8 PM ET), and will be moderated by Janet Freeman-Daily. The theme will be “Lung Cancer Screening – The Good, The Bad and the Indolent.”

Discussion topics for #LCSM Chat:

T1: For patients who don’t fit “older heavy smoker” profile, should doctor order low-dose CT screening if patient requests it? #LCSM

T2: Some lung nodules are not cancer. When are you comfortable just watching a lung nodule instead of treating it? #LCSM

T3: A new blood test detects w/ 90% accuracy if lung nodule IS NOT cancer (but can’t tell for sure if it IS). Is this useful when combined with low-dose CT screening? #LCSM

Background

The National Lung Screening Trial found 15% to 20% fewer lung cancer deaths among participants who were screened for lung cancer by low-dose helical CT scans compared to those screened by chest x-ray. Participants included 53,454 current or former heavy smokers ages 55 to 74 between 2002 and 2004.

From this statistic, it would seem obvious that lung cancer screening for older patients who are or were heavy smokers would be a slam dunk. However, the screening does raise some concerns. For instance, some studies show 20% to 60% of screening CT scans of current and former smokers show abnormalities, most of which are not lung cancer. Lung biopsies and surgery do carry risk, yet the uncertainty over having lung nodules might cause considerable anxiety for the patient. How do we determine whether or not to biopsy such abnormalities?

A biopsy of a nodule found by screening could determine if the nodule is cancerous. However, according to the NCI, studies indicate some small lung cancer tumors are indolent – that is, they so slow growing that they never become life threatening. This situation, called overdiagnosis, might cause some patients to be subjected to challenging and potentially damaging lung cancer treatment when they have no symptoms and an extremely low risk of death from lung cancer. Are the risks associated with biopsies and cancer treatment ALWAYS less than the risk of lung cancer death?

Another issue: this new CT screening is recommended only for patient who fit a specific profile (generally, current or former heavy smokers ages 55 to 79).Never smokers and some smokers and former smokers don’t fit this profile, but might have other risk factors for lung cancer. If a patient who doesn’t fit the recommended profile requests a low-dose helical CT scan, and agrees to pay for it, should their doctor agree to order the scan?

A new blood test announced in October (by Bioinformatics for Integrated Diagnostics and the Institute for Systems Biology) can determine if a detected lung nodule is NOT cancerous with 90% accuracy. However, it can’t reliably detect whether a nodule IS lung cancer. Used in combination with CT screening, this blood test might help determine whether a lung nodule warrants a biopsy. Do doctors and patients feel comfortable using a blood test that can say if the patient does NOT have lung cancer, but can’t say if the patient DOES have it?