Finding N.E.M.O.Marvin R. Balaan, MD, FCCPSystem Division Director, Division of Pulmonary and Critical Care Medicine

Allegheny Health Network, Pittsburgh PA

Associate Professor, Temple University School of Medicine

UP College of Medicine Class 1979

Finding Nodules Early Matters OptimisticallyScreening for early detection of lung cancer

A tale of two nodules

Does Finding N.E. M.O?

Sobering statistics Lung cancer is the leading of of cancer-related death among

men and women Third leading cause of cancer in the United States Surpassed breast cancer as cause of death in women 2015 American Cancer Society Prediction

221,000 new cases of cancer will be diagnosed 158,000 will die of lung cancer

Worldwide 1.4 M deaths in 2008

Cancer statistics, 2014

CA: A Cancer Journal for CliniciansVolume 64, Issue 1, pages 9-29, 7 JAN 2014 DOI: 10.3322/caac.21208http://onlinelibrary.wiley.com/doi/10.3322/caac.21208/full#caac21208-fig-0001

Men Women

Cancer deaths

Should we try to find lung cancer early?Facts:

Overall survival in lung cancer is about 16%

In over 75 % of cases patients present with widely metastatic disease

Survival in early stage lung cancer is good

How should we do it?

Should we Screen for lung cancer?

Screening for lung cancer Mayo Clinic Project (1984)- 10,993 male smokers

CXR and sputum cytology every 4 months x 6 years vs usual care

More early cancers detected but no survival benefit

PLCO Cancer Screening Trial (JAMA 2011) 154,901 participants between 1993 and 2001 Annual CXR x 3 vs usual care No difference in mortality

National Lung Screening TrialNEJM Aug 4 2011

NIH sponsored multicenter trial in 33 US medical centers Question: Whether low dose CT screening as compared with

CXR would reduce mortality from lung cancer in high risk pts 53, 454 high risk individuals ages 55-74 years, 30 pack year

smoker or quit within 15 years Randomized to low dose chest Ct versus routine chest x-ray About 26,700 in each group 3 studies separated by 1 year Followed from 2002 to 2009 Positive: lung nodule 4 mm or larger

What they found

National Lung Screening Trial

Low dose Chest Ct vs. Chest x-ray

The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409.

NLST: Results of Three Rounds of Screening.

NLST Results More positive findings in LDCT group compared to CXR Most of the positive findings (about 95% in each group)

were not cancer About 90% needed additional tests Most of these tests were additional imaging studies following

a pre specified protocol.

The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409.

Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer.

Key findings from NSLT Trial More cancers were detected in 3 rounds of annual screening

by LDCT compared to CXR There was relative reduction in lung cancer mortality of 20%

and 6.7 % of all cause mortality with LDCT vs CXR This is the very first time that any radiology based screening

for lung cancer has demonstrated a mortality benefit Finding NEMO! This became the basis for a Grade B recommendation from

USPTF (therefore it has to be a covered service) and recently by Medicare.

Nodule 1Ct guided biopsy : adenocarcinoma

Staging work up- evidence of metastatic disease

Nodule 2Folllowed yearly over 3 years

No change in appearance or character of nodule

Benign nodule

What if it got bigger?Biopsy +/- PET scan

Or resect potentially malignant nodule

So if it is all goodwhy not screen everybody with CT?

Finding Nodules Early

EconomicsCurrently about 7 million persons in the US would

meet the NLST entry criteria. That is a lot of low dose CTs!Estimates of about $81,000 per Quality adjusted

life year comparison- $47,700 per QALY for colorectal screening and $13,000-32,000 for breast cancer screening

Gould MK. N Engl J Med 2014;371:1813-1820.

Potential Benefits and Harms of Three Rounds of Annual Screening with Low-Dose CT, as Compared with Chest Radiography or No Screening.

Unanswered questions How many years should one screen? Does the benefit hold if it is extended to more “real world”

situations – non academic settings, less rigid adherence to work-up and

procedures for nodules, etc. What about the additional risk of cancer from radiation? Are you medicolegally liable if a high risk patient is found to

have cancer and you did not offer screening?

Conclusion Offer low dose CT for high risk patients with profile similar to

NLST 55-74 (80) yrs 30 pack year smoker Or quit within 15 years

Follow protocol very closely Most positive findings need only follow-up rather than an

invasive procedure

Let us not forgetLDCT CT is not a substitute for smoking cessation

Smoking cessation likely more cost effective than screening

Finding N.E.M.O.