Early Detection of Lung Cancer & Beyond

Early Detection ofLung 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.• Present LCP research results in the treatment

& prevention of Lung Cancer.

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

Estimated Five Leading Cancer Sites in 2005, Both Sexes


Number of Cases

Five Leading Causes of Cancer Deaths in 2005, Both Sexes


2000 - 2004

Lung Center of the Philippines Tumor Registry

Patients with Diagnosis of Bronchogenic Cancer at the Lung Center of the Philippines

2000 - 2004Histology 2000 2001 2002 2003 2004

BCA Unspecified NSCLC or SCLC

20 21 31 36 57

NSCLC AdenoCA Squamous CA Large cell CA Unspecified NSCLC Others

TOTAL NSCLC

88504

39

181

117440

54

215

142871488

2 *

333

168653

67

1+

304

167723

84

326

SCLC 26 40 48 46 46

TOTAL 227 276 412 386 429* Adeno-Squamous CA +Neuroendocrine CA

Number of Patients with Lung Cancer (NSCLC & SCLC) 2000 – 2004


Histopathologic Types of NSCLCLung Center of the Philippines Tumor Registry

Distribution of Patients with Lung Cancer 2000 – 2004


Distribution of NSCLC According to Stage of the Disease


Survival of Patients with Lung Cancer

Lung Center Tumor Registry

Stage 1 (T1-2 N0 M0) 96.8%

Stage II (T1-2 N1 M0) 94%

Stage IIIA (T1-2 N2 M0) 88.9%

Bronchogenic Carcinoma (152 cases)1986 - 1991

LCP Tumor Registry 1994


1 Year Survival by Stage

Average 1 Year Survival for all Types

93.2%

Lung Center of the PhilippinesBronchogenic Carcinoma (152 cases)

1986 - 1991


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%


Overall 5 year survival is LESS THAN 15%

Diagnostic Algorithm for Lung Cancer

Lung Center of the Philippines 2008

ALGORITHM IN THE GENERAL APPROACH IN THE DIAGNOSIS OF SUSPECTED LUNG CANCER

SPECIAL SITUATIONS

Follow-up every 3 months

*

Negative or low

suspicion of

neoplasm

Positive for pulmonary

mass

Establish diagnosis

Central

lesion

TTNAB/ Sputu

m cytolo

gy

High risk

Bronchoscopy with cytology and biopsy

Positive

Negative

Further testing:TTNA/TBNAEBUS-NAVATS

Bronchoscopy with Biopsy / Sputum cytology

Confirmdiagnos

is

Negative for malignancyor Non-specificdiagnosis

Do stagin

g

Low suspicion/ risk

High suspicion/ risk

Exploratory thoracoscopyother invasive procedures

Increase in mass

sizeNo change

inmass size

Positive

Negative

Repeat

biopsy

No further testing

Unresolved pneumonia of >1 month with abnormal CXR or asymptomatic with abnormal CXR

CT of chest/MR

I

CXR andENT Exam

Normal ENT examination with negative or positive CXR

Abnormal ENT examination

Refer to

ENT

Follow-up

evaluation

*B

*

B

Presence of extrapulmonary lymph

nodePleural effusion

Multiple pulmonary nodules

Atelectasis

Biopsy of lymph node, if accessible

Diagnostic thoracentesisPleural fluid cytology or pleural biopsyThoracoscopyVideo-assisted Thoracic Surgery (VATS)Open lung biopsy CT guided biopsyFiberoptic bronchoscopy (FOB)

* * *

Definition: *Low risk – age < 40 years old, non-smoker with (-) family History. *High risk – age > 40 years old, smoker/ passive (+) family History.

RAD/jbl06

CLINICAL PRESENTATION

Peripheral

lesionCough

or dyspnea

CXR

Pulmonary mass

Negative

A

Hemoptysis

(1)

(2)

(3)

Treat other diseases as indicated or follow up visit every 1 mo.

Low risk

* * *

Go to B

**

Inconclusive

Follow-up

Appropriate treatment

Go to B

Treatment of Lung Cancer



1986 - 1991

Total no. Of cases - 3,338

Total no. Of 0perations - 152 (4.55%)

Bronchogenic Carcinoma



Bronchogenic Carcinoma


Resection Rate of Operated cases

1982 – 1986 68.6%

1986 – 1991 92.7%

Percentage of Patients with Early Stage NSCCA who Underwent Surgery

2000 – 2004 Lung Center of the Philippines Tumor Registry

Number of Patients (%)

Stage I TOTAL With Surgery

58 22 (38%)

Stage IITOTAL With Surgery

44 8 (18%)

Stage IIIATOTAL With Surgery

128 14 (11%)

Lung Center of the Philippines Early Lung Cancer Detection Program

Lung Center OF THE Philippines Program, R. Montevirgen, MD

Study period: 1991 -1996

Subjects120 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%)

Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytology

L.L. Humphrey MD et al Ann Intern Med 2004;140:740-753 Study Sample Intervention Prevalence

n (%)Mortality rate per 1000 Person-Yrs

Northwest London Mass Radiography Service (1960)

29,733Men of >40 yrs; 19% former smokers; 67% current smokers

CXR & sputum cytology IG: 31 (0.10)

CG: 20 (0.08)

3 yr ff up IG: 0.7

CG: 0.8

Kaiser Permanente Study (1964)

10, 713Age 35-45 yrs; 17% smokers

CXR NR 16 yr ff upIG: 8.6CG: 7.6

Mayo L ung Project (1971)

10,933Male smokers age ≥ 45 yrs

CXR & sputum cytology vs usual care

91 (0.83) 20 yr ff upIG: 4.4CG: 3.9

Johns Hopkins Lung Project (1973)

10,387Male smokers age ≥ 45yrs

CXR & sputum cytology DSG: 39 (0.75)

CxG:40 (0.78)

5 to 8 yr ff upDSG: 3.4CxG: 3.8

Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytology

L.L. Humphrey MD et al Ann Intern Med 2004;140:740-753

Study Sample Intervention Prevalencen (%)

Mortality rate per 1000 Person-Yrs

Memorial Sloan Kettering Study (1974)

10,040 Male smokers age ≥ 45yrs

CXR & sputum cytology DSG:30 (0.6)

CxG: 23 (0.46)

5 to 8 yr ff upDSG: 2.7CxG: 2.7

Czech Study (1975)

6,345 Male smokers 40-64 yrs

CXR 19 (0.30) 15 yr ff up

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.

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

Project name Enrolled Baseline Annual

Lung Cancer PrevalenceBaseline Annual

% of Stage I Survival Rate

ELCAP (1993- 1999)>60y, >10Pk-yr

10001184

2.9%0.6%

85%86%

Nagano, Japan(1996-1998)>40y, Pk-yr not req’d

5,4838,303

0.4%0.4%

100%86%

ALCA-NCC,Japan(1993 – 2000)>40y, Pk-yr not req’d

1,6117,891

0.9%0.3%

79%82%

5 yr OS baseline : 71%

Hitachi, Japan(2001 – 2002)>40 y Pk-yr not req’d

7,9565,568

0.5%0.1%

85%100%

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

Project name Enrolled Baseline Annual

Lung Cancer PrevalenceBaseline Annual

% of Stage I Survival Rate

Mayo Clinic (1999 – 2004)Age>50,Pk yrs >20, quit < 10 y

15204,472

2.0%0.8%

77%71%72%

Instituto Tumori, Italy(2000 – 2001)Age >50y,Pk yrs >20

1,035996

1.7%0.5%

100%85%

I-ELCAP(1993-2006)Age>40y, Pk yrs not req’d

31, 56727,456

1.3%0.3%

86% 10yr OS : 80%

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.

No major medical professional organization currently recommends

screening for lung cancer

Alternatives to Lung Cancer

Screening ?????

National Smoking Prevalence Study

Research & 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%

21 February 2008

1 Unweighted data for the sample of responders

Manila, Philippines Prevalence of ever smoking in population1 ages >40 by

sex

Men Women83% 31%

Overall = 55%

Philippine BOLD Study . AS Buist et al, The Lancet 2007, Vol 370 pp 741 - 50

Cigarette Smoking Among Hospitalized Patients in Metro Manila

JCAlonzo 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.

Attitudes & Beliefs of Smokers

More than half of population thought seriously about quitting.2.5-3x serious attempts to quit – Urban group1 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

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

Teaching Lung Cancer Prevention to the Filipinos: an Inter-Agency Collaboration

Department 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.

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.

Documents

Early Detection of Lung Cancer & Beyond