CT Screening for Lung Cancer: International Early Lung Cancer Action Program.
Journal club lung cancer screening
-
Upload
ranjita-pallavi -
Category
Health & Medicine
-
view
94 -
download
3
description
Transcript of Journal club lung cancer screening
![Page 1: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/1.jpg)
JOURNAL CLUBRanjita Pallavi MD and Josef Bautista MD
Critical Appraisal of a Guideline
![Page 2: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/2.jpg)
THE AMERICAN ASSOCIATION FOR THORACIC SURGERY
Guidelines for Lung Cancer Screening using Low-dose
Computed Tomography Scans for Lung Cancer Survivors and other
High-risk groups
![Page 3: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/3.jpg)
Lung Cancer Screening
• Nine million US adults should get a yearly low-dose CT yearly until age 79
• This translates to $ 27 billion dollars of yearly healthcare cost for lung cancer screening alone
![Page 4: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/4.jpg)
The AATS Guideline
The AATS Guideline was developed by a 14-member task force and was based from the result of the NSLT trial and the current NCCN guidelines.
![Page 5: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/5.jpg)
OVERVIEW
• The potential benefits of a guideline are only as good as the quality of the guidelines themselves
• The quality of guidelines can be extremely variable and some often fall short of basic standards
• The AGREE instrument was developed to address the variability in guideline quality
![Page 6: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/6.jpg)
THE AGREE II INSTRUMENT
![Page 7: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/7.jpg)
The AGREE II Instrument
![Page 8: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/8.jpg)
GUIDELINE CONTENT
![Page 9: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/9.jpg)
NOMENCLATURE AND DESCRIPTION FOR RATING GUIDELINE RECOMMENDATIONS
![Page 10: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/10.jpg)
STRENGTH OF RECOMMENDATIONS AND LEVEL OF EVIDENCE FOR THE CLINICAL PRACTICE GUIDELINE
![Page 11: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/11.jpg)
TIER 1 GUIDELINE recommendations
• Guideline for Highest Risk Population
• Annual screening beginning age 55 for smokers and former smokers with 30-pack-year history (1a)
• Annual Screening may continue until age 79 (1a)
• Low-dose CT is the screening technology to be used (1a)
• CXR alone should not be used (1a)
• Exclusion: individuals who cannot be offered adequate treatment based on comorbidity or functional status, regardless of age (not graded)
![Page 12: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/12.jpg)
Tier 1 AlgorithmA
ge 5
5-7
9 a
nd
> 3
0
pack y
ear
No lung nodule
Annual LDCT up to
age 79
Solid nodule See Figure 3
Ground glass
opacity
See Figure 4
![Page 13: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/13.jpg)
TIER 2 GUIDELINE recommendations
• Guidelines for lung cancer survivors and patients with combined risk
• Annual screening for those treated for a primary lung Ca + completed 4 years of radiographic surveillance without evidence for recurrence (2b), or
• patients aged 50-79 years with a 20-pack-year smoking history + cumulative risk of developing lung Ca > 5% over the following 5 years (3)
![Page 14: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/14.jpg)
Tier 2 Algorithm
Lu
ng
Ca S
urv
ivor;
Ag
e >
50
an
d >
20 p
ack y
ears
an
d
Ad
ded
ris
k >
5%
of
develo
pin
g C
a w
ith
in 5
years
.
No lung nodule Annual LDCT up to age 79
Solid nodule See Figure 3
Ground glass nodule See Figure 4
![Page 15: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/15.jpg)
Management of LDCT Findings
Solid nodule
<4 mm
Annual LDCT screening to age
79
4-6 mm
LDCT in 6 mo
>6-8 mm
LDCT in 3 mo
No increase
LDCT in 6 mo
No increase
Annual LDCT
Increase
Referral to specialists
Increase
Surgery
>8 mm
Cosider PET-CT
Low suspicion High suspicion
Surgery
Solid Endobronchial
Bronchoscopy
![Page 16: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/16.jpg)
Management of LDCT FindingsGround Glass
Nodule
< 5 mm
Stable
Annual LDCT until age 79
5-10 mm
LDCT in 6 mo
Stable
Annual LDCT until age 79
Suspicious change
Surgical excision
No lung cancer
Lung cancer
> 10 mm
LDCT in 3-6 mo
Suspicious change
Stable
LDCT 6-12 mo or Biopsy or Surgery
![Page 17: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/17.jpg)
Management of LDCT FindingsNew nodule at
annual or followup LDCT
No suspected infection or
inflammation
Solid nodule
Ground glass nodule
Suspected infection or
inflammation
LDCT in 1-2 mo
Resolving
Radiographic follow-up to resolution
Resolved
Annual LDCT until 79
Persistent or enlarging
PET/CT
Suspicious of Ca
Surgical excision
No lung Ca
Annual LDCT until 79
Lung Ca
Biopsy
No lung Ca
Annual LDCT until 79
Lung Ca
Low suspicion
LDCT in 3 mo
![Page 18: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/18.jpg)
APPRAISAL OF THE GUIDELINEACCORDING TO THE AGREE II
TOOL
![Page 19: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/19.jpg)
Scope and Purpose
• Is there a utility for the use of low-dose CT scan as a lung cancer screening strategy for:
• high risk individuals defined as > 55 yo with > 30 pack years of smoking history
• lung cancer survivors
• 50-79 years with a 20 pack year smoking history and other factors producing a cumulative risk of developing lung cancer that is 5% or more over the following 5 years.
![Page 20: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/20.jpg)
Scope and purpose
Rating: 80%
• The scope and the purpose were clearly stated
• The target population was clearly identified
• However, the expected benefits for the target population were not explicitly stated in a measureable way
• No specified way to measure cumulative smoking risk
![Page 21: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/21.jpg)
Stakeholder Involvement• The guideline was developed by a 14-member committee.
• The task force was composed of thoracic radiologists, oncologists, thoracic surgeons, medical oncologists, a pulmonologist, an epidemiologist and a pathologist.
• The guideline mainly evolved from a well-designed single national trial, which was carried out according to a rigid protocol, without seeking views and opinions from the target population
![Page 22: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/22.jpg)
Stakeholder Involvement
Rating: 30%
• There was no mention of the institutions where the task force members came from, and the geographical location that developed the guideline.
• No involvement of the primary care physician in the development guideline
• No participation of the target group in the development of the guideline
![Page 23: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/23.jpg)
Rigour of Development
• The guideline was based on the NLST and the current NCCN guideline
• It referenced 16 articles
![Page 24: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/24.jpg)
Rigour of DevelopmentRating: 50%
• No other relevant literature was presented
• There is no explicit link between the recommendations and the evidence.
• There was no statement regarding the harm of the procedure or the financial aspect of it
• No sufficient description of the external validation of the guideline
• No statement on possible update of the guideline was present
![Page 25: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/25.jpg)
Clarity of Presentation
Rating: 81%
• The recommendations are specific and unambiguous
• Other options for management were not directly considered
• Specific algorithms for different CT findings were defined
![Page 26: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/26.jpg)
ApplicabilityRating: 35%
• Specific algorithm on different lung findings were presented
• The guideline did not identify barriers or facilitators of the implementation process
• No potential resource implications were considered
• There were no monitoring or auditing criteria defined
![Page 27: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/27.jpg)
Editorial Independence
Rating: 63%
• Funding body was clearly stated
• No description of competing interests
![Page 28: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/28.jpg)
GLOBAL APPRAISAL
• The overall quality of the guideline was moderate.
![Page 29: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/29.jpg)
DISCUSSION
![Page 30: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/30.jpg)
Basis of Tier 1 Recommendations
The National Lung Cancer Screening Trial
![Page 31: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/31.jpg)
Main Objective
• NLST compared two ways of detecting lung cancer: low-dose helical computed tomography (CT) and standard chest X-ray, to see if CT screening could reduce lung cancer specific mortality relative to chest X-ray.
![Page 32: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/32.jpg)
Design• Participants were randomized to 3 annual screens with either low-dose
helical CT or single-view chest X-ray
• Multicenter, parallel-group, randomized, control trial
• N = 53,454 adults at high risk for lung Ca
• LDCT n = 26,722
• CXR n = 26732
• Setting: 33 centers in the US
• Enrollment: 2002-2004
• Analysis: Intention-to-treat
• Follow-up: Median 6.5 ( 3.5 year no-intervention followup)
![Page 33: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/33.jpg)
Inclusion and Exclusion Criteria• Inclusion:
• 55 to 74 years of age
• Cigarette smoking history of at least 30 pack-years
• Former smokers must have quit within the past 15 years.
• Exclusion:
• Lung Cancer
• Chest CT in prior 18 months
• Hemoptysis
• Unexplained weight loss of > 15 lbs in prior year
![Page 34: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/34.jpg)
Population• Age: Race:
• 55-59: 42.8% White 90.9%
• 60-64: 30.6% Black: 4.5%
• 65-69: 17.8% Hispanic: 1.8%
• 70-74: 8.8%
• > 74: <0.1%
• Sex: Smoking Status:• Males: 59% Current 48.1%
• Females 41% Former: 51.9%
![Page 35: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/35.jpg)
Outcomes• Primary Outcomes:
• Lung cancer deaths: 247 vs 309 per 100,000 person-years (RR 0.80; 95% CI 0.73-0.93; p=0.004)
• Secondary Outcomes:
• All-cause mortality: 1877 vs 2000 deaths (RR 93.3; 95% CI 1.2-13.6; p=0.02)
• Lung cancer incidence: 645 vs 572 per 100,000 person-years (RR 1.13; 95% CI 1.03-1.23)
![Page 36: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/36.jpg)
Outcomes
• Positive result: Not cancer: Cancer diagnosis:
T0 27.3% vs. 9.2% 10.2% vs. 3% 3.8% vs. 5.7%
T1 27.9% vs. 6.2% 6.1% vs. 1.8% 2.4% vs. 4.4%
T2 16.8% vs. 5.0% 5.8% vs. 1.5% 5.2% vs. 5.5%
![Page 37: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/37.jpg)
Outcomes
![Page 38: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/38.jpg)
Adverse Events
• Complications following any invasive diagnostic interventions where lung cancer confirmed:
• Any complication: 28.4% vs 23.3%
• Complications following any invasive diagnostic interventions where lung cancer NOT confirmed:
• Any complication 0.4% vs 0.3%
![Page 39: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/39.jpg)
Discussion• Number needed to screen with LDCT is 320 to prevent 1
cancer death
• Good overall internal validity:
• Baseline characteristics were similar for both study groups
• Mixed external validity:
• The LDCT were read by highly trained radiologists
• Population screened was younger and had higher education
• High false-positive rate:
• Problem with overdiagnosis:
• In theory there should be the same number of lung cancers in both arms after followup. But the LDCT group had a persistent gap of 120 excress lung cancers
![Page 40: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/40.jpg)
High Risk Population
Why 79 years?
•Peak incidence of lung cancer :70 years in US
•Average life expectancy currently at 78.6 years
•Age alone is a risk factor: Incidence increases linearly with age
Age > 79 years with good functional status
Why annual screening beyond 3 years?
![Page 41: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/41.jpg)
Lung cancer survivors
• Patients treated for primary bronchogenic carcinoma+4 years of radiographic surveillance+No recurrence(level 3)
• HRCT obtained for 4 yrs after resection of stages IA to IIIA NSCLC foll. By annual LDCT screening starting in 5th yr.
• LDCT screening continue lifelong(funcional status+ pulmonary reserve present)
• These pts have continuing 3% risk of lung cancer diagnosis each year.
![Page 42: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/42.jpg)
Patients with combined risk
• 50-79 yrs with 20 pack-year smoking history+cumulative risk of > 5% over 5 years(similar to NCCN)(level 2)
a) COPD (FEV1<70%)
b) Environmental/Occupational exposure: Asbestosis, Silicosis, Radon
c) Prior cancer/Thoracic Radiation therapy(Radiation risks are linear with dose, risk begins after 2 decades)
d) Genetic/Family history
• Risk calculators: To help with self assessment of risk
a) Liverpool Lung Project Model for individual absolute 5 year risk
b) Prostate,Lung,Colorectal and Ovarian Screening trial: 9 yr probability
![Page 43: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/43.jpg)
LLP Model
![Page 44: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/44.jpg)
PLCO Model
![Page 45: Journal club lung cancer screening](https://reader036.fdocuments.us/reader036/viewer/2022081413/548f5a3cb4795977538b46c3/html5/thumbnails/45.jpg)
CONCLUSION• The guideline aimed to extend the use of NSLT results to
age 79 as extrapolated from the results of the study
• Based on our assessment using the AGREE tool, the guideline is modest in quality
• The guideline recommendations are clearly stated and specific
• There is lack of emphasis on the potential risks of the uncontrolled screening strategy in the general population.
• The rate of false positives and over-diagnosis must be addressed in subsequent updates.
• We feel that the screening strategy be offered with utmost care and only to high-risk individuals