Expert Calls Screening to the Forefront in Lung Cancer

Robert Jotte, MD, PhD

If physicians incorporated routine lung cancer screening into clinical practice, at least 40,000 lives could be saved annually, according to Robert M. Jotte, MD, PhD.

“If [screening] were to become a topic that's discussed akin to cholesterol or hypertension, those percentages of screening would go up tremendously,” said Jotte, medical director and co-chair of the USON Thoracic Committee at Rocky Mountain Cancer Centers. “If we institute screening, we can cure a lot more patients of early-stage lung cancer than we could if they presented at later stages.”

In the National Lung Screening Trial (NLST) screening with low-dose CT indicated a reduction in mortality from lung cancer. In the trial, 53,453 patients at high-risk for lung cancer were randomized to 3 annual screenings with low-dose CT or single-view posteroanterior chest radiography. Results showed a 20% relative reduction in lung cancer mortality with the use of low-dose CT (95% CI, 6.8-26.7; P = .004).¹

Still, screening remains at an all-time low, said Jotte, who noted that taking the time to educate patients and providers, as well as invest in resources to detect high-risk patients, can improve lung cancer outcomes.

An analysis presented at the 2018 ASCO Annual Meeting showed that 1.9% of more than 7.6 million current and former heavy smokers in the United States underwent lung cancer screening in 2016, suggesting that it remains inadequate despite recommendations from the United States Preventive Services Task Force.²

OncLive: What should be known about screening in lung cancer?

In an interview during the 2018 OncLive^® State of the Science Summit^TM on Advanced Non—Small Cell Lung Cancer, Jotte addressed the underutilization of lung cancer screening in the United States and the importance of multidisciplinary management in improving patient outcomes.Jotte: The NLST was a large trial that [screened] over 53,000 patients for lung cancer and followed them for lung cancer—specific outcomes with low-dose spiral CT versus chest x-ray. We found that the incidence of lung cancer detection was much greater with the low-dose CT scan.

Equally important was patient outcomes. If those patients had their lung cancers identified, they tended to be earlier-stage cancers. [These are] much more amenable to surgical resection and therefore show much higher outcomes in terms of overall survival (OS). Several years ago, it became a new standard of care to screen patients with CT scans if they met the appropriate criteria based on age and smoking history. These kind of constituted their risk factors.

Why is there such a low rate of screening?

How does shared decision-making factor into it?

Unfortunately, a very high percentage of diagnoses correlate with disease-specific survival and death with regard to lung cancer. If we instituted screening, we could save a tremendous number of lives in the United States alone, let alone globally. The statistics I talked about were more here in the United States. The equivalence of over 40,000 [lives] could be saved per year just by instituting screening and getting patients the operating room rather than getting them to the intravenous chemotherapy chair.The reason why there is such a low rate of screening, as presented in the 2018 ASCO Annual Meeting, is a result of multiple factors. The primary reason is that the topic just isn't being brought up. I see it in my office all the time. Many primary care providers are expected to wear so many different hats. They have to take care of so many different problems, and lung cancer screening is yet another thing that has to be mentioned in a relatively brief office visit. You have to prioritize what the immediate risk to the patient is. It's sometimes hard for us to focus on those risks that are down the road.There are specific criteria that we follow called the Fleischner criteria, and those criteria have recently been updated. The whole purpose of those criteria is to minimize unnecessary invasive procedures and maximize the detection rate. Therefore, if someone comes in we can identify a solitary pulmonary nodule as early lung cancer.

Radiologists will allude to those criteria in their radiology reports in terms of who needs to be worked up and who needs to be biopsied. It's a shared decision-making process that takes place between the provider and the patient so that the patients understand what all those things are.

Have any studies addressed the areas of the United States with better screening rates and examined what those programs look like?

How often should a patient be screened?

[In the 15 minutes we’ve talked, a patient is expected to] disclose all their problems, address those problems, [and take] a couple minutes to discuss a risk that may never materialize. For the patients in whom it does materialize, it can be lifesaving.The abstract that I presented broke down the United States into 4 geographic areas. The Northeast had a higher rate of screening, but that rate is still only 4%. The lowest rate was out here in the West at 1%. Clearly, there is a tremendous amount of opportunity to offer patients more screening.That is a gray box. Nobody knows what to recommend in terms of the frequency of screening. When someone institutes a screening program, a lot of patients will come in at once. There are the patients whose CT scan at that time was negative, but 2 years from now might turn positive. That might be the one patient whom you can capture and operate on early so that they have that improvement in OS, despite their diagnosis. The problem is that once patients get screened and find that they’re OK, they think they don’t have to be screened anymore. You lose a lot of those patients in the screening process that should continue down the road.

Have any other trials addressed the use of screening?

What is the key takeaway?

We don't have any specific recommendations as to how often someone should get a CT scan. Should they have once a year, every 2 years, 3 years, 5 years, etc.? For example, if someone has identified an abnormality, such as a solitary pulmonary nodule, that's where those Fleischner criteria come into play. The criteria are used to capture those patients who are potentially going to develop a lung cancer versus those who have benign etiologies.Multiple trials have looked at the use of screening. Many of them looked at chest x-rays versus best supportive care. In other words, they follow patients normally; if they have a symptom then they send them for imaging. The NLST was one of the largest studies that was very well done with controlled follow-up. That's the most substantial data we have to date, which is why that led to the implementation of screening with low-dose CT scans.The key takeaway is that we need to be doing a much better job of screening our smokers and our high-risk patients, so those patients will never have to have the topic of chemotherapy, immunotherapy, or all the other topics that were presented in the program. There are a lot of barriers, but the key piece is how poorly we are doing as a medical group in terms of screening high-risk patients.

What is the importance of multidisciplinary lung cancer management?

As far as a multidisciplinary approach to lung cancer, the data out there certainly have a strong leaning toward improved outcomes, improved use of therapy modalities such as radiation, and implementation of chemotherapy. If we treat patients as a team as opposed to as individuals, those patients' outcomes are likely to be much better.There are a whole host of physicians. There is the medical oncologist like myself, but you also have surgeons, radiologists, pathologists, and radiation oncologists. You can also include other disciplines, like social workers, financial counselors, physical therapists, occupational therapists, and nutritionists. All of these people can help play a role in the management of these patients and can potentially improve their quality of life and maybe even their OS.

If someone is followed or presented in a multidisciplinary clinic or tumor board, are their outcomes any different than someone who sees a physician who tells them which direction to go? The data suggest that there are certainly some advantages of going through a multidisciplinary clinic. There are also some caveats. Just because a patient gets presented, that doesn't mean that someone is following up on how that patient should be managed. You need to have an administrator or somebody that has taken that responsibility. If our recommendation is A, B, and C, someone needs to make sure that that that patient does indeed get recommended and follows through on A, B, and C. Then, that multidisciplinary approach might start showing improvements in patient outcome data.

References

1. The National Lung Cancer Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi: 10.1056/NEJMoa1102873.
2. Pham D, Bhandari S, Oechsli M, et al. Lung cancer screening registry data reveals very low screening rate. J Clin Oncol. 2018;36 (suppl; abstr 6504).