1. The Case for Lung
Cancer Screening
Kimberly Ann Luse, Ed.D, RT(R)

2. My Background
 Born and raised in Newport, Kentucky
 Began smoking in high school
 Stopped smoking when I became pregnant with my first of four
children in 1984
 Became a Radiologic Technologist in 1985
 Had a partial lung resection in 2000 after discovering a mass that was
thought to be malignant

3. Dense Material Ahead!

4. Background
 Lung Cancer is the leading killer of all cancers combined
 There has been evidence of the connection between smoking and lung
cancer than goes back four decades
 Smoking cessation programs and efforts have increased
 Lung Cancer screening needs to catch up to the evidence

5. Raising Awareness
 February: Go Red For Women
 October: Go Pink For Women
 November: No Shave November
 What month represents Lung Cancer Awareness?
 November!

6. The High Fatality Rate is Staggering
 The Center for Disease Control and Prevention lists the following on
their cancer statistics webpage, referencing 2010:
 201,144 people in the United States were diagnosed with lung cancer,
including 107,164 men and 93,980 women
 158,248 people in the United States died from lung cancer, including
87,698 men and 70,550 women

7. LOTS and LOTS of Acronyms Ahead!

8. More Context
 The surgeon general first exposed the link between smoking and lung
cancer in a report that was released in 1964
 Lung cancer is prevalent not only in the United States, but worldwide,
with particular elevations in third world countries
 The International Agency for Research on Cancer estimated 1.6 million
new diagnoses in 2008 of lung cancer worldwide which translates into
12.7% of new manifestations of all cancers worldwide
 Until a former smoker is past fifteen years smoke-free, they are
considered to be at approximately the same risk factor as patients
who are currently smoking

9. NCCN and USPSTF
 The National Comprehensive Cancer Network (NCCN) is a
collaboration of twenty-five highly regarded cancer centers
 They routinely issue consensus-based clinical practice guidelines on
how to most effectively diagnose and treat various forms of cancer
 NCCN has recommended screening for high risk individuals but only
recently has any momentum begun
 The United States Preventative Services Task Force (USPSTF) helped
move the fight forward in July 2013, endorsing low-dose CT screening
for those at the highest risk of developing lung cancer

10. ELCAP
 The Early Lung Cancer Action Program (ELCAP) is an organization formed in
1992, consisting of a group of physicians from Cornell University Medical
Center and other specialists to establish research parameters to positively
impact lung cancer detection
 This design utilized both chest radiography and low-dose chest CT
 Baseline scanning was established followed by repeat annual screening
 This research forged the way for others to build upon
 ELCAP was scrutinized for not randomizing the trial

11. NCI and NLST
 The National Cancer Institute (NCI) funded a randomized trial in 2002
 The National Lung Screening Trial (NLST) enrolled 53,454 patients
identified to be high risk for lung cancer between 2002-2004
 Clinical trial participants were randomly assigned to undergo three
annual screening with either low-dose chest CT (26,722) or single-
view PA chest radiography (26,732)
 Data was collected through 2009
 Researchers found a 20% reduction in deaths from lung cancer among
current or former heavy smokers who were screened with low-dose
helical CT vs. chest X-rays

12. Significance of the NLST
 20% decrease in mortality from lung cancer was documented in the
low-dose chest CT group when compared with the group that received
only chest X-Rays
 Official endorsement for low dose CT screening for lung cancer by:
The National Comprehensive Cancer Network, The International
Association for the Study of Lung Cancer, The American Cancer
Society, The American Lung Association, The American Thoracic
Society, The American College of Chest Physicians and The American
Society of Clinical Oncology occurred as a result

13. I Mustache You a Question

14. True or False?
True
 As early as 2007, data
demonstrated less than 7% of lung
cancer was cured in patients
 In Stage I, survival rates are
greater than 90% for patients,
especially if the tumors are equal
to or greater than 10%
 The combined mortality rate for all
stages of lung disease is 90%
False
 Contact with radon is not an
indication for early screening
 A history of other types of cancer
does not influence a patient’s
likelihood of developing lung
cancer
 Research groups have come to
consensus on what constitutes risk
factors for inclusion in low dose CT
screening for detection of lung
cancer

15. Recommended Risk Factors Include:
 Tobacco smoking
 Contact with radon
 Contact with asbestos or other cancer-causing agents
 History of other cancer(s)
 Family history of lung cancer/other lung diseases
 Contact with second hand smoke
 Patients greater than 50 years old and greater than 20 pack years
 Regular exposure to second hand smoke

16. Pack Years?
 “Pack Years” is defined by the number of packs of
cigarettes smoked times the number of years the patient
has smoked, for example having smoked more than one
pack of cigarettes a day for thirty years, or two packs of
cigarettes a day for fifteen years would be translated as
“30 pack years”

17. Five Points for Consideration

18. Confounding Factors
 Participants are still impacted by the stigma associated with lung
cancer due to smoking
 Patients in the lower socio-economic ranks may not have access to the
education necessary to participate or the monetary ability to do so
 Lack of consensus about what inclusion criteria to follow has fueled
the argument against the screening with low-dose CT
 Participants who develop a secondary illness are disqualified
 High rate of false positives leading to unnecessary follow up
procedures

19. Major Progress from the Centers for Medicare
and Medicaid Services February, 2015
 Decision Memo for Screening for Lung Cancer with Low-Dose CT

20. CMS Criterion
 Age 55-77 years
 Asymptomatic
 Tobacco smoking history of at least 30 pack years
 Current smoker or someone who has quit within the last 15 years
 Receives a written order for LDCT lung cancer screening

21. Indirect Benefits of Screening
 Lung cancer screening programs serve as an entry point to other
services that generate revenue for the hospital system
 Patients with a positive lung screening will require further evaluation
in the form of more imaging or surgical services for biopsy
 Patients diagnosed with lung cancer will additionally require some
combination of surgical, oncology, and radiation oncology services
depending on the stage of the cancer
 Screening programs can assist the health system in building strong
relationships within their neighborhoods

22. What is Your Why?

23. REFERENCES
1. Lung Cancer Alliance; www.lungcanceralliance.org.
2. Humphrey LL, Deffebach M, Pappas M, Baumann C, Atis K, Mitchell JP, Zaker
B, Rogwei F, Slator, CG. Screening for lung cancer with low-dose computed
tomography. Annals of Internal Medicine. July 2013; www.annals.org.
3. Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen
IF, Gatsonis C, Marcus PM, Sicks JD. Reduced lung-cancer mortality with low-
dose computed tomographic screening. New England Journal of Medicine.
2011; 365: 395-409.
4. Moyer VA. Benefits and harms of computed tomography lung cancer
screening strategies. Annals of Internal Medicine. December 2013;
www.annals.org.
5. Henschke CI, Yankelevitz DF, Smith JP, Miettinen OS, ELCAP GROUP.
Screening for lung cancer: The early lung cancer action approach. Lung
Cancer. 2002; 35(2): 143-148.
6. Henschke CI, Yankelevitz DF. CT screening for lung cancer: Update 2007.
The Oncologist. 2008; 13: 65-78.
7. Tavernise S. Task force urges scans for smokers at high risk. The New York
Times. July 29, 2013.
8. Sox HC. Better evidence about screening for lung cancer. The New England
Journal of Medicine. 2011; 365: 455-457.
9. Henschke CI, Altorki N, Farooqi A, Hess J, Libby D, McCauley DI, Pasmantier
MW, Reeves AP, Smith JP, Vazquez M, Yankelevitz DF, Yip R, Zhang L, Agnello
K, Ostroff J, Miettinen OS. Computed tomographic screening for lung cancer:
Individualizing the benefit of the screening. European Respiratory Journal.
2007; 30: 843-847.