Clinician-to-Clinician Update Clinician-to-Clinician Update

New Therapies and Screening Efforts Improve Lung Cancer Outcomes

April 2018

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— Low-dose computed tomography screening has been demonstrated to help reduce lung cancer mortality by 20%. Photo alvarez©iStock.

Lung cancer is the most common cause of death from cancer in the United States. An estimated 234,030 cases of lung cancer will occur in 2018, with 154,050 deaths.1 Lung cancer has multiple subtypes but is currently categorized into non-small cell lung cancer (NSCLC) and small-cell lung cancer (SCLC). NSCLC constitutes about 80% to 85% of cases and begins as a slow-growing tumor that eventually metastasizes.2 SCLC makes up the remainder of cases and spreads rapidly during its initial stage. Because NSCLC does not present with symptoms until later stages of the disease, screening measures are important for early detection and effective therapy.2,3

More than 80% of the deaths from lung cancer are attributed to tobacco use, mostly cigarette smoking.1,3 Among risk factors examined, cigarette smoking is the most prevalent, appearing in the highest proportion and number of cancer cases (23.6% of cases in men; 14.5% in women).3 Key measures in preventing or reducing the impact of lung cancer include helping patients avoid smoking, encouraging tobacco-cessation programs, and implementing screening programs for current or previous smokers.

The National Lung Screening Trial and studies at academic medical centers have demonstrated that, compared against standard radiography, low-dose computed tomography screening reduces lung cancer mortality by 20% in high-risk patients.4,5,6 The U.S. Preventive Services Task Force now recommends such annual screening for high-risk individuals: those 55 to 80 years old who have a 30-year history of smoking a pack a day and who smoke currently or who have quit within the past 15 years.6

Smoking-cessation interventions are key to maximizing the value and benefit of lung cancer screening.7,8 The University of Minnesota Health lung screening program, recognized as a center of excellence by the Lung Cancer Alliance, couples its screening services with smoking-cessation programs. One of its interventions, Tobacco Longitudinal Care (TLC), has been shown to be effective in promoting smoking cessation. The program provides counseling and nicotine replacement for 1 year. Because cessation efforts may require multiple attempts and different methods before being successful, the University of Minnesota Health program clinicians are investigating the optimal sequence of therapies. Using a sequential, multiple assignment, randomized trial format, the study will allow researchers to compare the results of different adaptive interventions. The trial is tied to the screening program and focuses on whether TLC can be further strengthened by the addition of medication therapy management (prescribed bupropion or varenicline).

Early detection of cancer provides greater likelihood of effective therapy. New treatments, however, are also emerging for patients with early or advanced lung cancers. Therapies vary depending on disease type and stage.9,10 Early-stage NSCLC can be treated with surgery, stereotactic body radiation therapy, or radiofrequency ablation. Early-stage patients with high-risk features should have adjuvant chemotherapy.9,10 In later-stage cancer patients, chemotherapy currently produces only a 15% to 30% response rate; however, immunotherapy (for example, with checkpoint inhibitors) can improve outcomes in some patients.11 Patients with SCLC and clinically limited stage cancer can have chemoradiation.10 Additional trials are underway to assess additional immunotherapeutic agents and food-based chemoprevention. (See Case Study and Specialty Updates.)

References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin. 2018;68(1):7-30.

2. Zappa C, Mousa SA. Non-small cell lung cancer; current treatment and future advances. Transl Lung Cancer Res. 2016;5:288-300.

3. Islami F, Sauer AG, Miller KD, et al. Portion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin. 2018;68(1):31-54.

4. Ahmed A, Verma N, Barreto I, Mohammed TL. Low-dose lung cancer screening at an academic medical center: initial experience and dose reduction strategies. Acad Radiol. 2018 Jan 30; pii: S1076-6332(18)30005-9. DOI: 10.1016/j.acra.2017.12.023 [Epub ahead of print]

5. Begnaud A, Hall T, Allen T. Lung cancer screening with low-dose CT: implementation amid changing public policy at one health care system. Am Soc Clin Oncol Educ Book. 2016;35:e468-475.

6. Moyer VA, U.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5)330-338.

7. Villanti AC, Jiang Y, Abrams DB, Pyenson BS. A cost-utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions. PLOS ONE. 2013;8(8):e71379. doi.org/10.1371/journal. pone.0071379

8. Tanner NT, Kanodra NM, Gebregziabher, M, et al. The Association between Smoking Abstinence and Mortality in the National Lung Screening Trial. Am J Respir Crit Care Med. 2016 March 1;193(5):534-541.doi: 10.1164/ rccm.201507-1420OC.

9. National Cancer Institute. Non-small cell lung cancer treatment (PDQ®). 2018. https://www.cancer.gov/types/lung/hp/non-small-cell-lung-treatment-pdq. Accessed February 22, 2018.

10. National Cancer Institute. Small cell lung cancer treatment (PDQ®). 2018. https://www.cancer.gov/types/lung/hp/small-cell-lung-treatment-pdq. Accessed February 22, 2018

11. Cho J. Immunotherapy for non-small cell lung cancer: current status and future obstacles. Immune Netw. 2017;17(6):378-391.

​When to Refer

Lung cancer screening is recommended for individuals 55 to 80 years of age who have smoked a pack or more per day for 30 years and who are currently a smoker or have quit within the last 15 years. High-risk patients who undergo annual screening can reduce their risk of death by about 20%.

Certified as a lung cancer screening center, the University of Minnesota Health lung imaging program is recognized by the Lung Cancer Alliance as one of the only screening centers of excellence in Minnesota. Screening is performed by specially trained radiologists using special low-dose X-ray technology. Lung screening is covered for qualified patients through public and private insurance providers. (Medicare covers patients 55 to 77 years of age.)

Screening detects nodules that may be cancerous and helps determine what additional tests or procedures are required. More than 97% of nodules are not cancerous and can be caused by infections or scar tissue. About 25% of screenings find something that requires additional evaluation.

Our treatment team of pulmonologists, radiologists, clinical nurse specialists, and other staff members facilitate treatment. Lung nodules with suspicious features are assessed by specialists in our Lung Nodule Program. University of Minnesota Health physicians can suggest appropriate treatment options in consultation with the patient and their primary care physicians.

To refer for lung screening, call 855-486-7226

Physician Outreach Program

To schedule a physician meeting or to visit our facility, contact Melinda Tuma, System Manager, Outreach Services at 612-273-9947 or marvold1@fairview.org.

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