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Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012.

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Presentation on theme: "Www.Lahey.org/LungScreening 1-855-CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012."— Presentation transcript:

1 CT-CHEST Andrea McKee, M.D. Chairman Department Radiation Oncology Sophia Gordon Cancer Center Lahey Clinic May 15, 2012

2 CT-CHEST Disclosures None

3 CT-CHEST Outline Lung Cancer Background Incidence/Mortality National Lung Screening Trial (NLST) National Comprehensive Cancer Network (NCCN) Lung Cancer Screening at Lahey Clinic Program Structure Structured Reporting – LUNG-RADS Classification System Challenges Rescue Lung, Rescue Life

4 CT-CHEST Lung Cancer Incidence/Mortality: US Number one cause of cancer-related death in the US and World Kills more women than Breast, Ovarian, and Uterus Cancer Combined 200K new cases/yr 160K deaths/yr

5 CT-CHEST Risk Factors?

6 CT-CHEST Tobacco Trends History of tobacco use – <20% in 2006 – 42% in 1965 – Demonization campaign Higher prevalence – Military (1 in 3) vs (1 in 5) – Less educated Higher risk – Rescue workers – Occupational exposure

7 CT-CHEST Tobacco Trends Competition has been tough - tobacco industry, Hollywood, press Guard against withholding of health care services or advocacy based on social history – slippery slope

8 CT-CHEST Lung Cancer Incidence/Mortality: US Primary Prevention (Smoking Cessation) Success Decreased number of overall lung cancer deaths in US Despite success 160K still die every year from lung cancer Most people who die from lung cancer now are FORMER SMOKERS

9 CT-CHEST Lung Cancer Incidence/Mortality: US Primary Prevention (Smoking Cessation) Success Decreased number of overall lung cancer deaths in US Despite success 160K still die every year from lung cancer Most people who die from lung cancer now are FORMER SMOKERS 35% of Lung Cancer Diagnosis Current Smokers 50% of Lung Cancer Diagnosis Former Smokers 15% of Lung Cancer Diagnosis Never Smokers Lung Cancer 5-Year Overall Survival Remains Unchanged %, Current 15%

10 CT-CHEST Lung Cancer Incidence/Mortality: US Primary Prevention (Smoking Cessation) Success Decreased number of overall lung cancer deaths in US Despite success 160K still die every year from lung cancer Most people who die from lung cancer now are FORMER SMOKERS Lung Cancer 5-Year Overall Survival %, Current 15% Stagnant survival result of absent Secondary Prevention FORMER SMOKERS cannot benefit from PRIMARY PREVENTION Secondary Prevention = LUNG SCREENING LUNG SCREENING Find disease at early more treatable stage LUNG SCREENING GOAL Decrease Mortality not Incidence

11 CT-CHEST Lung Cancer Screening Data to support screening been around awhile NEJM October 2006 – 31,567 patients baseline screened with low dose CT from – 484 lung cancers detected (85% clinical stage I) – 10 year survival 92% for those having surgery – 8 patients refusing therapy died within 5 years of diagnosis

12 CT-CHEST Lung Cancer Treatment NSCLC: Unscreened Population NSCLC Stage I, II, IIIA – Potential Cure Surgical resection Radiotherapy Chemotherapy Stage IIIB/IV – Palliative Goldstraw P, Crowley J, Chansky K, et al. (2007) The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2:706–714.

13 CT-CHEST National Lung Screening Trial Results: Stage Shift

14 CT-CHEST Stage IV NSCLC <1% = 5 year OS

15 CT-CHEST Incidental Finding on CXR 58% 5-year Overall Survival Stage T1BN0 Goldstraw P, Crowley J, Chansky K, et al. (2007) The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2:706–714.

16 CT-CHEST Annals of Internal Medicine October year-old female with a history of well-controlled hypertension presents for routine follow-up. She is asymptomatic and feels well. She has jogged 3 miles 3 times weekly for years with no recent change in exercise tolerance. She has a 30 pack-year history of tobacco use but quit 10 years ago. Normal physical exam. She read a recent study that found a benefit to screening with LDCT and inquires if this is appropriate for her? What should you recommend?

17 CT-CHEST Secondary Prevention Preclinical Diagnosis: Screening Awareness What is this patients 5-year overall survival? 5mm nodule 6 month fu diagnostic CT recommended 7mm NSCLC treated with lobectomy and nodal evaluation T1aN0 (screened)

18 CT-CHEST Secondary Prevention Preclinical Diagnosis: Screening Awareness 92% = 5 year OS

19 CT-CHEST Secondary Prevention Preclinical Diagnosis: Screening Awareness Asymptomatic Screening Stage I 92% 10-year OS 85% of patients in screened population have stage I lung cancer 58% 5-year OS Stage IV 1% 5-year OS Symptomatic

20 CT-CHEST US Cancer Mortality Rates Secondary Prevention U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; Available at:

21 CT-CHEST US Cancer Mortality Rates Secondary Prevention PSA Mammography Colonoscopy U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; Available at:

22 CT-CHEST National Lung Screening Trial (NLST): 6/29/2011 National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395– 409.

23 CT-CHEST National Lung Screening Trial Design Overview Multicenter Randomized Controlled Trial – Sponsor: NCI Division of Cancer Treatment and Diagnosis – 33 US Screening Centers NCI Division of Cancer Prevention (LSS) American College of Radiology Imaging Network (ACRIN) $300,000,000 +

24 CT-CHEST National Lung Screening Trial Design Overview 53,456 participants Enrolled 2002 – 2004 Ages Greater than 30 pack-year smoking history Active or quit < 15 years Exclusions Metallic implants chest or back Treatment or evidence of cancer in previous 5 years History of lung cancer Prior lung resection except needle biopsy Home O2 requirement Symptoms: Hemoptysis, weight loss, treated respiratory infection within past 12 weeks Chest CT within previous 18 months Participation in other cancer screening/prevention trial Unable to lie on back with arms above head National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395– 409.

25 CT-CHEST National Lung Screening Trial Design Overview Treatment Arms: – Low Dose Chest CT (1.5 mSv) – PA Chest Radiograph (0.02 mSv) Screening Intervals: – T0: Baseline prevalence screen – T1: Year 1 incidence screen – T2: Year 2 incidence screen Positive Test – Non-calcified nodule greater than 4mm in mean diameter – Other findings suspicious for lung cancer (adenopathy, effusion…) – Workup of positives determined by PCPs not NLST NLST reading radiologist recommendation available

26 CT-CHEST National Lung Screening Trial Results: Mortality Lung cancer specific mortality – 20% reduction in lung cancer specific mortality – LDCT = 356 deaths, CXR = 443 deaths – Median follow-up 6.5 years Overall mortality – 6.6% reduction in overall mortality – LDCT = 1877 deaths, CXR = 2000 deaths – Not statistically significant when lung cancer deaths excluded National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395– 409.

27 CT-CHEST National Lung Screening Trial Results: Other Lung cancer prevalence: 1% – 1 in 100 at risk patients have cancer Lung cancer annual incidence: 0.5 – 0.8% – Decrease in # of late stage cancers in CT group vs CXR – Real stage shift not just overdiagnosis Small cell lung cancer – Not detected at earlier stage – Overrepresented as interval cancers Number Needed to Screen (NNS) is 320 National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395– 409.

28 CT-CHEST National Lung Screening Trial Results: Rate of Positive ScreeningsAq CT (24.2%) > 3x more sensitive than CXR (6.9%) – T0 & T1 Rate: 27-28% – T2 Rate: 16.8% 2 year stability benign (Fleischner Guidelines) Expected rate for ongoing LDCT screening At least one positive result (3 screens): 39.1% Significant incidental finding: 7.5% Not screening everyone – highly selected group (3%) National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395– 409.

29 CT-CHEST National Lung Screening Trial Results: Positive Workup/Adverse Events False Positives – Most have noninvasive imaging follow-up CXR: 14.4% Chest CT: 49.8% PET/CT:8.3% – Invasive diagnostic procedures: 2.6 % – Complication rate: 1.4% – Major complication rate:0.06% True Positives – Invasive procedure major complication: 11.2% – Surgical resection mortality: 1%

30 CT-CHEST NLST Results: False Positive Workup/Adverse Events False Positive Rate: – 20-25%: Chance you will end up with a false positive – ~10-12% for Mammography (Call back) False Discovery Rate (1-PPV): – 96%: Chance if you are positive you do not have cancer – Same as mammography False Positive Biopsy Rate – %: Chance if screened you will have an unnecessary invasive procedure (LDCT) – 7-15%: Chance if you end up having a biopsy it will be negative (mammography).

31 CT-CHEST NLST NEJM 6/29/2011NCCN 10/26/2011 NLST Summary 20% lung cancer mortality benefit 7% overall mortality benefit 1 in 100 has lung cancer NNT = 320 Opportunity to save 30,000 lives/yr NCCN Considerations Prolonged debate Cost to Society Patient anxiety Radiation exposure False positives/informed consent Operational concerns

32 CT-CHEST National Comprehensive Cancer Network (NCCN): 10/26/2011 NCCN Guidelines® for Lung Cancer Screening (V )

33 CT-CHEST NCCN Recommendation Categories NCCN Guidelines® for Lung Cancer Screening (V )

34 CT-CHEST NCCN Recommendation Categories NCCN Guidelines® for Lung Cancer Screening (V )

35 CT-CHEST NCCN High-Risk Groups

36 CT-CHEST NCCN High-Risk Group 2 Risk Factors Personal Cancer History – Lung, lymphoma, smoking related cancers Family History Lung Cancer in 1 st Degree Relative Chronic Lung Disease – Emphysema – Pulmonary Fibrosis Carcinogen Exposure – Arsenic, asbestos, cadmium, chromium, diesel fumes, nickel, radon, silica

37 CT-CHEST NCCN Guidelines Solid or Part Solid Nodules Follow-up NCCN Guidelines® for Lung Cancer Screening (V )

38 CT-CHEST Lung Cancer Screening Risks and Benefits (NCCN) NCCN Guidelines® for Lung Cancer Screening (V )

39 CT-CHEST Overdiagnosis, Survival, Mortality DiagnosisDeath Survival

40 CT-CHEST DiagnosisDeath Survival Mortality Overdiagnosis, Survival, Mortality

41 CT-CHEST DiagnosisDeath Survival Mortality Death due to lung cancer = 20% Lung Cancer Mortality

42 CT-CHEST DiagnosisDeath Survival Mortality Death due to any cause across entire group= 6.6% Overall Mortality

43 CT-CHEST Overall Survival Benefit 7% Adjuvant Therapy Reduces Risk Breast cancer ACT chemotherapy 5 years anti-estrogen therapy Post-mastectomy RT Prostate Cancer Post prostatectomy RT Head and Neck cancer Post-operative chemoRT Cervix Cancer Post-operative chemoRT Medical-legal consequences

44 CT-CHEST DiagnosisDeath Mortality Overdiagnosis Determine time and cause of death in those patients diagnosed and treated for lung cancer

45 CT-CHEST CT Lung Cancer Screening Morbidity Radiation exposure – MDCT resolution allows for dose reduction – LDCT <1mSv, Mammography 0.7mSv 1 mSv 10 mSv

46 CT-CHEST Radiation Exposure LDCT<1 mSv Years of annual lung screening Mammogram.7 mSv Lumbar Spine Films2 mSv2 Diagnostic Chest CT10 mSv10 Triphasic CT AB/P25 mSv25 Background Exposure Colorado 3 mSv/year 4.5 mSv/year Occupational Exposure 50 mSv/year50 Transatlantic Flight.1 mSv7 flights = 1 LDCT year latency period to develop secondary malignancies from RT exposure Average age of patients in screening trials is 62

47 CT-CHEST LUNG-RADS Overview Purpose: Establish a standardized quality assurance tool to mirror the tool widely utilized in Mammography (BI-RADS). Objectives: – Standardize terminology – Organized reporting and assessment structure – Data collection tool to facilitate outcome monitoring

48 CT-CHEST LUNG RADS Lung Number Category Category 1: Negative (12mo) Category 2: Negative with benign pulmonary findings (12mo) Category 3: Positive/likely benign (follow-up per NCCN guidelines) Category 4: Positive/suspicious for malignancy Category 5: Known cancer S Category Positive for extra- pulmonary finding not suspicious for lung cancer but requiring clinical follow- up – Thyroid mass – Aneurysm – Kidney Mass

49 CT-CHEST LUNG RADS Lung Number Category Category 1: Negative (12mo) Category 2: Negative with benign pulmonary findings (12mo) Category 3: Positive/likely benign (FU per NCCN guidelines) Category 4: Positive/suspicious for malignancy Category 5: Known cancer S Category Positive for extra- pulmonary finding not suspicious for lung cancer but requiring clinical follow- up – Thyroid mass – Aneurysm – Kidney Mass – Fracture

50 CT-CHEST An Actuarial Analysis Shows That Offering Lung Cancer Screening As An Insurance Benefit Would Save Lives At Relatively Low Cost Cost per life-year saved would be below $19,000 Pyenson et al, Health Affairs 31, No : April 2012

51 CT-CHEST Cost-Effectiveness Private Insurance Coverage 11/2011 Anthem California 12/2011 Wellpoint

52 CT-CHEST Productivity Loss due to Cancer

53 CT-CHEST Who Is Screening? MDACC Brigham and Womens Hospital Georgetown University Thomas Jefferson University Hospital UCSF Cedars-Sinai Medical Center Yale University Cancer Center Mayo Clinic John Hopkins Medical Center Memorial Sloan Kettering Cancer Center Lahey Clinic Self pay rate $170 to $1000 (Average $230) Oncology Round Table Survey 3/2012 – 32% Currently screening (n=104) – 77% Starting screening program (n=77) – Most CT lung screening programs have been launched in the past 9 months – Mean # of patients screened in 2011 = 70 – 88% of patients pay out of pocket The Advisory Board Company 3/12

54 CT-CHEST The Advisory Board Company 3/12

55 CT-CHEST Barriers to Screening Applicability to patients outside study group? Duration of screening? Education/awareness/endorsement Access to care in the absence of established reimbursement – Rescue Lung, Rescue Life

56 CT-CHEST Lung Cancer Screening Practices of Primary Care Physicians: Results From a National Survey 962 family physicians, general practitioners and general internists surveyed in – 38% no test – 55% CXR – 22% LDCT – <5% sputum cytology Multivariate modeling: – Lung cancer screening endorsed by expert groups – Screening shown to be effective – Patients ask about screening Klabunde, PhD et al: Annals of Family Medicine Vol. 10, No.2 March/April 2012

57 CT-CHEST Lung Cancer Screening Practices of Primary Care Physicians: Results From a National Survey To date, because of a lack of evidence from rigorous studies, major expert groups have not recommended screening asymptomatic individuals, even those with heavy or long- term smoking histories, for lung cancer – US Preventative Services Task Force – American Cancer Society 2009 guidelines – American College of Chest Physicians Klabunde, PhD et al: Annals of Family Medicine Vol. 10, No.2 March/April 2012

58 CT-CHEST Screening Endorsements NCCN – Category I recommendation to screen high-risk patients October 2011 American Lung Association – April 2012 – Best way to prevent lung cancer is to never smoke or quit – LDCT for NLST group (does not give parameters on frequency) – Do not screen with CXR – LDCT not for everyone – ALA to develop public health materials to educate patients – Call to action to hospitals and screening centers to screen responsibly

59 CT-CHEST James Mulshine, MD, associate provost and vice president for research at Rush University Medical Center "With this positive trial result, we have the opportunity to realize the greatest single reduction of cancer mortality in the history of the war on cancer.

60 CT-CHEST Why Free? Ethical – Make lung screening available for all socioeconomic groups until CMS reimburses Power of Free – Human Motivation – Few people screened when charge – Helping to Raise Awareness Multidisciplinary centers may not need to charge (TBD) Seize Opportunities to fulfill Hospital Mission Save Lives, Growth, Innovation, Sustainability, Teamwork

61 CT-CHEST How Free? Existing Infrastructure – Pilot – Use existing time in CT schedule (30 slots on PET/CT per week) – CTCHEST – Use downtime on installed CT Scanners M – F: 6PM-9PM (12 scans per shift) Additional capacity exists at LCN and Burlington Sat/Sun: 12Hrs x 2 – IT - build/manage database of findings – January 9 th started free lung screening

62 CT-CHEST LDCT Lung Screening Patient Flow Intake Staff Evaluate Eligibility FAQ Given PCP Order Patient Calls (855-CT-CHEST)

63 CT-CHEST LDCT Lung Screening Patient Flow Group 3 (Refer to PCP) Intake Staff Evaluate Eligibility FAQ Given PCP Order Patient Calls (855-CT-CHEST) Dont Qualify

64 CT-CHEST LDCT Lung Screening Patient Flow Group 3 (Refer to PCP) Intake Staff Evaluate Eligibility FAQ Given PCP Order Patient Calls (855-CT-CHEST) Call Back (Cancer History, Risk Factors) Dont Qualify May Qualify Dont Qualify

65 CT-CHEST LDCT Lung Screening Patient Flow Group 3 (Refer to PCP) Intake Staff Evaluate Eligibility FAQ given PCP Order Patient Calls (855-CT-CHEST) Call Back (Cancer History, Risk Factors) Dont Qualify May Qualify Dont Qualify Group 1 & Group 2 1. Record PCP 2. Assign Lahey PCP if no PCP 3. Schedule Appointment 4. Asymptomatic Disclosure Do Qualify

66 CT-CHEST LDCT Lung Screening Patient Flow Group 3 (Refer to PCP) Intake Staff Evaluate Eligibility FAQ Given Screen Patient 1. No IV 2. No changing 3. Scan < 10 sec PCP Order Patient Calls (855-CT-CHEST) Call Back (Cancer History, Risk Factors) Dont Qualify May Qualify Dont Qualify Group 1 & Group 2 1. Record PCP 2. Assign Lahey PCP if no PCP 3. Schedule Appointment 4. Asymptomatic Disclosure Do Qualify Obtain PCP Order Appt Reminder Call (48 hrs before exam)

67 CT-CHEST LDCT Lung Screening Patient Flow Group 3 (Refer to PCP) Intake Staff Evaluate Eligibility FAQ Given Screen Patient 1. No IV 2. No changing 3. Scan < 10 sec PCP Order Credentialed Radiologist Interpretation Patient Calls (855-CT-CHEST) Call Back (Cancer History, Risk Factors) Dont Qualify May Qualify Dont Qualify Group 1 & Group 2 1. Record PCP 2. Assign Lahey PCP if no PCP 3. Schedule Appointment 4. Asymptomatic Disclosure Do Qualify Obtain PCP Order Appt Reminder Call (48 hrs before exam)

68 CT-CHEST LDCT Lung Screening Patient Flow Group 3 (Refer to PCP) Intake Staff Evaluate Eligibility FAQ Given Screen Patient 1. No IV 2. No changing 3. Scan < 10 sec PCP Order (2/3 Screenings) Schedule Rescreen (<74y) Credentialed Radiologist Interpretation Patient Calls (855-CT-CHEST) Call Back (Cancer History, Risk Factors) Dont Qualify May Qualify Dont Qualify Group 1 & Group 2 1. Record PCP 2. Assign Lahey PCP if no PCP 3. Schedule Appointment 4. Asymptomatic Disclosure Do Qualify Obtain PCP Order Appt Reminder Call (48 hrs before exam) S Negative & Lung-Rads 1, 2

69 CT-CHEST LDCT Lung Screening Patient Flow Group 3 (Refer to PCP) Intake Staff Evaluate Eligibility FAQ Given Screen Patient 1. No IV 2. No changing 3. Scan < 10 sec PCP Order (2/3 Screenings) (1/3 Screenings) Schedule Rescreen (<74y) Follow NCCN Guidelines Credentialed Radiologist Interpretation Patient Calls (855-CT-CHEST) Call Back (Cancer History, Risk Factors) Dont Qualify May Qualify Dont Qualify Group 1 & Group 2 1. Record PCP 2. Assign Lahey PCP if no PCP 3. Schedule Appointment 4. Asymptomatic Disclosure Do Qualify Obtain PCP Order Appt Reminder Call (48 hrs before exam) S Negative & Lung-Rads 1, 2 S Positive or Lung Rads 3, 4, 5

70 CT-CHEST CT Lung Screen Pilot Statistics As of the week of 2/24/12 – Patients verbally screened209 – Patients scheduled 17985% – Patients scanned*10559% – Lahey patients* 15687% – Non Lahey Patients* 2313% * percentage of Patients Scheduled

71 CT-CHEST Patient Survey

72 CT-CHEST Statistical Correlation to the NLST Study Lahey PilotNLST study Finalized cases 101 – Negative (cat 1,2) 70 – Positive (cat 3,4,) 31 – Incidentals (S pos) 3 – Lahey PCP assigned 1 Total Screened26,000 Negative72.7% Positive27.3% Incidentals 7.5% Cancers found 1%

73 CT-CHEST How did you start? Multidisciplinary coordinated effort Steering Committee Evidence based Business plan Legal Compliance Education and CME Concerns – Informed consent – Involvement of PCP – Education regarding screening as process – Enticement or hidden cost – Uninsured – Volume overload of radiology, PCPs, and specialists – Perception of outside hospitals and clinicians – How long before reimbursement is established?

74 CT-CHEST Rescue Lung, Rescue Life Movement Steering Committee: Radiology – Brady McKee, MD – Sebastian Flacke, MD – Robert French, MD – Christoph Wald, MD Oncology – Andrea McKee, MD – Paul Hesketh, MD GIM – Guy Napolitana, MD – Brendan Connell, MD Pulmonary – Andrew Villanueva,MD – Anthony Campagna, MD – Jeffrey Klenz, MD – Carla Lamb, MD Administration – Richard Guarino – Jeffery OBrien – Samuel Skura – Patricia Grady – Patricia Doyle – Angela Tambini Marketing – Erika Clapp Finance – Kevin Bennett Business Development – Robert Toporoff Philanthropy – Elizabeth Garvin

75 CT-CHEST Volume Reassurance MammographyLDCT Screen US Population60,000,0009,000,000 (high-risk) Lahey30, screenings per week

76 CT-CHEST Volume Reassurance MammographyLDCT Screen US Population60,000,0009,000,000 (high-risk) Lahey30, screenings per week 1 cancer per week

77 CT-CHEST Volume Reassurance MammographyLDCT Screen US Population60,000,0009,000,000 (high-risk) Lahey30, screenings per week 1 cancer per week 27 positives

78 CT-CHEST Volume Reassurance MammographyLDCT Screen US Population60,000,0009,000,000 (high-risk) Lahey30, screenings per week 1 cancer per week 27 positives 7 potentially significant findings

79 CT-CHEST Volume Reassurance MammographyLDCT Screen US Population60,000,0009,000,000 (high-risk) Lahey30, screenings per week 1 cancer per week 27 positives 7 potentially significant findings After 2 years we will save 1 life every 3 weeks

80 CT-CHEST Volume Reassurance 100 screenings per week 1 cancer per week 27 positives 7 potentially significant findings After 2 years we will save 1 life every 3 weeks ~75 patients: Qualify for lung screening (NCCN high-risk) ~20 patients: Positive for a lung nodule ~5 patients: Potentially significant incidental findings Clinic Example Individual PCP: 2500 Patient Panel

81 CT-CHEST When Will CMS Reimburse? Lung vs Breast Screening Lung CancerBreast Cancer 5 Yr Overall Survival %75% 5 Yr Overall Survival %89% Screening ModalityLDCTMammogram Screening FrequencyAnnualAnnual/Biannual Patient Population30PY, 55-74yFemales 40-80y Patient Number Estimates9,000,00060,000,000 Cost of Exam$300$100 Per Year Cost of 1 Screen$2.1 B$6 B Radiation Exposure mSv0.7 mSv Mortality Reduction20%10-35% NNS (40-49y) Overdiagnosis< 17% vs CXR*5-50% False Positive Rate~35%/ 3 years30-35%/10 years (annual) Cost/QALY < $50,000$38K - 58K (40-80y)

82 CT-CHEST Risks of Free Screening States where health insurance is not required by law – Massachusetts >98% insured – US Population statistics – ~ <4% of high-risk patients will not have insurance Operational endeavor – Instructional CD Potential for patient harm - Lung Cancer Alliance National Framework For Excellence

83 CT-CHEST Rescue Lung, Rescue Life Movement Mission: Save lives through the early detection of lung cancer with responsible CT lung screening Encourage the government to establish reimbursement for CT lung screening Encourage other centers of excellence in the treatment of lung cancer to offer FREE CT lung screening until CMS establishes reimbursement Break down barriers and prejudice faced by those at risk for lung cancer Raise public awareness of the power of CT lung screening to save lives

84 CT-CHEST Thank You


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