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Benjamin Besse, Philippe Girard 1ers MACA – Ajaccio – 10 mai 2012.

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Presentation on theme: "Benjamin Besse, Philippe Girard 1ers MACA – Ajaccio – 10 mai 2012."— Presentation transcript:

1 Benjamin Besse, Philippe Girard 1ers MACA – Ajaccio – 10 mai 2012

2 LUNG CANCER Incidence = 1,600,000/yr Mortality = 1,370,000/yr Lethality 85% Cancer Incidence and Mortality (world)

3 Screening: why ? Goal: cancer mortality reduction Detect asymptomatic cancers Asymptomatic cancers = better prognosis (?)

4 31% Stade III 31% Stade III 38% Stade IV 38% Stade IV 24% Stade I 24% Stade I 7% Stade II 7% Stade II Clinical Stages and Survival/Prognosis Fry, Cancer 1999;86: Groome, IASLC Lung Cancer staging project, JTO 2007;2:

5 Screening for Lung Cancer What Tools ? Sputum cytology Chest X-ray Chest CT Autofluorescence bronchoscopy Markers (serum, exhaled air, urine…)

6 Lung Cancer Screening Tools Sputum Cytology Chest X-ray Bach, ACCP guidelines, Chest 2007;132:69S-77S

7 The PLCO (Prostate, Lung, Colorectal and Ovarian) trial Oken, JAMA 2011;306(17): annual chest X-rays (n=77445) vs usual care (n=77456) yrs, 45% never smokers Number of lung cancers 1696 vs 1620

8 Oken, JAMA. 2011;306(17): Deaths from lung cancer 1213 vs 1230 The PLCO (Prostate, Lung, Colorectal and Ovarian) trial 3 annual chest X-rays (n=77445) vs usual care (n=77456) yrs, 45% never smokers

9 Screening for Lung Cancer What Tools ? Sputum cytology Chest X-ray Chest CT Autofluorescence bronchoscopy Markers (serum, exhaled air, urine…)

10 Bach, ACCP guidelines, Chest 2007;132:69S-77S Lung Cancer Screening with CT Diameter2 mm 8 mm40 mm200mm Nb of cells Screening « window »

11 Smith-Bindman, N Engl J Med 2010; Computed Tomography (CT) of the Chest 938mGy/cm 15.9 mSv 88mGy/cm 1.5 mSv RoutineLow-dose

12 ELCAP, NEJM 2006;355: It works ? 31,567 subjects ( ) 481 lung cancers detected 85% stage I (n=412) Screening with Low-dose CT

13 National Lung Cancer Screening Trial (NLST) Fumeurs Anciens fumeurs 30 PA Age Fumeurs Anciens fumeurs 30 PA Age ,000 PLCO 10,000 ACRIN Scanner low dose Radiographie Years RANDOMISATIONRANDOMISATION NLST, NEJM 2011; 365(5):

14 n « Positive » (diam>=4mm) Lung cancers Lung cancer deaths Risk reduction Low-dose CT (68.5%) (1.3%) 20,0% Chest X-ray (19.2%) (1.6%) NLST: Trial discontinuation in oct ! NNS to prevent 1 lung cancer death = 320… NLST, NEJM 2011; 365(5): to 74 yrs, > 30P-Y, active or stop<15 yrs

15 Probably healthier vs. base population < 65 years –73% vs 65% in the base population Less current smokers –48% vs 57% Better educated –6% with less than a high school education vs 21% NLST: Highly selected population NLST, JNCI 2010

16 155 ponctions, 206 fibros, 297 chirurgies 270 cancers ! (4%)

17 NLST : Compliance > 90% Women adherence to mammography screening higher if –Younger –Higher education –Lived in an area with a higher percentage of mammography facilities NLST: Magic Compliance Philips KA, Health Serv Res Apr;33(1):29-53.

18 Cause of Death (CT group) n % Reduction vs control group Lung cancer % 20% (6.8 – 26.7, p <0.004) Other Neoplasm % 3.2% (p = 0.28) Cardiovasc. Illness % Respiratory illness1759.4% Complication of medical or surgical care 120.6% Other % All % (1.2 – 13.6%, p = 0.02 NLST, NEJM 2011; 365(5):

19 Deaths from lung cancer NLST, NEJM 2011; 365(5): but… « NCI is not yet recommending such screening » NLST: Trial discontinuation in oct !

20 Unanswered Questions How to diminish the false positive rate ?

21 The NELSON trial (Nederlands-Leuvens Longkanker Screenings Onderzoek) van Klaveren, NEJM 2009, 361:123 Automated volumetric measurment for non-calcified nodules NPV of diagnostic strategy at 1 yr = 99.9% 4,147mm 3

22 Unanswered Questions How to diminish false positive rate? Should the ongoing trials go on?...

23 European Screening Trials Overview NELSONDLCSTITALUNGLUSIDANTEMILD Nr rounds or 5 Enrollement15,4644,1043,2063,5512,4723,581 CompletedYYYNYN Baseline detection 0.9%0.8%1.5%1.0%2.2%0.8% Incidence0.5%0.6%0.4%-0.5% de Koning, ECCO-ESMO meeting, Sept. 2011

24 PISA position Statement (March 2011) 6 ongoing European trials have enrolled 32,000 subjects with about 150,000 person-years of follow-up (approx. half of NLST) European trials continuation ! Concrete plan for interim analyses and/or pooling Discouragement of opportunistic screening outside clinical trials !

25 Unanswered Questions How to diminish false positive rate? Should the ongoing trials go on?... How many screen rounds?

26 Lung cancer was diagnosed frequently after the third low-dose CT screening This observation suggests that continuing to screen high-risk individuals annually will provide a net benefit.

27 Unanswered Questions How to diminish false positive rate? Should the ongoing trials go on?... How many screen rounds? False reassurance (license to smoke)?...

28 IELCAPI, NEJM 2006;355: It works ? 31,567 subjects ( ) 481 lung cancers detected 85% stage I (n=412) Screening with Low-dose CT Negative CT ? Keep smoking ! Positive CT ? Keep smoking ! (we can cure your cancer)

29 Screening routine nightmare McMullan and Cohen NEJM 2006, 354 (4): 397

30 Unanswered Questions How to diminish false positive rate? Should the ongoing trials go on?... How many screen rounds? False reassurance (license to smoke)?... Where to go ?

31

32 Blood is the issue NSLT collected > blood samples

33 Quit at age 50: risk reduction about 66% Effects of Smoking Cessation on the Risk of Lung Cancer Peto, BMJ 2000,321:323

34 Deal ? 1 CT scan (138 ) = 27 packs of cigarettes = 1 month of tobacco consumption = 2.5 months of nicotine substitutes

35 Séminaire de réflexion sur la littérature récente concernant le dépistage scanographique du Cancer broncho-pulmonaire février 2012 – GOLF et IFCT Dépistage à léchelon individuel Après information sur les bénéfices et risques encourus Sujets âgés de 55 à 74ans et ont fumés plus de 30PA Information sur sevrage tabagique impératif GOLF : Fabrice Barlési Etienne Lemarié GOLF : Fabrice Barlési Etienne Lemarié


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