1. 폐암검진, 누구에게 필요한가?
분당서울대병원
내과 윤 호일

2. 무료 폐암검진 시범사업 2017.4- 국립암센터 등 전국 9개 지역암센터, 서울대학교병원 55~74세 30갑년 이상의 흡연력
현재 흡연자 또는 금년한지 15년 이내의 과거흡연자
저선량 CT + 금연상담

3. Lung cancer worldwide
The proportion of lung cancer patients in developing nations increased from 31% to 49.9% in the last two decades
15% of men and 53% of women with lung cancer worldwide are never smokers
Geographic differences: the proportion of lung cancer of never smoking women:
83% in Asian countries, 15% in US
IRAC, 2002, Global Cancer Statistics
Geographic proportion of LC among never smoker women: Curr Poin Oncol 2009; 21:

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

5. 폐암검진의 역사 1960-London CxR – No mortality difference
1970’s – MSKCC, Johns Hopkins, Mayo
CxR/Sputum – No benefit of adding sputum cytology
1990;s – PLCO- No benefit of CxR screening
ELCAP – LDCT better than CxR at detecting cancer
Mayo – LDCT better than CxR
NLST – 20%reduyction in mortality LDCT
2010 – AFB, genomic, proteomic analysis, seruum molecular markers

6. CDC guideline for lung cancer screening
Yearly screening with LDCT for people who-
Have a history of heavy smoking (>30PY), and
Smoke now or have quit within the past 15 years, and
Are between 55 and 80 years old

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

9. Computed Tomography (CT) of the Chest
Routine
Low-dose
938mGy/cm
15.9 mSv
88mGy/cm
1.5 mSv
Computed Tomography (CT) of the Chest -- Routine (Left) versus Low Dose (Right). The surveillance of small pulmonary nodules is a common indication for chest CT, and several protocols can be used for these studies. Routine chest CT (Panel A) is associated with a radiation dose to the patient that is 10 times that of low-dose chest CT (Panel B) (dose-length product, 938 mGy per centimeter vs. 88 mGy per centimeter; effective dose, 15.9 mSv vs. 1.5 mSv) -- yet each shows the small pulmonary nodule equally well (Panels A and B, arrows). The pulmonary parenchyma and upper abdomen are better visualized on the higher-dose routine scan (Panels A and C, respectively) than the low-dose scan (Panels B and D, respectively), but these areas are irrelevant to follow-up of a small pulmonary nodule. A recent survey of radiologists who perform chest CT showed that low-dose CT was not routinely used for examinations performed solely for the purpose of nodule follow-up and that most radiologists were unaware of the CT settings used for initial versus follow-up CT.1 Standardization of CT protocols could result in substantial reduction in patients' radiation doses without loss of diagnostic accuracy. Images courtesy of Dr. Michael J. Flynn, Department of Radiology, Henry Ford Health Systems.
Smith-Bindman, N Engl J Med 2010;

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

11. National Lung Cancer Screening Trial (NLST)
smokers
ex-smokers
≥ 30 PA Age 55-74
LDCT
Chest PA
Years 1 2
RANDOM I S A T ON
NLST, NEJM 2011; 365(5):

13. NNS to prevent 1 lung cancer death = 320…
55 to 74 yrs, > 30P-Y, active or stop<15 yrs n
« Positive »
(diam>=4mm)
Lung cancers
Lung cancer deaths
Risk
reduction
Low-dose CT
26.455
18.146
(68.5%)
1.060
346
(1.3%)
20,0%
Chest X-ray
26.232
5.043
(19.2%)
941
425
(1.6%)
NNS to prevent 1 lung cancer death = 320…
NLST, NEJM 2011; 365(5):

14. NLST: Highly selected population
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, JNCI 2010

16. European Screening Trials Overview
NELSON
DLCST
ITALUNG
LUSI
DANTE
MILD
Nr rounds 4 5
10 or 5
Enrollement
15,464
4,104
3,206
3,551
2,472
3,581
Completed Y N
Baseline detection
0.9%
0.8%
1.5%
1.0%
2.2%
Incidence
0.5%
0.6%
0.4% -
de Koning, ECCO-ESMO meeting, Sept. 2011

17. How many screen rounds?
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.

18. 잠재적 이득
잠재적 손실
폐암사망율 20% 감소
방사능 노출
사망율 7% 감소
그릇된 안도
정상일 경우 안도감
over diagnosis
금연치료에 도움
위양성

19. Linear non-threshold model
CT with an effective dose of 10 mSv
Increased risk of fatal cancer of 1 in 2000
Natural incidence of fatal cancer 400 in (in the US population)

20. Radiation dose in adults
Procedure
Approximate effective dose
Comparable natural background radiation
Abdomen and pelvic CT
10 mSv
3 years
Abdomen and pelvic CT, pre- and post contrast
20 mSv
7 years
Brain CT
2 mSv
8 months
Chest CT
7 mSv
2 years
Low dose CT
1.5 mSv
6 months
Chest PA
0.1 mSv
10 days
Coronary CT
12mSv
4 years
DEXA
0.001mSv
3 hours
PET/CT
25mSv
8 years
Mammography
0.4mSv
7 weeks

21. non-smoking lung cancer patients
Adenocarcinoma, especially bronchioloalveolar carcinoma
Asian ethnicity
Female
Better response to Epithelium Growth Factor Receptor (EGFR) Tyrosine Kinase (TK) inhibitors, such as erlotinib and gefitinib
Iressa – AstraZeneca
Tarceva - Genentech

22. Etiologic and molecular features
Several etiologic factors have been proposed:
Occupational and environmental factors: exposure to radon, asbestos, heavy metals
Cooking fumes
Environmental tobacco smoke
Human papilloma virus (HPV) infection
Inherited genetic susceptibility
Molecular features
EGFR mutations, p53 mutations, K-ras mutations

23. Exposure to cooking fumes
A meta-analysis reported an increased risk of lung cancer in China
Exposure to domestic coal for heating and cooking
Indoor exposure to coal dust and chronic exposure to cooking oil vapor, though publication bias might affect these two factors
More cooking dish-years, higher the OR of lung cancer
Different frying methods: deep-frying have the highest risk
Chinese women have higher proportion of non-smoking related lung cancer

24. Subsolid nodules

25. 폐암검진, 누구에게 필요한가? 반드시 필요 (금연 교육과 함께)
55-74세
>30 갑년 흡연력
<15년 금연기간
고위험군이 아니더라도 폐암검진이 도움이 될 수 있다. 하지만 이 경우 대상연령이나 검사 기간 등은 차이가 있을 가능성이 있다.

26. Thank you