1. Finding N.E.M.O. Marvin R. Balaan, MD, FCCP System Division Director, Division of Pulmonary and Critical Care Medicine Allegheny Health Network, Pittsburgh PA Associate Professor, Temple University School of Medicine UP College of Medicine Class 1979

2. Finding Nodules Early Matters Optimistically Screening for early detection of lung cancer

3. A tale of two nodules

4. Does Finding N.E. M.O?

5. Sobering statistics  Lung cancer is the leading of of cancer-related death among men and women  Third leading cause of cancer in the United States  Surpassed breast cancer as cause of death in women  2015 American Cancer Society Prediction  221,000 new cases of cancer will be diagnosed  158,000 will die of lung cancer  Worldwide 1.4 M deaths in 2008

6. Cancer statistics, 2014 CA: A Cancer Journal for Clinicians Volume 64, Issue 1, pages 9-29, 7 JAN 2014 DOI: 10.3322/caac.21208 http://onlinelibrary.wiley.com/doi/10.3322/caac.21208/full#caac21208-fig-0001 Volume 64, Issue 1, http://onlinelibrary.wiley.com/doi/10.3322/caac.21208/full#caac21208-fig-0001

7. MenWomen Cancer deaths

8. Should we try to find lung cancer early? Facts: Overall survival in lung cancer is about 16% In over 75 % of cases patients present with widely metastatic disease Survival in early stage lung cancer is good

10. How should we do it? Should we Screen for lung cancer?

11. Screening for lung cancer  Mayo Clinic Project (1984)- 10,993 male smokers  CXR and sputum cytology every 4 months x 6 years vs usual care  More early cancers detected but no survival benefit  PLCO Cancer Screening Trial (JAMA 2011)  154,901 participants between 1993 and 2001  Annual CXR x 3 vs usual care  No difference in mortality

12. National Lung Screening Trial NEJM Aug 4 2011  NIH sponsored multicenter trial in 33 US medical centers  Question: Whether low dose CT screening as compared with CXR would reduce mortality from lung cancer in high risk pts  53, 454 high risk individuals ages 55-74 years, 30 pack year smoker or quit within 15 years  Randomized to low dose chest Ct versus routine chest x-ray  About 26,700 in each group  3 studies separated by 1 year  Followed from 2002 to 2009  Positive: lung nodule 4 mm or larger

13. What they found National Lung Screening Trial Low dose Chest Ct vs. Chest x-ray

14. The National Lung Screening Trial Research Team. N Engl J Med 2011;365:395-409. NLST: Results of Three Rounds of Screening.

15. NLST Results  More positive findings in LDCT group compared to CXR  Most of the positive findings (about 95% in each group) were not cancer  About 90% needed additional tests  Most of these tests were additional imaging studies following a pre specified protocol.

16. The National Lung Screening Trial Research Team. N Engl J Med 2011;365:395-409. Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer.

17. Key findings from NSLT Trial  More cancers were detected in 3 rounds of annual screening by LDCT compared to CXR  There was relative reduction in lung cancer mortality of 20% and 6.7 % of all cause mortality with LDCT vs CXR  This is the very first time that any radiology based screening for lung cancer has demonstrated a mortality benefit  Finding NEMO!  This became the basis for a Grade B recommendation from USPTF (therefore it has to be a covered service) and recently by Medicare.

18. Nodule 1 Ct guided biopsy : adenocarcinoma Staging work up- evidence of metastatic disease

19. Nodule 2 Folllowed yearly over 3 years No change in appearance or character of nodule Benign nodule

20. What if it got bigger? Biopsy +/- PET scan Or resect potentially malignant nodule

21. So if it is all good why not screen everybody with CT? Finding Nodules Early

22. Economics  Currently about 7 million persons in the US would meet the NLST entry criteria.  That is a lot of low dose CTs!  Estimates of about $81,000 per Quality adjusted life year comparison- $47,700 per QALY for colorectal screening and $13,000-32,000 for breast cancer screening

23. Gould MK. N Engl J Med 2014;371:1813-1820. Potential Benefits and Harms of Three Rounds of Annual Screening with Low-Dose CT, as Compared with Chest Radiography or No Screening.

24. Unanswered questions  How many years should one screen?  Does the benefit hold if it is extended to more “real world” situations –  non academic settings, less rigid adherence to work-up and procedures for nodules, etc.  What about the additional risk of cancer from radiation?  Are you medicolegally liable if a high risk patient is found to have cancer and you did not offer screening?

25. Conclusion  Offer low dose CT for high risk patients with profile similar to NLST  55-74 (80) yrs  30 pack year smoker  Or quit within 15 years  Follow protocol very closely  Most positive findings need only follow-up rather than an invasive procedure

26. Let us not forget LDCT CT is not a substitute for smoking cessation Smoking cessation likely more cost effective than screening

27. Finding N.E.M.O.