Lung cancer is usually detected at an advanced stage. Attempts at demonstrating the benefits of screening and early detection had been elusive, until the results of the National Lung Screening Trial (NSLT), sponsored by the National Cancer Institute, were published in the New England Journal of Medicine on Aug. 4, 2011. This landmark study demonstrated a 20 percent relative reduction in mortality from lung cancer and any cause death by 6.7 percent in the low-dose annual CT screened group when compared with annual chest radiographs. Cancers detected by screening were primarily early stage, with 51.8 percent stage IA, and 70.2 percent amenable to surgical intervention. Unfortunately, the remainder of screen-detected cancers was advanced, as were cancers not detected by screening. As there are approximately 94 million current or ex-smokers in the U.S., the number of people at risk is quite high.
Most medical centers lack coordinated care for the management of patients with a pulmonary nodule. At Thomas Jefferson University Hospital in Philadelphia, we established a streamlined approach for one-stop management. With coordination of care by physicians from pulmonary medicine, primary care, radiology, thoracic surgery and medical and radiation oncology of Jefferson’s Kimmel Cancer Center, we established a lung cancer screening program for high-risk patients. A major emphasis was placed on maximal patient convenience, scheduling with a single phone call and performing all evaluations at a single location in one session with attached parking.
CT scanning is performed in strict accordance with the NLST protocol, with acquisition variables decreasing average effective dose to 1.5 mSv. Patients are screened at pre-registration for meeting the inclusion criteria of the NLST, and pre-screening counseling is performed regarding the three annual low-dose screening exams. Patients present to our office and are escorted to the CT suite, where a low-dose spiral CT is performed. Patients are seen immediately post-CT by a pulmonologist, both for results and the apprehension that accompanies screening. Spirometry is performed to document the presence of chronic obstructive pulmonary disease, a risk factor for lung cancer, which is treated according to international guidelines. CT findings are discussed with the patient, and appropriate investigations are arranged if a positive finding is present. If the patient is a current smoker, smoking cessation is addressed, as this is the single most important factor in reducing the risk of lung cancer. For patients with a normal CT, a follow-up low-dose screening CT is ordered at the one-year anniversary, with same-day follow-up. The cycle is repeated until three CTs have been performed.
As 24.2 percent of all screening CTs in the NLST had a positive finding (any non-calcified nodule at least 4mm diameter, mass, adenopathy or effusion), we believe that immediate post-CT physician evaluation and counseling are an incredibly important component of a successful screening program. This minimizes risk of loss to follow-up or delay in diagnosis, and improves patient satisfaction. Our multidisciplinary team is able to expedite obtaining a tissue diagnosis, if required, to proceed with treatment.
Prior to launching a screening program, facilities may want to consider several issues: development of lung cancer between screening studies and patient management/counseling after the third CT. No data exist regarding low-dose CT screening after the third CT, despite the detection of lung cancer on the third scan in 5.2 percent of patients and the 34.6 percent detected between or post-screening testing. Finally, recommendations from national organizations regarding CT screening are currently lacking, although in development. HI
Mani S. Kavuru, MD, is division director of pulmonary & critical care medicine at Thomas Jefferson University & Hospital (TJU). Boyd T. Hehn, MD, is clinical associate professor of medicine at TJU.