MD Anderson Cancer Center
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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas M.D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today we have exciting news in the field of screening for lung cancer. There is an article that's going to come out sometime in the summer with the results of the National Lung Screening Trial and Dr. Reginald Munden, one of our guests; he is a professor of Diagnostic Radiology. He was one of the principal investigators on this trial. Our other guest today is Therese Bevers, she is the medical director of the Cancer Prevention Center. First of all, Dr. Munden, talk about the National Lung Screening Trial. What was that all about?
Dr. Reginald Munden: The National Lung Screening Trial was a trial sponsored by the National Cancer Institute for determining if we could reduce lung cancer mortality and lung cancer specific mortality by using low-dose CT screen versus chest radiograph. The trial started in 2002 of September in road over 53,000 participants in about 18 months. The study was done where people were randomized into a chest x-ray or a CT screening study and they had a baseline study and then an annual study for 2 years and then we followed them by survey up to 9 or 10 years after they have enrolled. That trial ended and we reach the goal of 20 percent reduction in lung cancer specific mortality in October 2010 and that's when the trial ended.
Lisa Garvin: What is it about low-dose CT scan that is superior to x-rays for lung screening?
Dr. Reginald Munden: Well, most of us it's just the sensitivity. The--how and well, how much detail you can see or how much more detail you can see on a CT than you can on a chest radiograph. But the issue with lung cancer is often, it was not detected until they were fairly well advanced disease or the growing cancer was large enough that it had possibly spread to the rest of the body. So, at CT we picked up lung cancer that were smallest, 8 millimeter or 1 centimeter in size which we would not see with chest radiograph. So it's just the increased sensitivity of using CT over in the other modality that we had prior to this trial.
Lisa Garvin: So, Dr. Munden, at the NLST showed that there was a certain subset of people in a risk category that benefit from low -dose CT?
Dr. Reginald Munden: Yeah, correct. It was basically was considered how risk participants for lung cancer and that varies according to who you ask but in general for the NLST it was 55 years of age to 75 and the smoking history of 30 pack years of smoking. In other words, they have smoked at least one pack a day for 30 years.
Lisa Garvin: And what happens after the trial results are published. Where do you go next from there?
Dr. Reginald Munden: Well, that's the big question actually. We've answered probably the most significant question about lung cancer screening today and then that is that it actually works and we can't reduced lung cancer mortality. The other details that have fallen are quite or the questions that have fallen out are quite numerous. For instance, we used 55 years of age but maybe 50 years of age is the correct age to start. 30 pack years is a fairly significant smoking history and some of the other trials that we're not randomized such as NLST had enrolled people with 20 pack years of smoking. So there's no real set numbers right now. We just know from the NLST that if you're 55 years of age or older and you have a 35 pack year, we can reduce your mortality of about 20 percent from lung cancer.
Lisa Garvin: And that sound small but it's actually a huge leap considering there really is no standard screening for lung cancer.
Dr. Reginald Munden: Sure. That's actually major in screening trials that reduced mortality about 20 percent. In the early 70s, there were a number of clinical trials using chest radiograph to see if chest radiograph would reduce lung cancer mortality compared to no chest radiograph basically and all of those trials uniformly were considered to have failed and that they didn't reduced lung cancer mortality. So, to go from 0 to 20 percent is quite substantial.
Lisa Garvin: And M.D. Anderson was one of several institutions taking part it the trial?
Dr. Reginald Munden: Yeah. There were actually two groups. The ACRIN which American College of Radiology Imaging Network and then the LSS which is the Lung Study Section that was part of PLCO screening group combined to give us a large enough population of people. So, 53,000 ultimately were enrolled but those two groups worked through the NCI to establish this [inaudible] trial.
Lisa Garvin: And Dr. Bevers, as medical director of the Cancer Prevention Center here at M.D. Anderson, it must have been frustrating not to be able to screen lung--for lung cancer given its prevalence.
Dr. Therese Bevers: Exactly. We would see individuals who were current or former smokers recognized that they were at increased risk of developing lung cancer but didn't have anything to offer them that would reduce their chance of dying from the disease.
Lisa Garvin: So this must be very exciting for you the fact that we can actually start doing this at least in a very limited way.
Dr. Therese Bevers: Exactly. And to that extent we have put together a lung cancer screening program here at the M.D. Anderson where we can offer lung cancer screening to individuals who are at increase risk.
Lisa Garvin: Now, as far as other cancer screening guidelines like first skin and breast and so forth, these are standardized by several groups. Talk about how something becomes a standardized screening recommendation.
Dr. Therese Bevers: Well, I think it depends on the different group or organization. There are different entities that make screening recommendation such as the American Cancer Society or the National Comprehensive Cancer Network and they will typically have panels of experts that will convene on this topic. M.D. Anderson also has cancer screening guidelines for different disease sites and since the results of the NLST were announced we have convene the panel of experts to develop what M.D. Anderson is recommending for lung cancer screening.
Lisa Garvin: I know, I was a former smoker and when I've gone to my doctor and asked for lung screening she's like, well, you know, the insurance doesn't pay for that and it's not a recommended screening. Even though I asked for it, I wasn't able to get it. I think that's very frustrating for me as a health consumer.
Dr. Therese Bevers: It's very frustrating for the clinician as well and I think now we can at least say there is data in regards to benefits of lung cancer screening with his spiral CT scan. We don't have the other part accomplished yet where it is covered by payors. Nonetheless, many different organizations recognizing the benefit and that individuals will want it and at this time may be willing to pay out of pocket are now offering it even though different insurance companies were still reviewing the data to make determinations about coverage.
Lisa Garvin: Is there anything specific that the, and this is probably a question for you Dr. Munden, is there any specific thing that the diagnostic radiology has to know, I mean is there a learning curve here? I mean, its obviously well used equipment but used for something new.
Dr. Reginald Munden: Well, the process of interpretation is similar to what we do everyday but the process of interpreting the screening exam is quite different and there is certainly a learning curve. The trial has shown that about 25 percent of the cases were false positive cases where we thought there were cancers and they were not but there also was a 24 percent missed lung cancer cases. So, in other words, 1 out of 4 were missed. There are so many reasons for that to be a case. Sometimes, it depends on where the lesion is and so forth. So, the learning curve is a steep learning curve and is probably just as in mammography it's not so much that you don't see it. Its how do you interpret what you see and then how do we managed on what we find on the CT studies. The management part is gonna be the part that we don't have a lot of experience in. There are a number of previous trials that have experienced but we don't have a standardized policy across lung cancer screening as to how we manage the findings.
Lisa Garvin: So I know Dr. Bevers that M.D. Anderson is offering lung cancer screening. Are any of the other institutions that were involved in the National Lung Screening Trial ready to do that as well or is M.D. Anderson kind of alone in offering this service?
Dr. Therese Bevers: I think there's a lot of interest across the country to be able to offer this to at risk individual so we're not the only one. Certainly, we're very excited to be able to offer it to our patient.
Lisa Garvin: Is this something that can only be done at a comprehensive cancer center or can this be done in the doctor's office? I mean, I know here at M.D. Anderson we are doing it here as part of the cancer prevention center but.
Dr. Reginald Munden: Well, you know, our philosophy is that, this is not just a CT that you do and then you go on about your marry way. We feel this is really a multidisciplinary process so it does involved prevention with smoking cessation. It involves the pulmonologist and the surgeons on how we manage the situations. So, yes you can do this in any community setting. It can be done but the--as again, I mentioned the management on how we do screening is what's important and that was gonna make it actually work really well or not so well.
Lisa Garvin: So, if somebody were seeking lung cancer screening here at M.D. Anderson, how do they do that?
Dr. Therese Bevers: They will contact, ask M.D. Anderson at 1-877-MDA-6789 or 1-877-632-6789. During the course of a discussion with the person answering the phone at ask M.D. Anderson, we would determine if they have a physician of record that would essentially be the ordering physician. If not, then they come in to see someone in the Cancer Prevention Center who will be the physician of record, order the screening CT scan and will also assist with the management of the findings as well as offer tobacco cessation assistant should they be a current smoker or a recent quitter.
>> Now, this is of course not covered by insurance at this time. What would be the estimated out-of-pocket cost for a lung cancer screening?
Dr. Therese Bevers: So, typically, the clinic visits would be covered as a part of a preventive medicine or office visit charge. It's the CT scan that is currently not covered by insurance payors and M.D. Anderson is offering it at a rate of 400 dollars for the scan.
Lisa Garvin: And who are the eligible? I think we touched on it a little bit but who are the people who are eligible for lung screening?
Dr. Therese Bevers: Well, as Dr. Munden mentioned the NLST use age 55 to 75 and a 30 pack year of smoking history or smoking equivalent of one pack a day for 30 years. But he also mentioned that there are maybe some benefits for individuals that are under the age of 55 or don't have a 30 pack year smoking history. When M.D. Anderson's panel of experts put together our the lung cancer screening guidelines we actually indicated that current or former smokers age 50 and over and have the equivalent of having smoked 1 pack a day for 20 years or a 20 pack year smoking history would be eligible for screening.
Lisa Garvin: Do you feel like the cost situation might be a barrier for people who are eligible?
Dr. Therese Bevers: For some it may be. Others may have significant interest in being proactive in their health, being able to obtain a scan. It really quite a good rate compared to what yo would normally pay for a CT scan and be able to learn if there is a problem and catch it early when it's treatable.
Lisa Garvin: What about people who are current or former smokers and have a clean scan. I mean, they might feel a false sense of security, do you provide information for people even though they may have a negative finding?
Dr. Therese Bevers: The benefits of screening are really seen when you have annual evaluations or examinations. In this case, we'd be coming in every year for a CT scan. So we would certainly talk to them about being sure to return in a year to get their followup up screening and do that annually. That would afford the earliest possible detection of any developing problem. But clearly, there is no test, no screening test that is perfect to catching every cancer and so we do also cautioned them about that. And if they are smoker, encourage them to quit so they can start to reduce the risk.
Lisa Garvin: And I know there are lot of supportive programs right here that they could possibly be funneled in to as depending on their findings.
Dr. Therese Bevers: As far as if the CT scan does find something, we have programs here that can help to evaluate what that finding is and manage it.
Dr. Reginald Munden: One of really exciting things about the NLST was not only did it find the reduction in mortality from lung cancer but it also showed an overall reduction in mortality of 6.9 percent. So that means that people, diseases that people would have normally died from other than lung cancer were detected and successfully treated. So that also gonna be part of a lung cancer screening program. It is what you do with those findings such as aortic aneurysm or coronary artery disease or something of that nature.
Lisa Garvin: And I think we should really stress the prevalence of lung cancer. We were talking before the podcast begin about it's that--well, you can go ahead and talk about the facts and figures that--I mean, a lot of people don't realized it's more prevalent. I mean, deaths from lung cancer are more than breast cancer.
Dr. Reginald Munden: Yes, substantial number of deaths has always been the number one cause of death in men for as long as I've been around and also now in women much more so than other diseases so it's over a 150,000 per year that are deaths from lung cancer.
Lisa Garvin: So the fact that we have a screening method on the horizon is very good news for the entire population really.
Dr. Reginald Munden: Yeah.
Lisa Garvin: Dr. Bevers what is generally, I mean what is your hope? Do you hope to see this a standard recommendation in 5 years, 10 years, what do you see down the road?
Dr. Therese Bevers Oh, I'm hoping much sooner than that. I'm hoping that within the next year that we see that not only M.D. Anderson but other organizations including some of the national organizations I've mentioned put out lung cancer screening recommendations. These will fuel insurance payors to gives strong consideration to providing this as a covered benefit for the individuals that cover.
Lisa Garvin: Do you worry in this odd, you know, atmosphere of health care reform that this might affect lung cancer screening becoming a standardized test?
Dr. Therese Bevers: I think if anything, it may be influenced and get it on as covered service sooner because there is a great deal of interest with the affordable health care act of preventive services and early detection of disease when it's more treatable and cost less.
Dr. Reginald Munden: Yeah. And another aspect of the NLST that we hoped is coming out sometime later this fall is the cost analysis of the lung cancer screening. So there is a study that will show whether that cost benefit ratio is very favorable or not for lung cancer screening and that should have major impact on a third party payors participation in this.
Lisa Garvin: Great. Thank you both very much. Again, very exciting news about the National Lung Cancer Screening Trial and lung cancer screening available at M.D. Anderson. If you have questions about anything you've heard today on Cancer Newsline, contact Ask M.D. Anderson at 1-877-MDA-6789, or online at www.MDAnderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.
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