Robert Jotte, MD, PhD
If physicians incorporated routine lung cancer screening into clinical practice, at least 40,000 lives could be saved annually, according to Robert M. Jotte, MD, PhD.
“If [screening] were to become a topic that's discussed akin to cholesterol or hypertension, those percentages of screening would go up tremendously,” said Jotte, medical director and co-chair of the USON Thoracic Committee at Rocky Mountain Cancer Centers. “If we institute screening, we can cure a lot more patients of early-stage lung cancer than we could if they presented at later stages.”
In the National Lung Screening Trial (NLST) screening with low-dose CT indicated a reduction in mortality from lung cancer. In the trial, 53,453 patients at high-risk for lung cancer were randomized to 3 annual screenings with low-dose CT or single-view posteroanterior chest radiography. Results showed a 20% relative reduction in lung cancer mortality with the use of low-dose CT (95% CI, 6.8-26.7; P
Still, screening remains at an all-time low, said Jotte, who noted that taking the time to educate patients and providers, as well as invest in resources to detect high-risk patients, can improve lung cancer outcomes.
An analysis presented at the 2018 ASCO Annual Meeting showed that 1.9% of more than 7.6 million current and former heavy smokers in the United States underwent lung cancer screening in 2016, suggesting that it remains inadequate despite recommendations from the United States Preventive Services Task Force.2
In an interview during the 2018 OncLive®
State of the Science SummitTM
on Advanced Non–Small Cell Lung Cancer, Jotte addressed the underutilization of lung cancer screening in the United States and the importance of multidisciplinary management in improving patient outcomes.
OncLive: What should be known about screening in lung cancer?
: The NLST was a large trial that [screened] over 53,000 patients for lung cancer and followed them for lung cancer–specific outcomes with low-dose spiral CT versus chest x-ray. We found that the incidence of lung cancer detection was much greater with the low-dose CT scan.
Equally important was patient outcomes. If those patients had their lung cancers identified, they tended to be earlier-stage cancers. [These are] much more amenable to surgical resection and therefore show much higher outcomes in terms of overall survival (OS). Several years ago, it became a new standard of care to screen patients with CT scans if they met the appropriate criteria based on age and smoking history. These kind of constituted their risk factors.
Unfortunately, a very high percentage of diagnoses correlate with disease-specific survival and death with regard to lung cancer. If we instituted screening, we could save a tremendous number of lives in the United States alone, let alone globally. The statistics I talked about were more here in the United States. The equivalence of over 40,000 [lives] could be saved per year just by instituting screening and getting patients the operating room rather than getting them to the intravenous chemotherapy chair.
Why is there such a low rate of screening?
The reason why there is such a low rate of screening, as presented in the 2018 ASCO Annual Meeting, is a result of multiple factors. The primary reason is that the topic just isn't being brought up. I see it in my office all the time. Many primary care providers are expected to wear so many different hats. They have to take care of so many different problems, and lung cancer screening is yet another thing that has to be mentioned in a relatively brief office visit. You have to prioritize what the immediate risk to the patient is. It's sometimes hard for us to focus on those risks that are down the road.
How does shared decision-making factor into it?
There are specific criteria that we follow called the Fleischner criteria, and those criteria have recently been updated. The whole purpose of those criteria is to minimize unnecessary invasive procedures and maximize the detection rate. Therefore, if someone comes in we can identify a solitary pulmonary nodule as early lung cancer.
Radiologists will allude to those criteria in their radiology reports in terms of who needs to be worked up and who needs to be biopsied. It's a shared decision-making process that takes place between the provider and the patient so that the patients understand what all those things are.