Transcription:
Screening for Lung Cancer Saves Lives

Caitlin White (Host): Lung cancer is the leading cause of cancer death for both men and women. One of the primary reasons for these sobering statistics is that it is detected late in the course of disease when it has already compromised the function of one or more vital organs or has spread beyond the lung into other parts of the body. Today we’ll hear from Dr. Patrick Nana-Sinkam, Chair of the Division of Pulmonary Disease and Critical Care Medicine at VCU Massey Cancer Center. He discusses screening for lung cancer, who should be screened and the screening resources available at VCU Health.

Welcome to Healthy with VCU Health. I’m your host Caitlin White. So, Dr. Nana-Sinkam, what is cancer screening and how is the test performed?

Patrick Nana-Sinkam, MD (Guest): Sure. First, I think it’s important to mention that the rationale for lung cancer screening is this: Up until approximately seven years ago, we really had no way to identify lung cancer at an early stage. For the most part, most people would present to their physician usually with symptoms that were concerning – whether it be an unrelenting cough or unintentional weight loss. And in many cases, when individuals would be diagnosed with lung cancer, they would be diagnosed very late in the course of their disease.

Lung cancer screening is focused on trying to identify subgroups of individuals in our community who may be at higher risk for lung cancer and trying to identify an early stage lung cancer through CT screening. A CT scan is essentially a fancy chest x-ray and it really just involves taking pictures of your chest without any IV dye. The test itself takes perhaps ten seconds, and by doing that, in a subgroup of individuals, we can identify spots in the lungs and, in some cases, those spots end up being essentially lung cancers that an individual would not even be aware that they had unless it progresses to the point where they develop symptoms.

Host: And this is all about early detection, but what are some other benefits of screening for lung cancer?

Dr. Nana-Sinkam: I think the main benefit for lung cancer screening is that by identifying lung cancers early people have a better chance for survival. We know that in individuals who are diagnosed with lung cancer in the early stages when they can have curative treatment, the five-year survival can approximate 60 to 70%. Conversely, when people present late in the course of their disease, often their five-year survival is less than 10%. So, it’s important to stress that the primary impact of lung cancer screening is a reduction in lung cancer associated mortality. That reduction is about 20%. That being said, there are other benefits of lung cancer screening.

We know that many of the individuals who we end up screening because of their age and their smoking history, they often have additional smoking-related disease, whether it’s COPD or coronary artery disease. It’s not unusual that when we screen people for lung cancer, we may not find a lung cancer; but in fact, we find that an individual has unrecognized coronary artery disease, or they have unrecognized chronic obstructive pulmonary disease. So, there’s the benefit in terms of reducing lung cancer associated mortality but there’s also the benefit of, in some cases, identifying additional diseases that may have gone unrecognized for many years.

Host: So, if I walk into VCU Health, how good is this screening test in detecting possible lung cancer? What percentage am I looking at?

Dr. Nana-Sinkam: With the standard way of screening individuals, if you are determined to be at risk, you get a screening CT. After your screening CT, the results are sent to your primary care physician and then subsequently they discuss the results and what the implications may be of those results, whether it’s a spot on the lung or it’s COPD or heart disease.

What we’ve done at VCU is a little bit different. We’ve actually put into place an early detection program, and that really involves having individuals who are high risk coming to visit with us. We first spend time discussing with them the risks and the benefits of being screened. We talk about what the likelihood is that they will have a spot on their lung, which is about 25%, so one out of four individuals who are high-risk active or former smokers will have a spot on the lung. But the important second point is that the majority of spots that we detect are not cancerous. And it’s important to stress that to a patient before they have the screening CT scan.

Among high -risk smokers or former smokers lung cancer is usually found in about two individuals out of 100. So, it’s not that many when you think about it, but obviously it’s extremely important to those two individuals. Once the individual decides that they want to be screened we also talk about what their six-year risk is of getting lung cancer. So, we make that discussion very individualized. They subsequently undergo their CT scan and, again, it only takes about ten seconds and there is no IV dye. It’s a completely harmless test. And then afterwards, they wait about 15 to 20 minutes, and then we discuss the results with them in real time, which we find has been very beneficial because it takes away some of that anxiety of waiting for a call from your physician or waiting for a letter or receiving a report in the mail and not really understanding how to decipher those results.

Host: You’re mentioning this high-risk patient that leads me to my next question. Who should be screened for lung cancer?

Dr. Nana-Sinkam: In terms of screening, it’s a very particular subset of individuals. When we look at the largest clinical trial that has really set the standard, we are talking about individuals that are between 55 to 80 years of age and actively smoking what we call a 30-pack year. We determine smoking based on pack years. To give you an idea of what a pack year is; if, for example, you have smoked a pack a day of cigarettes for 30 years, we would say that you have a 30-pack year smoking history. Equally, if you smoked two packs a day for 15 years; again, when you take two by fifteen, you get again 30 pack years.

So, we are talking about individuals who have that degree of tobacco consumption and either are actively smoking or if they quit, they quit within the last 15 years. Why is 15 years important? Because we know that even when people quit smoking there is a substantial risk for still developing lung cancer, and that risk goes out to almost about 15 years. So, we still screen people even if they have, for example, quit smoking 13 to 14 years ago. They are still within that window, so we screen them. All that being said, the literature is now demonstrating that there are additional risk factors beyond just age and smoking history. We know that if an individual has a first-degree relative with lung cancer or if an individual has a history of chronic obstructive pulmonary disease, or some people use the term emphysema occasionally, that those also increase risk. If someone has been exposed to asbestos that also increases risk.

So, when we have individuals who maybe don’t meet the clear criteria in terms of age and smoking but have these additional factors, we still take the opportunity to sit down, evaluate their six-year risk and then it becomes a very individualized discussion in terms of risk benefit and whether or not screening is best for them.

Host: And looking at the resources at VCU Health, what are some of the lung cancer screening options there?

Dr. Nana-Sinkam: There are a couple of options. We have two programs for lung cancer screening at VCU Health. The first program is a very standard program in which people can have their lung cancer screening CT done pretty much any day of the week. In that case, what often happens is once there is a report, that report goes to the primary care physician who then will connect with their patient and discuss the results and implications of the findings on their report.

The second program that we have, that I described previously, involves upfront, shared decision-making, i.e., discussing risks and benefits, and I conduct that myself with the patient. With this program, we also have a nurse navigator as well as one of our senior radiologists onsite who help navigate the patient through the process that day, including doing an initial reading or results review of the findings on the CT scan.

We also offer onsite smoking cessation counseling. We recognize that the most important intervention that a person can make to decrease their risk of getting lung cancer is for them to not smoke. So, we use that particular opportunity to provide some education on smoking cessation if a patient is so inclined.

Host: Tell me more about the approach to screenings. I’m hearing a lot about quick turnaround with results, making nurses available to patients. It seems like you really prioritize keeping patients at ease throughout the screening process. What are the advantages of that?

Dr. Nana-Sinkam: There are a few advantages. I think one is certainly providing patients with the proper education about lung cancer screening. I think one of the reasons why so few people actually undergo screening, and when I say so few, there’s a recent analysis that has been conducted that demonstrates in the United States, of the individuals who, based on criteria, would qualify to be screened, we actually only screen less than 5%. And think about that: only 5% of people who should be screened for lung cancer are actually being screened. And there are many reasons for that.

One reason is just access. Access to screening centers that understand the importance of shared decision making, they have the proper CT scanners, the proper reading of the results and interpretation of the results and then a system in place for appropriate follow-up if someone requires an intervention. So, just access is a major issue. But another issue is lack of education about screening. Many people believe that a screening CT will automatically lead to a biopsy. Many people have concerns about the radiation exposure of getting a CT scan, when, in fact, the CTs that we use are low radiation. Then there’s the fear – the fear of, “If I go to be screened, then I am most certainly going to have lung cancer.”

So, the type of program we put into place is really to try to allay many of those fears, with an intention of educating people upfront on what they can expect. I think the second value to our type of program is that we recognize in those few individuals who do have a spot of concern, there’s a second phase of education that’s required in helping put into context for them what that spot means. “Does it mean I have cancer? Is it in the gray zone? Should I not even be worried about it?” And then following that, if we determine that they need a biopsy, by having this type of comprehensive program, we are in a position to expedite the evaluation. Because the next fear among patients when they do have something is the question, “How quickly are we going to do something about it?”.

So, by having patients already in the program, we can expedite the evaluation so that it’s streamlined, and they get the results that are necessary in a very quick manner.

Host: Great. Dr. Nana-Sinkam, thank you so much for your time and for sharing this information with us. That was very helpful.

Thank you for listening to Healthy with VCU Health. To learn more about lung cancer screening at VCU Massey Cancer Center, visit www.masseycancercenter.org. That is M-A-S-S-E-Y cancer center.org or call 804-827-LUNG, that is 804-827-L-U-N-G. To listen to other podcasts from VCU Health, visit www.vcuhealth.org/podcast. This is Healthy With VCU Health. I’m Caitlin White.