Paul A. Bunn, Jr., MD: The National Lung Cancer Screening Trial. What Does It Mean?

Paul A. Bunn, Jr., MD discusses The New England Journal of Medicine highlighted results from the National Lung Screening Trial (NLST) at WCLC 2011. The study showed that lung cancer deaths fell by 20% and all-­‐cause mortality fell by 7% when smokers were screened regularly using low-dose spiral CT scans compared to standard x-ray.

The Group Room at the 14th Annual World Conference on Lung Cancer (WCLC) was made possible, in part, by:

 

VIDEO TRANSCRIPT

Selma R. Schimmel, Founder & CEO, Vital Options International:

This is Selma Schimmel for The Group Room at the 14th World Conference on Lung Cancer, WCLC; organized by the IASLC, the International Association for the Study of Lung Cancer.  We are in Amsterdam.  And I am joined now by the Executive Director of IASLC, Dr. Paul Bunn- Professor of Medical Oncology at the University of Colorado in Denver.  Hello, Dr. Bunn.

Paul A. Bunn, Jr., MD, Executive Director, IASLC:

Good afternoon, Selma.

Selma R. Schimmel:

Dr. Bunn, I’ve been saving one story just for you and that’s the screening and diagnostics story involving low dose spiral CT… versus x-ray.  And let’s begin by explaining there are different types of CT scans.

Paul A. Bunn, Jr.:

In a standard chest x-ray the x-ray equipment is in front of you and it sends out x-rays and they go through you from front to back.  And that gives you a two-dimensional view, but a two-dimensional view only.  So, for example, if there is a tumor behind your heart what you’ll see on the chest x-ray is the heart and you won’t see the tumor behind the heart.

Paul A. Bunn, Jr.:

Now, in a standard CT scan the scanner is going around you at a slow rate and it may take five minutes to collect all the information.  Well during that period of time you are breathing and so your diaphragms are going up and down.  So, if there is a small nodule in your lung the nodule is going up and down.  And so, there are software programs to try to reduce motion artifact, okay.  But you’re also, as that scanner is going around you, getting a lot of radiation.  So, in a spiral CT scan the whole scan is done in one breath hold, so your diaphragm doesn’t move.  So, small nodules that might be detected when the CT program eliminates motion artifact it may eliminate the small nodule as well.  So you can find small nodules much better in a spiral CT scan, you can get much less radiation.  In addition, in a standard CT scan you have a dye that you have to ingest orally and that you inject intravenously and that can damage your kidney and cause other side effects.  So, a low dose spiral CT scan is way safer and is actually better for detecting small nodules compared to a standard CT scan.

Selma R. Schimmel:

This story has been all over the news.  I don’t know what happens now with patients calling up their doctors saying, ‘I have a smoking history, I’d like to have a spiral CT scan.’  How do you see this playing out with the public and what does the public need to know?  Because it takes time for standards of care to change and the way medicine practices, I mean there is that cycle of natural activity.

Paul A. Bunn, Jr.:

So, the study included patients ages 55 to 74 who had more than 30 pack-years of smoking; that would be one package a day for 30 years or two packages a day for 15 years.  Those are high risk patients.  We know those subjects are at high risk for developing lung cancer and we know that they benefited.  And then the question becomes, would people with a lower risk also benefit?  So if you smoked 5-pack years, would a spiral CT scan benefit you?  And the answer to that, since it hasn’t been studied is, we don’t know.  So, is there any reason why you wouldn’t?  Well, of course there is.  One of the issues about the study is that 96% of the positive studies – positive, meaning there was a nodule – the patient did not end up having lung cancer.  So there’s all the worry, and the expense, and the problems associated with working up a nodule to find out whether it’s cancer or not.  So there is the potential for harm, and so if the benefit is tiny in a lower risk group and the potential for harm is just as much it might not be beneficial.  So at the present time, any recommendation that anyone will make will be similar to the trial entry criteria, mainly someone 55 years of age or older who smoked 30-pack years or more.  In the future there will be studies that look at other patients with a little lower risk, and of course we still need to know and develop tests for never-smokers who are also at risk for lung cancer.

Selma R. Schimmel:

So, we’re speaking in terms of screening?

Paul A. Bunn, Jr.:

Correct.

Selma R. Schimmel:

That’s different than as the diagnostic tool?

Paul A. Bunn, Jr.:

Correct.  If in fact you are working up somebody who has symptoms, cough, out of breath, coughing up blood, chest pain, or somebody who has a nodule on a spiral CT scan, the first step is to do a diagnostic CT scan and that involves the intravenous contrast administration, a longer time to scanning, and so on.  Sometimes a PET scan would be indicated and sometimes a biopsy of the nodule would be indicated.  And what a statement of the IASLC is saying is, ‘if you do fit the criteria of this risk, you don’t just go to anybody, because anybody might do the wrong scan, and somebody might work up these nodules that are likely not to be cancer in the wrong way, and anybody might scare the heck out of you, because most of these nodules are in fact not cancer.’  So, not only do you have to decide with your doctor whether to have one, but you need to decide with your doctor who is the expert that is going to evaluate the CT once it’s done.

Selma R. Schimmel:

Thank you, Dr. Paul Bunn- Executive Director of the International Association for the Study of Lung Cancer, IASLC for organizing the 14th World Conference on Lung Cancer, WCLC, which takes place every two years.  I know two years from now we will be reconvening in Australia.

Paul A. Bunn, Jr.:

Sydney, Australia.  And after that, Denver and after that, Vienna, Austria.

Selma R. Schimmel:

Thank you for inviting The Group Room to be here to help you in your communication efforts for patients, for your really humanistic, the nature of just how you are and congratulations on a really fabulous meeting. I hope as it comes to an end that you feel really good about your accomplishments here in Amsterdam.

Paul A. Bunn, Jr.:

The largest meeting on lung cancer ever held.

Selma R. Schimmel:

Congratulations again.

Paul A. Bunn, Jr.:

Thank you.

END OF VIDEO

 

 

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