Lung Cancer Screening: what we know and what we can do in Maryland

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Lung cancer is the second most common cancer and the leading cause of cancer death in both men and women in Maryland. The incidence and mortality of lung cancer keep in as high as national level based on the 2014 cancer report of Maryland. Smoking is the most common high risk in lung cancer responsible for 90% of lung cancer in male and 78% of lung cancer in female in Maryland. There is 14.9% of the adult population (aged 18+ years)—over 640,000 individuals— who are current cigarette smokers. Across all states, the prevalence of cigarette smoking among adults ranges from 9.3% to 26.5%. According to the largest National Lung Screening Trial (NLST) in America, LDCT (Low-dose CT) screening for lung cancer had a 15 to 20 percent lower risk of dying from lung cancer than participants who received standard chest X-rays.

lung-cancer-facts

Source: National Cancer Institute; National Lung Screening Trial (NLST)

USPSTF defined the people who are under the high risk of lung cancer as having the history of heavy smoking (smoking at least one pack a day for 30 years, either the current smokers or former smokers who quit within the past 15 years) between the ages of 55 to 80, and also recommended annual screening(level B) for lung cancer with LDCT in this selected population.

Screening histroy of USPSTF.jpg

Source: Lung Cancer Alliance (LCA)

Center for Cancer Prevention and Control in Maryland Department of Health and Mental Hygiene plans to implement LDCT lung cancer screening among the heavy smoking population over the state. We Marylanders will get continuous smoking cessation education and qualified screening process guideline, and the screening centers will be monitored in instruments, physicians and technicians following the quality and safety standard of ACR. In addition, the follow-up schedules and treatment strategies will be built up simultaneously.

The percentage of smokers is parallel with the education and income level nation widely. The LDCT screening among heavy smokers can be better intervened based on the policy and financial support from government, it’s really critical to make efforts for the better future of heavy smokers in Maryland.

 

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10 Responses to “Lung Cancer Screening: what we know and what we can do in Maryland”

  1. mcunni25 Says:

    Lwang108,

    Thank you for your thought provoking blog post involving a very prominent and serious health issue here in Maryland. Your post educated me on just how high the morbidity and mortality rates of lung cancer are, particularly compared to other common cancers. Many of us here in Maryland have had a loved one or a friend have their life impacted from the effects of chronic cigarette smoking. I personally had a grandparent die from complications related to Emphysema and another from Adenocarcinoma likely brought on by a lifetime of chronic cigarette smoking.
    One of my close friends is an additions counselor here in Maryland and recounted to me recently how many more people he is now counseling for opioid addition and gambling addiction (now that our casinos are open this has become somewhat of an epidemic for us locally). His role in counseling individuals for smoking cessation has been limited and he attributes it to the fact that many smokers, now a generation or more into being well aware of the negative health effects of smoking, simply don’t want help. Society has stigmatized smokers, particularly given the wealth of peer reviewed literature associated with second-hand smoke, but smoking is still readily available. I read a study out of the U.K. this week that discusses success rates of smoking cessation relative to the proximity where the smoker can procure cigarettes. In other words, the study substantiated that if smokers live close to a convenience store or an establishment where they can buy cigarettes, they have a lower chance of quitting. With that said, we live in the land of the convenience store here in the U.S. Bloomberg.com reported in 2013 that over 38% of non-gasoline sales in convenience stores in the U.S. still come from tobacco. http://www.bloomberg.com/news/articles/2013-01-17/in-convenience-stores-more-food-fewer-cigarettes
    With a convenience store seemingly on every corner here in Maryland, we will likely never be able to help smokers quit by controlling close access.
    Regardless of access and counseling, your blog points to astonishing cancer rates among smokers and it is incredibly encouraging to see new health interventions and recommendations for patients who have a history of chronic smoking over many years. This was very educational for me. Thank you!

    • lwang108 Says:

      Thanks for your encouragement and the facts you supply to us. It’s really serious problem for smoking and tough work to implement the smoking cessation campaign.The staffs working in Cigarette Constitution Fund Program in CCPC always consider smoking cessation as their priority task, that is also the main point why they plan to support the lung cancer screening and make the project with smoking counseling and cessation going through the whole screening process from registry to treatment.The heavy smokers need healthcare not only in the aspect to persuade them stop smoking, but also in the other aspect to support them evaluating their health status with smoking history, and lung cancer screening is one of the necessary step for them. Although it’s still in contemplation stage, I believe it will be transferred to planning stage soon. Let’s looking forward to implementing this project in future Maryland!

  2. omaralmatrafi Says:

    Thank you for your post. Screening for lung cancer has been a heated topic for quite sometime. At the core of the debate is the cost and benefit analysis. As such, I would like to dig deeper into the details of the evidence provided in the post. The NLST showed that using LDCT to have “15 t o20 percent lower risk of dying from lung cancer” as compared to chest X-rays. Though sounds good, it is not followed by any cost and benefit analysis. Because of our finite resources, we cannot make a decision without taking into account the financial burden of the new measure. I would like to know how much would a person and the public pay for such an intervention, and then try to think whether this is the best health investment for our community. That is no to say its ineffective; to the contrary, in fact, I personally lean more toward its effectiveness.1 According to a study published in the New England Journal of Medicine LDCT showed 20% in mortality and cost effectiveness but it has to be further investigated.
    I would also think about smoking prevention programs versus screening programs and weigh the effects of each and probably put the money where it is most beneficial.

    1 http://www.nejm.org/doi/full/10.1056/NEJMoa1312547#t=articleTop

    • lwang108 Says:

      Thanks for your points. It’s definitely very priority to have the smoking cessation campaign and education in community for a long time. However, they don’t conflict to each other between smoking cessation and LDCT screening program.
      Based on one systematic review about LDCT screening,1 we can get some conclusions such as” For younger individuals or those with lower risk of developing lung cancer the tradeoff would be less favorable.” or ” Preliminary modeling studies suggest that potential risks may vastly outweigh benefits in non-smokers or those ≤ age 42. ” or ” Further study, including the effects of ongoing annual LDCT beyond three successive years, is needed. ” In addition, we all know USPSTF sets the recommendation based on the solid-based evidences. Level B means there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial, which also inform us LDCT screening for lung cancer recommendation is also based on the cost and benefit analysis. That’s the reason why USPSTF restricts the high risk people(heavy smokers) as the target population.
      As I mentioned in the blog, the lung cancer screening project has the very important part to counsel and educate people for smoking cessation, and it’s free for all people who concern about it, and it’s always better choice to screen the high risk people after you finish counseling of smoking cessation. I believe this screening implementation will impress more community members with the fact that you care about their health in every level and will encourage them easily to accept the campaigns for smoking cessation. Thanks!

      1 http://www.natap.org/2012/newsUpdates/jrv120003_2418_2429.pdf

  3. angelalamacchia Says:

    An interesting article. Similar to Omar, I wonder about the costs of these CTs. Will patients be paying out of pocket or is it planned to be fully government funded? I know this 20% figure has been repeated continuously but what about specificity? Has consideration been made to all of the ‘incidentalomas’ that would be detected and subsequently biopsied, only to turn out to be normal? Not to mention that such procedures created from all the screening CTs are not without complications or costs…

    In Australia we still use chest X-rays. I can’t imagine the burden and costs to our healthcare system for introducing LDCT…

    • lwang108 Says:

      Thank you for your comment. First of all, we need to emphasize the LDCT screening population in this project. They are heavy smokers while not all the patients suspected with the high risk factors of lung cancer. There are already several lung cancer screening centers in Maryland, most of the process are covered by insurance. However, as I mentioned above”The percentage of smokers is parallel with the education and income level nation widely.”, we estimate high percentage of heavy smokers will suffer the smoking related diseases without the health insurance cover among which lung cancer is the most deadly disease.We aim to support this selected population through this project.There is a department in CCPC, they focus on evaluating the cost benefits analysis in all projects including the LDCT screening one. Although this is the secondary stage intervention, we should act on it for heavy smokers. It is urgent because we know the damages already exist in their health. Again, it’s about safety to introduce LDCT for lung cancer screening in heavy smokers while not for general population.Thanks!

  4. agulamhusein Says:

    Thought provoking post, thanks! This really got me thinking about the concepts of efficacy vs. effectiveness and potential unintended consequences of an intervention as alluded to by Angela and Omar. We all know that clinical trials are done in the most optimal settings and positive diagnostic/therapeutic studies in general suggest effective interventions. What happens in the real world is sometimes, perhaps often, a different story. Its possible that the outcomes reported in the cited literature would bear out, but I think understanding how this strategy performs in the real world would be important. Certainly, costs would come into play.

    The structure of a health care system would also be important to consider. Do you think the implications of this sort of program would be different in a public vs. privately funded system? Being from Canada with a publicly funded system, I wonder how the system would absorb the cost associated with such a screening strategy. If the program is implemented as it is intended i.e. for high risk people with very specific risk factors (i.e. specific age groups, 30 pack-year history, done in specialized centers) then perhaps real world outcomes may approach those seen in trials. That said, implementation of such a strategy in the real world is hard:

    1) what do you do if people don’t stick to these guidelines and order a LDCT in someone who doesn’t meet “inclusion criteria” and a finding is detected?
    2) How do you ensure that screening is done in limited centers with expertise in lung cancer management? At least in Canada, any physician can order a test – what the right thing to do with the result is another issue.

    Thanks for your points and responses – this was a useful discussion!

    • lwang108 Says:

      Thank you for your comment. I admit that the clinical trials are usually different from the real world. However, this NLST testified the LDCT is safer screening method compared with X-ray. It is not the study on target population, such as heavy smokers. Our project plans to focus on heavy smoking population because this is the conclusion after we investigate and evaluate the whole process based on the references, insurance policies and other screening centers’ experiences. There should be the potential barriers for us to execute this project, we will try to resolve them one by one,while not give up at the planning stage, because we know the damages in heavy smoker’s lung and how fatal lung cancer is, as public health practitioners, we are responsible for their health prevention at earlier stage.
      Our project just covers heavy smokers, however, the other people who are under high risk factors, such as the radon exposure, second hand smoking exposure, the chronic lung diseases, such as COPD etc., they can counsel their PCP and get further exam for their concern.
      Now, American College of Radiology (ACR) 1 build up several trainings for LDCT screening, we will monitor the centers involved in out project following ACR standard, and we also have the detail criteria for the centers in the aspects of staff training, equipment maintenance and license monitoring.
      Hope this is helpful for you. Thank you for all questions!
      1.http://www.acr.org/Quality-Safety/Resources/Lung-Imaging-Resources

  5. pamelamcdonaldblog Says:

    This was really interesting to read, thank you! I’ve never heard of a program like this, and I love how they are using high risk testing AND continual education together. In one of your links it mentioned that the rates in Maryland were all declining- do you attribute that to the education and awareness component or other policies (increases in taxes on cigarettes for example)?

    Both of parents were smokers and they finally did quit about 3 years ago, but I have concerns about their health. I think the LDCT initiative is wonderful! I’m also thankful to have read about it because I’m certainly going to see if PA has anything similar. Unfortunately, both of my parents would classify as (past) heavy smokers. How do insurance companies play into this plan? Is it completely government funded? Obviously, there has been a great deal of changes to the healthcare system and I am just curious if there is push back when it comes to paying for a diagnostic test in a symptom free individual (?). Thanks again for sharing this…thought provoking and exciting!

    • lwang108 Says:

      Thank you to share your concerns fro your family. I can understand your feelings as the heavy smokers’ family.That’s the reason why we set the counseling and education for smoking cessation to heavy smokers and their families as the priority step during the whole project. Actually, our project is based on state funding which maybe doesn’t cover the situation in PA. However, I believe there should be some healthcare centers to provide lung cancer screening for local residents nationwide. As I know, there are around 10 medical centers to supply LDCT screening in Maryland, most of them will be covered by insurance. Share your concern with your PCP to get the guidance, counseling for smoking cessation in case to stop the damage from smoking ASAP.As a public health practitioner, we know it’s better to get intervention from very upstream. Good luck! Thanks!

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