Lung Cancer Screening Bruce - PowerPoint Presentation

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Lung Cancer Screening

Bruce

Peyser

MD, FACP

June 2021

The issues

What about screening for lung cancer?

Risks of Lung Ca Screening

Low Dose Chest CT

Scans do not involve contrast. Must utilize a multidetector CT scanner

Test requires a single maximum inspiratory breath hold

Scanning time is under 25 seconds!

High resolution ( 1.0-2.5 mm interval) images are reconstructed using a special algorithm.

Who should be screened?

Adults age 50-80 years old

High risk ( at least 30 pack year smoking history and are either current smokers or former smokers quit within past 15 years)Lower risk ( at least 20 pack year smoking history and other risk factors for lung ca such as exposure to radon, asbestos, silica or other carcinogen, personal history of lymphoma, head/neck cancer, or bladder cancer, or family history of lung cancer)

Stop the screening if patient has not smoked for > 15 years, or if patient has limited life expectancy.(Note USPSTF have reduced the 30 pack history to 20 pack years, but Duke is waiting for insurance plans to make the change.)

What about consensus guidelines?

What’s the deal with prompts within epic??

Lung cancer screening was added to health maintenance tab on 2/23/21.

But the prompt will only fire if pack years are known, and quit date is recorded.

No flexibility to add whether someone smoked variable amounts over time.

So how well do people remember how much they have smoked in past?

1) People don’t always consistently smoke same amount. Habits vary.

2) My patient smoked anywhere from several cig per day to ½ PPD to 1 PPD.

(From Art of Memory Forum)

Small study in Texas using repeated measures design asked smokers past and present about their smoking history.

Confusing, limited data presented, analyzed Kappa and intraclass correlation coefficients. (??)

There is some inconsistent self reporting of smoking, especially amongst smokers. This was also affected by pack year threshold- different 20 pack

yr

vs 30 pack yr.

Beware there is known recall bias.

Best to have discussion at office visit to facilitate shared decision making.

Also best to document smoking hx at each visit!

Who likes to order low dose Ct Scans?

Use these diagnosis codes:

Z72.0 Tobacco Abuse

Z87.891 History of Tobacco AbuseZ12.2 Lung Ca ScreeningZ87.891 Persistent history of Tobacco use + personal hazard to healthF17.21 Smoker with nicotine dependence.IMG9125( Set up speed button- Can someone help us with that??)

In a nutshell….

This study compared eligibility rates for low dose CT scan lung cancer screening across different demographic groups.

Overall eligibility rate was 10% higher for men than women.

Non Hispanic whites had highest eligibility rates, followed by blacks, then Asians, and then Hispanics.

Black men have longer smoker duration but lower reported intensity ( # packs )

Black men have highest risk of lung cancer.

Disparities

Take Home points

Lung cancer screening needs to be on our radar, and we can not depend on prompts from EPIC to know when its indicated.

Plan to spend some time talking about this to patients, to help determine if they should have testing, and whether they will qualify or not.

While 30 pack years was used in past, this is going to change. Don’t forget the other risks like family history and bladder cancer that are important.

Be aware of recall bias- who remembers their social habits from 10-30 years ago?

Think about other disparities based on sex or race that could be critical too.

Will this change your behavior when caring for your smoking patients???

References

Deffebach

and Humphrey, Screening for Lung Cancer, Up to Date, topic last updated May 3, 2021Nadler, Lisa (correspondence with)Pinsky P et al, Potential Disparities by Sex and Race or Ethnicity in Lung Cancer Screening Eligibility Rates, Chest 2021 (article in press)

Volk R et al, Reliability of Self-Reported Smoking History and Its Implications for Lung Cancer Screening, Preventive Medicine Reports 17 (2020) 101037