Program may help catch lung cancer in individuals ineligible for screening
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Key takeaways:
- Individuals aged 35 to 49 years and aged older than 80 years are ineligible for lung cancer screening.
- Five-year overall survival was low in those aged older than 80 years from the lung nodule program.
For individuals with an incidentally detected lung nodule who are ineligible for lung cancer screening based on age, a lung nodule program may catch lung cancer early, according to results published in Journal of Thoracic Oncology.
“We believe this work will enable us to better identify the true candidates for lung cancer screening beyond the current criteria that limit to age and smoking history,” Raymond U. Osarogiagbon, MBBS, FACP, chief scientist for Baptist Memorial Health Care, told Healio.
In a prospective observational study, Osarogiagbon and colleagues assessed two sets of individuals from a Lung Nodule Program ineligible for lung cancer screening because they are either too young (aged 35 to < 50 years; n = 3,630) or too old (aged older than 80 years; n = 2,503). Researchers noted that Lung Nodule Programs tend to use management guidelines from Fleischner Society, which enable screening starting at age 35 years with no upper age limit.
Researchers compared 2-year cumulative lung cancer incidence, diagnosis risk, characteristics and overall survival of these two groups with individuals who underwent low-dose CT (LDCT) screening (aged 50-80 years; n = 9,594).
“The Lung Nodule Program cohort provides a rich resource for discovery, to better understand who is truly at risk for lung cancer and why, beyond the prevailing notion of age and cigarette smoking,” Osarogiagbon told Healio. “It also provides a rich source of material for developing early lung cancer detection biomarkers and optimizing the use of digital images for prediction of future lung cancer risk, such as using machine learning/artificial intelligence.”
Characteristics, lung cancer diagnosis
Within the three cohorts, more individuals from the younger cohort were Black (37.82% vs. older cohort, 18.22% vs. LDCT cohort, 19.74%) or Hispanic (3.39% vs. 0.76% vs. 0.44%).
Current smoking appeared most common in the LDCT cohort (67.23%) compared with the younger (36.34%) and older (9.27%) Lung Nodule Program cohorts, and very few patients who underwent LDCT screening reported never smoking (0.33% vs. young cohort, 44.79% vs. older cohort, 45.39%).
Notably, 32.19% of LDCT patients quit smoking, as did 41.87% of the older cohort and 13.53% of the younger cohort.
A history of COPD appeared highest in the LDCT cohort (40.1%) compared with the younger (5.81%) and older (22.42%) cohorts. The older cohort had the highest percentage of individuals with a history of cancer (33.68% vs. LDCT cohort, 18.34% vs. younger cohort, 7.99%).
Among those in the LDCT cohort, 37.95% had no nodules (Lung-Reporting and Data System [RADS] score of 1), but around half (48.62%) had a benign lesion (Lung-RADS 2), 6.64% had likely benign lesions (Lung-RADS 3) and 6.79% had lesions suspicious for lung cancer (Lung-RADS 4).
The group with the highest percentage of patients diagnosed with lung cancer between 2015 and 2022 was the older cohort (6.87%; n = 172), followed by the LDCT cohort (3.43%; n = 329) and the younger cohort (1.07%; n = 39).
Likewise, the older cohort demonstrated the highest 2-year cumulative incidence of lung cancer at 6.5% compared with 3% in LDCT patients and 0.79% in the younger cohort.
Overall, the younger cohort showed a comparable risk for lung cancer diagnosis as those with a baseline Lung-RADS score of 1 (adjusted HR = 0.88; 95% CI, 0.5-1.56) or a Lung-RADS score of 2 (aHR = 1; 95% CI, 0.58-1.72) after adjusting for sex, race, COPD, smoking status and insurance.
However, the older cohort faced a significantly greater risk than individuals with a Lung-RADS score of 3 (aHR = 2.34; 95% CI, 1.5-3.65) but a reduced risk compared with individuals with Lung-RADS 4 (aHR = 0.28; 95% CI, 0.22-0.35).
Characteristics, survival of those with lung cancer
Among individuals with lung cancer, the younger cohort had significantly more Black individuals than the LDCT cohort (38.46% vs. 15.81%; P = .0002).
Current smoking also was significantly more common in the LDCT cohort (72.95%) than the younger (66.67%) and older (23.36%; P < .0001 for both) cohorts.
More individuals who underwent LDCT screening received a diagnosis of stage I/II lung cancer vs. individuals in the older and younger cohorts (62.92% vs. 48.26%; P = .0004 and vs. 33.33%; P = .0003). Stage IV cancer appeared more common among individuals too young (41.03%) or too old (29.65%) for screening compared with the LDCT cohort (16.72%).
Notably, among the groups, the rate of surgery was comparable between the LDCT cohort (42.86%) and younger cohort (30.77%) but significantly lower in the older cohort (19.77%; P < .0001).
Of the three cohorts, older individuals from the Lung Nodule Program had the lowest aggregate 5-year overall survival rate at 24% (95% CI, 14-40), followed by the younger cohort (55%; 95% CI, 39-79) and LDCT cohort (57%; 95% CI, 48-67).
When divided by the stage of cancer, researchers again found that older individuals vs. individuals from the younger cohort and individuals screened for cancer had the lowest aggregate 5-year overall survival for stage I/II cancer (39% vs. 100% vs. 75%) and stage III/IV cancer (6% vs. 40% vs. 17%).
“In ongoing studies, we are delving into understanding the drivers of differences between these populations (young, elderly and screened lung cancer populations),” Osarogiagbon told Healio.
“For example, why [do] the lung cancers diagnosed in the young seem to be so aggressive, despite significantly less tobacco exposure?” he said. “Why is the outcome of cancer in the elderly so much worse than in the other groups? Is it because of competing causes of death, cancer biology [or] relative frailty? ... Why did so much more of the elderly not receive treatment? Were they too sick or did they refuse or were they not offered treatment? How many of the adverse outcomes in the young (such as the tendency to present with more advanced disease) are caused by aggressive cancer biology vs. delayed access to care vs. perceived (but erroneous) low risk for lung cancer?”
Clinician takeaways, future research
These results should demonstrate to clinicians the importance of implementing processes that guarantee patients with incidentally detected lung nodules are managed based on guidelines, Osarogiagbon said.
“All health care systems should seriously consider investing in these processes and putting the teams together to ensure safe and effective management of all such patients,” he told Healio. “To achieve this, there has to be a structure for identifying all such patients and ensuring that their care is managed in an evidence-based manner; providing access to the diversity of populations whose lung cancer can be identified early through this means should be of paramount importance.
“Given the complexity of decision-making, there should be a dedicated team assigned to manage these patients,” Osarogiagbon added. The everyday clinician needs a place to direct these patients to so their care can be standardized, safe and effective. Guideline-concordant management of incidentally detected lung nodules saves lives. The everyday clinician needs to figure out how to make it happen in their environment of care.”
In terms of what research still needs to be done, Osarogiagbon told Healio lung cancer prediction must be improved.
“Future studies will attempt to improve the prediction of future lung cancer risk in individual patients, in order to winnow out the small minority of the lung nodule cohort (approximately 7%) who are destined to develop lung cancer, from the vast majority who will never develop lung cancer,” Osarogiagbon said.
Reference:
- Lung nodule program benefits patients ineligible for lung cancer screening. https://www.iaslc.org/iaslc-news/press-release/lung-nodule-program-provides-benefits-patients-ineligible-lung-cancer. Published Dec. 18, 2023. Accessed Dec. 18, 2023.