lung cancer

Importance: Small cell lung cancer (SCLC) is a high-grade neuroendocrine carcinoma with an incidence of 4.7 cases per 100 000 individuals in 2021 in the US and a 5-year overall survival of 12% to 30%.

Observations: Cigarette smoking is the primary risk factor for development of SCLC, as 95% of patients diagnosed with SCLC have a history of tobacco use. Patients with SCLC may present with respiratory symptoms such as cough (40%), shortness of breath (34%), hemoptysis (10%), or metastases with corresponding local symptoms (30%) such as pleuritis or bone pain; approximately 60% of patients with SCLC may be asymptomatic at diagnosis. Chest imaging may demonstrate central hilar (85%) or mediastinal lymphadenopathy (75%). At diagnosis, approximately 15% of patients have brain metastases, which may present as headache or focal weakness. Diagnosis is confirmed by biopsy of a primary lung mass, thoracic lymph node, or metastatic lesion. Small cell lung cancer is classified into limited stage (LS-SCLC; 30%) vs extensive stage (ES-SCLC; 70%) based on whether the disease can be treated within a radiation field that is typically confined to 1 hemithorax but may include contralateral mediastinal and supraclavicular nodes. For patients with LS-SCLC, surgery or concurrent chemotherapy with platinum-etoposide and radiotherapy is potentially curative in 30% of patients. More recently, median survival for LS-SCLC has reached up to 55.9 months with the addition of durvalumab, an immunotherapy. First-line treatment for ES-SCLC is combined treatment with platinum-etoposide chemotherapy and immunotherapy with the programmed cell death 1 ligand 1 (PD-L1) inhibitors durvalumab or atezolizumab followed by maintenance immunotherapy until disease progression or toxicity. Although initial rates of tumor shrinkage are 60% to 70% with platinum-etoposide and immunotherapy treatment, the median overall survival of patients treated for ES-SCLC is approximately 12 to 13 months, with 60% of patients relapsing within 3 months. Second-line therapy for patients with ES-SCLC includes the DNA-alkylating agent lurbinectedin (35% overall response rate; median progression-free survival, 3.7 months) and a bispecific T-cell engager against delta-like ligand 3, tarlatamab (40% overall response rate; median progression-free survival, 4.9 months).

Conclusions and relevance: Small cell lung cancer is a smoking-related malignancy that presents at an advanced stage in 70% of patients. Three-year overall survival is approximately 56.5% for LS-SCLC and 17.6% for ES-SCLC. First-line treatment for LS-SCLC is radiation targeting the tumor given concurrently with chemotherapy and followed by consolidation immunotherapy. For ES-SCLC, first-line treatment is chemotherapy and immunotherapy followed by maintenance immunotherapy.

Author/s:

So Yeon Kim, Henry S Park, Anne C Chiang

Cancer-Specific Mortality, All-Cause Mortality, and Overdiagnosis in Lung Cancer Screening Trials: A Meta-Analysis

Brian Desmarais — Thu, 12 Nov 2020 16:45:00 +0000

Date Added:

November 12, 2020

Journal/Publication:

Annals of Family Medicine

Publication Date:

November 1, 2020

Issue:

Volume:

Pages:

545-552

URL:

Cancer-Specific Mortality, All-Cause Mortality, and Overdiagnosis in Lung Cancer Screening Trials: A Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1370/afm.2582

Keywords

cancer screening

health services

low-dose computed tomography

An unbiased meta-analysis documenting that screening with low-dose CT reduces lung cancer mortality with a 20% rate of overdiagnoses. The number needed to screen to prevent one lung cancer death is 294. However, there is as yet no conclusive evidence that it reduces all-cause mortality. James W. Mold, MD, MPH

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Abstract

Purpose: Benefit of lung cancer screening using low-dose computed tomography (LDCT) in reducing lung cancer-specific and all-cause mortality is unclear. We undertook a meta-analysis to assess its associations with outcomes.

Methods: We searched the literature and previous systematic reviews to identify randomized controlled trials comparing LDCT screening with usual care or chest radiography. We performed meta-analysis using a random effects model. The primary outcomes were lung cancer-specific mortality, all-cause mortality, and the cumulative incidence ratio of lung cancer between screened and unscreened groups as a measure of overdiagnosis.

Results: Meta-analysis was based on 8 trials with 90,475 patients that had a low risk of bias. There was a significant reduction in lung cancer-specific mortality with LDCT screening (relative risk = 0.81; 95% CI, 0.74-0.89); the estimated absolute risk reduction was 0.4% (number needed to screen = 250). The reduction in all-cause mortality was not statistically significant (relative risk = 0.96; 95% CI, 0.92-1.01), but the absolute reduction was consistent with that for lung cancer-specific mortality (0.34%; number needed to screen = 294). In the studies with the longest duration of follow-up, the incidence of lung cancer was 25% higher in the screened group, corresponding to a 20% rate of overdiagnosis.

Conclusions: This meta-analysis showing a significant reduction in lung cancer-specific mortality, albeit with a tradeoff of likely overdiagnosis, supports recommendations to screen individuals at elevated risk for lung cancer with LDCT.

Keywords: cancer screening; health services; low-dose computed tomography; lung cancer; mass screening; overdiagnosis; preventive medicine; public health.

Author/s:

Ebell, M.H., Bentivegna, M., Hulme, C.

Lung Cancer Screening: A Clinician’s Checklist

Jeffrey Wilson — Mon, 22 Oct 2018 16:17:09 +0000

Date Added:

October 22, 2018

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

March 1, 2016

Issue:

URL:

Lung Cancer Screening: A Clinician’s Checklist

Type:

Clinical Decision Aids

Format:

Web Page

Keywords

MeSH

This is a checklist for use when helping smokers decide whether to be screened for lung cancer with low-dose CT.

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This checklist was developed to help clinicians meet the Centers for Medicare & Medicaid Services (CMS) criteria for a lung cancer screening counseling and shared decisionmaking visit. All of the criteria listed below must be met for the screening to be covered as a preventive service benefit under Medicare.

Lung cancer screening with low-dose computed tomography (LDCT) reduces mortality from lung cancer. There are also potential harms associated with lung cancer screening, including a high-false positive rate and the associated need for diagnostic followup, known and unknown risks of additional testing associated with incidental findings, cumulative radiation exposure, and overdiagnosis. Shared decisionmaking is a collaborative patient-centered process in which patients and clinicians make decisions together, within the context of the best evidence and recommendations and based on the patient’s values and preferences.