lung neoplasms

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

Lung Cancer Screening with Low-Dose CT: a Meta-Analysis

Carly Hughes — Wed, 21 Oct 2020 14:34:36 +0000

Date Added:

October 22, 2020

Journal/Publication:

Journal of General Internal Medicine

Publisher:

Society of General Internal Medicine

Publication Date:

June 24, 2020

Issue:

Volume:

Pages:

3015-3025

URL:

Lung Cancer Screening with Low-Dose CT: a Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1007/s11606-020-05951-7

Keywords

low-dose computed tomography

lung cancer screening

lung neoplasms

meta-analysis

mortality

PMID (1):

32583338

MeSH

lung neoplasms

tomography, x-ray computed

Carcinoma

The abstract of a met-analysis showing that lung cancer screening with low-dose CT reduces the risk of lung cancer deaths with around 8% false positive screens and a very low rate of documented untoward effects of those false positives. James W. Mold, MD, MPH

Commercial full text (fees may apply)

View

Background: Randomized controlled trials have evaluated the efficacy of low-dose CT (LDCT) lung cancer screening on lung cancer (LC) outcomes.

Objective: Meta-analyze LDCT lung cancer screening trials.

Methods: We identified studies by searching PubMed, Google Scholar, the Cochrane Registry, ClinicalTrials.gov , and reference lists from retrieved publications. We abstracted data on study design features, stage I LC diagnoses, LC and overall mortality, false positive results, harm from invasive diagnostic procedures, overdiagnosis, and significant incidental findings. We assessed study quality using the Cochrane risk-of-bias tool. We used random-effects models to calculate relative risks and assessed effect modulators with subgroup analyses and meta-regression.

Results: We identified 9 studies that enrolled 96,559 subjects. The risk of bias across studies was judged to be low. Overall, LDCT screening significantly increased the detection of stage I LC, RR = 2.93 (95% CI, 2.16-3.98), I2 = 19%, and reduced LC mortality, RR = 0.84 (95% CI, 0.75-0.93), I2 = 0%. The number needed to screen to prevent an LC death was 265. Women had a lower risk of LC death (RR = 0.69, 95% CI, 0.40-1.21) than men (RR = 0.86, 95% CI, 0.66-1.13), p value for interaction = 0.11. LDCT screening did not reduce overall mortality, RR = 0.96 (95% CI, 0.91-1.01), I2 = 0%. The pooled false positive rate was 8% (95% CI, 4-18); subjects with false positive results had < 1 in 1000 risk of major complications following invasive diagnostic procedures. The most valid estimates for overdiagnosis and significant incidental findings were 8.9% and 7.5%, respectively.

Discussion: LDCT screening significantly reduced LC mortality, though not overall mortality, with women appearing to benefit more than men. The estimated risks for false positive results, screening complications, overdiagnosis, and incidental findings were low. Long-term survival data were available only for North American and European studies limiting generalizability.

Author/s:

Hoffman, Richard M., Atallah, Rami P., Struble, Roger D., Badgett, Robert G

Incidental Pulmonary Nodules Detected on CT Images

Tracy Ashby — Mon, 12 Nov 2018 06:00:00 +0000

Date Added:

November 12, 2018

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

November 8, 2018

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2018.16336

Keywords

pulmonary nodules

ct scan

MeSH

multiple pulmonary nodules

tomography, x-ray computed

lung neoplasms

These are the current recommendations for management of pulmonary nodules found on CT.

Commercial full text (fees may apply)

View

Summary of the Clinical Problem

An incidental lung nodule on CT scan can create uncertainty for clinicians and anxiety for patients and families, given that lung cancer is the leading cause of cancer mortality in the United States. Incidental lung nodules are not uncommon. A systematic review of CT screening lung cancer trials noted that a lung nodule was detected in up to 51% of study participants.1 More than 95% of detected nodules are benign and have a wide variety of causes, including infections, granulomatous disease, hamartomas, arteriovenous malformations, round atelectasis, and lymph nodes.

Author/s:

Anderson, Irsk J., Davis, Andrew M.

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.

Free full text

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.