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Matthew Eric Callister



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    MS16 - Implementation of Lung Cancer Screening (ID 795)

    • Event: WCLC 2018
    • Type: Mini Symposium
    • Track: Screening and Early Detection
    • Presentations: 1
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      MS16.05 - Optimal Approach to Integrate Smoking Cessation into Screening Program (ID 11472)

      14:30 - 14:45  |  Presenting Author(s): Matthew Eric Callister

      • Abstract

      Abstract

      Smoking cessation should be an integral part of low dose CT (LDCT) screening for lung cancer. Smoking cessation and LDCT screening have additive effects on reducing lung cancer mortality, with 7 years smoking abstinence delivering a mortality reduction comparable with the benefit of screening itself [1]. It is well known that a positive screening result increases the likelihood of quitting [2]. However, the majority of people undergoing screening receive a negative result (73% and 78% in the National Lung Screening Trial at prevalence and incidence rounds, rising to 86% and 94% when scans were re-evaluated using the Lung-RADS classification) [3].

      A negative result has the potential to falsely reassure participants and thus reduce the incentive to quit - the so-called ‘licence to smoke’ effect. This effect can only be properly assessed by comparison with an unscreened control population. Analysis from the NELSON study suggested such an effect may exist by demonstrating a higher quit rate in the unscreened control group compared to screened participants, although the effect lost statistical significance following intention to treat analysis [4]. However, this finding has not been replicated in two subsequent European studies. LDCT screening appeared to have no effect on smoking behaviours in the Danish Lung Cancer Screening Trial [5], and the LDCT screened arm had a higher quit rate than non-screened controls in the UK Lung Screening Pilot [6]. All three studies showed higher quit rates in both study arms compared to the background population, although such comparisons are likely to be subject to significant bias related to participation in a CT screening study.

      Thus although there is no convincing evidence of a licence-to-smoke effect, smoking cessation interventions in screening programmes are vital to guard against this, and to maximise the mortality benefits of these two interventions combined. One of the key questions regarding smoking cessation and screening is whether interventions that have worked in other settings should simply be transferred to screening programmes, or whether bespoke smoking cessation interventions are needed for this particular scenario.

      LDCT screening for lung cancer is itself a relatively recent phenomenon, having been introduced in the US and Canada following recommendations in 2013 and 2016 respectively. Accordingly, research into Smoking Cessation in the context of Lung Cancer Screening is in its relative infancy, a point acknowledged by the joint guideline on this topic produced by the Association for the Treatment of Tobacco Use and Dependence, and the Society for Research on Nicotine and Tobacco published in 2016 [7]. Most of the active research in this area is occurring within the SCALE collaboration (Smoking Cessation within the Context of Lung Cancer Screening) [8], constituting 8 clinical trials, 7 funded by the National Cancer Institute and 1 by the Veterans Health Administration. These trials are assessing various strategies of smoking cessation support including on-site individual counselling, use of a telephone quit-line, digital cessation tools, motivational interviewing, nicotine replacement medications and message framing (gain vs. loss). Many of these studies are assessing the cost-effectiveness of these interventions, as incorporation of successful smoking cessation interventions into screening is likely to significantly improve the cost effectiveness of the bundle.

      Whilst outcome data is awaited from these studies, interventions that have been shown to be effective in other settings should be applied to lung cancer screening programmes. Brief interventions by clinicians should cover the 5As of smoking cessation (ask, advise, assess, assist, and arrange follow-up). Analysis of primary care-delivered smoking cessation in NLST showed that arranging follow-up was associated with the highest chance of quitting (OR 1.46; 95% CI 1.19-1.76) but was only delivered in 10% of cases [9]. The UK National Institute for Clinical Excellence (NICE) has produced evidence based guidelines for Stop Smoking Interventions and Services [10]. These include providing behavioural support by trained stop smoking staff together with provision of bupropion, varenicline or nicotine replacement therapy; setting quit dates; and checking self-reported abstinence using carbon monoxide monitoring at 4 weeks after the quit date. Studies mentioned above are testing whether less labour intensive alternatives might achieve similar results to on-site individual smoking cessation counselling. However, until such proof of equivalence is available, it might be argued that given the importance of combining screening with effective smoking cessation, the ‘gold-standard’ described by NICE or equivalent bodies should be routinely available to any current smoker undergoing LDCT screening.

      1. Tanner, N.T., et al., The Association between Smoking Abstinence and Mortality in the National Lung Screening Trial. Am J Respir Crit Care Med, 2016. 193(5): p. 534-41.

      2. Tammemagi, M.C., et al., Impact of lung cancer screening results on smoking cessation. J Natl Cancer Inst, 2014. 106(6): p. dju084.

      3. Pinsky, P.F., et al., Performance of Lung-RADS in the National Lung Screening Trial: a retrospective assessment. Ann Intern Med, 2015. 162(7): p. 485-91.

      4. van der Aalst, C.M., et al., Lung cancer screening and smoking abstinence: 2 year follow-up data from the Dutch-Belgian randomised controlled lung cancer screening trial. Thorax, 2010. 65(7): p. 600-5.

      5. Ashraf, H., et al., Smoking habits in the randomised Danish Lung Cancer Screening Trial with low-dose CT: final results after a 5-year screening programme. Thorax, 2014. 69(6): p. 574-9.

      6. Brain, K., et al., Impact of low-dose CT screening on smoking cessation among high-risk participants in the UK Lung Cancer Screening Trial. Thorax, 2017. 72(10): p. 912-918.

      7. Fucito, L.M., et al., Pairing smoking-cessation services with lung cancer screening: A clinical guideline from the Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco. Cancer, 2016. 122(8): p. 1150-9.

      8. Joseph, A.M., et al., Lung Cancer Screening and Smoking Cessation Clinical Trials. SCALE (Smoking Cessation within the Context of Lung Cancer Screening) Collaboration. Am J Respir Crit Care Med, 2018. 197(2): p. 172-182.

      9. Park, E.R., et al., Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial. JAMA Intern Med, 2015. 175(9): p. 1509-16.

      10. Stop smoking interventions and services, 2018, National Institute for Clinical Excellence.

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    P2.16 - Treatment of Early Stage/Localized Disease (Not CME Accredited Session) (ID 965)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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      P2.16-16 - SABRTOOTH: A Fasibility Study of SABR Versus Surgery in Patients with Peripheral Stage I NSCLC Considered to be at Higher Risk for Surgery. (ID 13679)

      16:45 - 18:00  |  Author(s): Matthew Eric Callister

      • Abstract

      Background

      Stage I NSCLC is curable by surgery and Stereotactic Ablative Radiotherapy (SABR). Many patients have co-morbidities that place them at higher risk of surgical complications. For such patients it is unknown whether the potential benefits of surgery are outweighed by the risks since published randomised trials comparing surgery with SABR have been underpowered. The SABRTooth study was designed to determine the feasibility of randomising patients between the two treatments and thus performing a larger RCT.

      Method

      Four thoracic oncology centres and a referral site participated. Patients with peripheral (>2cm from the main airways) stage T1-T2bN0M0 NSCLC were considered for study entry. Patients at higher risk were identified using several criteria including Thoracoscore and the Nottingham Risk Score and confirmed by multidisciplinary team consensus.

      Eligible patients were approached by a respiratory physician and research nurse, consented and randomised (1:1) before consulting a surgeon or oncologist. Surgery was preferably by lobectomy with lymph node sampling/resection although sub-lobar resection was permitted. SABR was delivered as per the UK SABR guidelines.

      An average recruitment rate of 3 patients/month from the 5 centres over a formal monitoring period was set to prove feasibility of a larger RCT. Meetings with the trial sites and patient representatives were held through-out to improve recruitment. Qualitative research was embedded into the study with interviews for patients who declined participation or randomised treatment.

      Result

      Between July 2015-January 2017 318 patients were assessed for eligibility of which 106 were initially considered eligible. 84 patients were approached for the study and 24 (29%) were randomised (10 surgery, 14 SABR); a mean recruitment rate of 1.7 per month. The median age was 75 (range 54-88). The main reason for declining the study was patient preference with 29% preferring surgery and 42% SABR. Overall 9/24 (38%) did not receive their randomised treatment. Of 7 patients randomised to surgery, 6 received SABR, 1 radical radiotherapy and of 2 patients randomised to SABR, 1 received radical radiotherapy, 1 was lost to follow-up.

      Conclusion

      Despite recruiting at higher rate/centre than previous SABR versus surgery trials, the SABRTooth study failed to meet its recruitment target and the majority of patients randomised to surgery subsequently underwent SABR. Therefore, conducting a large RCT in the UK was shown not to be feasible. However, establishing which patients should have surgery or SABR for early stage NSCLC remains a critical question and alternative study designs are being developed to provide an answer for patients and clinicians.

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    P3.16 - Treatment of Early Stage/Localized Disease (Not CME Accredited Session) (ID 982)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/26/2018, 12:00 - 13:30, Exhibit Hall
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      P3.16-08 - Baseline Quality of Life is Influenced by the Duration of Abstinence from Smoking in Candidates to Lung Cancer Surgery (ID 12350)

      12:00 - 13:30  |  Author(s): Matthew Eric Callister

      • Abstract

      Background

      The optimal interval of smoking cessation before Non-Small Cell Lung Cancer (NSCLC) surgery is still unknown. The objective of this study is to evaluate the influence of smoking cessation on the preoperative quality of life (QoL) of surgical NSCLC patients.

      Method

      266 consecutive ever smokers (133 females) with a pack year history >=20 undergoing lung resections for NSCLC and with complete preoperative QoL data were analysed. The EORTC QoL summary score was calculated (SumS) as the average of the individual functional and reversed symptom scales (excluding Global-Health and Financial-Impact scales). The following smoking-related variables were tested for a possible association with SumS: age when the patient quit smoking and months elapsed from smoking cessation (for current smokers a value of 0 was used). These variables were entered as independent predictors in a stepwise multivariable regression analysis along with several patient-related baseline factors.

      Result

      108 patients were current smokers, 158 were ex smokers (quit at least 1month before surgery). We found no difference of preoperative QoL SumS between current smokers and ex smokers (81.5 vs. 83.0, p=0.66). Amongst the 158 ex-smokers, 69 quit smoking before the age of 60. Their SumS was similar to the one of those who quit older (84.2 vs. 82.0, p=0.30). A linear regression showed a significant association between the duration of abstinence from smoke and their QoL SumS (coefficient 0.02, SE 0.009, p=0.03). When the analysis was adjusted for other confounders using a multivariable regression analysis, the duration of abstinence from smoking (p<0.0001-longer time better QoL)(Fig1) and the age at which the patient quit smoking (p=0.001-older age better QoL)remained independently associated with SumS along with performance score.

      Figure 1: Lowess Curve plotting SumS against the months elapsed from the time quit smoking.

      fig 1.tif

      Conclusion

      Patients should be counselled to stop smoking prior surgery independently as the QoL has expected to increase.

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    S01 - IASLC CT Screening Symposium: Forefront Advances in Lung Cancer Screening (Ticketed Session) (ID 853)

    • Event: WCLC 2018
    • Type: Symposium
    • Track: Screening and Early Detection
    • Presentations: 1
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      S01.17 - Session V: Panel Discussion: Next Steps for Lung Screening? (ID 11898)

      10:30 - 11:30  |  Presenting Author(s): Matthew Eric Callister

      • Abstract
      • Slides

      Abstract not provided

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