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Harry J De Koning
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MA03 - Lung Cancer Screening - Next Step (ID 896)
- Event: WCLC 2018
- Type: Mini Oral Abstract Session
- Track: Screening and Early Detection
- Presentations: 1
- Moderators:
- Coordinates: 9/24/2018, 10:30 - 12:00, Room 206 AC
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MA03.05 - New Subsolid Pulmonary Nodules in Lung Cancer Screening: The NELSON Trial (ID 11998)
11:00 - 11:05 | Author(s): Harry J De Koning
- Abstract
- Presentation
Background
A central challenge in low-dose computed tomography (LDCT) lung cancer screening is the identification of clinically relevant lung cancer, while preventing overdiagnosis and overtreatment. Subsolid nodules are particularly challenging as they carry a relatively high malignancy rate but possess a slow growth rate. Current guidelines propose a watchful waiting approach with CT surveillance. While new solid nodules after baseline screening have a high lung cancer probability at small size and require lower size cutoff values than baseline nodules, there only is limited evidence on management of new subsolid nodules. Aim of this study was to assess the occurrence and lung cancer frequency of new subsolid nodules and to determine whether a more aggressive follow-up approach is necessary for new subsolid nodules.
a9ded1e5ce5d75814730bb4caaf49419 Method
Within the Dutch-Belgian randomized controlled LDCT lung cancer screening trial (NELSON), 7557 participants underwent baseline screening between April 2004 and December 2006. Three incidence screening rounds took place 1 year, 3 years, and 5.5 years after baseline screening. Participants with new subsolid nodules detected after the baseline screening round were included. A nodule was classified as (pre-)malignancy when it was diagnosed as lung cancer during diagnostic workup including histologic assessment.
4c3880bb027f159e801041b1021e88e8 Result
In the three incidence screening rounds 60 new subsolid nodules not visible in retrospect (43 [72%] part-solid, 17 [28%] nonsolid) were detected in 51 participants (0.7% [51/7295] of participants with at least one incidence screening). Eventually, 6% (3/51) of participants with a new subsolid nodule was diagnosed with a (pre-)malignancy in such a nodule. The (pre-)malignancies were adenocarcinoma (in situ) and diagnostic work-up (referral 950, 364, and 366 days after first detection respectively) showed favorable staging (stage I). Overall, 65% (33/49) of subsolid nodules with follow-up screening were resolving.
8eea62084ca7e541d918e823422bd82e Conclusion
Less than 1% of participants in LDCT lung cancer screening presents with a new subsolid nodule after baseline. Contrary to new solid nodules, new subsolid nodules do not require a more aggressive follow-up approach than baseline nodules.
6f8b794f3246b0c1e1780bb4d4d5dc53Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MA18 - Modelling, Decision-Making and Population-Based Outcomes (ID 920)
- Event: WCLC 2018
- Type: Mini Oral Abstract Session
- Track: Treatment in the Real World - Support, Survivorship, Systems Research
- Presentations: 1
- Moderators:
- Coordinates: 9/25/2018, 13:30 - 15:00, Room 201 F
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MA18.06 - Patterns of Lung Cancer Care in the United States: Developments and Disparities (ID 11991)
14:00 - 14:05 | Author(s): Harry J De Koning
- Abstract
- Presentation
Background
The level of adherence to lung cancer treatment guidelines is unclear. The aims of this current study were to provide an overview of current patterns of lung cancer care in the United States and to identify possible disparities in receiving standard of care.
a9ded1e5ce5d75814730bb4caaf49419 Method
Using the National Cancer Database, we evaluated the first course therapy of 468,422 lung cancer cases diagnosed between 2010-2014. We used a series of multivariate logistic regression models to identify relationships between patient, tumor, and health care provider characteristics and receiving predefined stage-specific standards of care.
4c3880bb027f159e801041b1021e88e8 Result
Most common treatments were surgery only (15.2%), radiotherapy only (12.8%), chemotherapy only (13.5%), and radiotherapy and chemotherapy (26.2%). 22.1% of subjects received no treatment. Between 2010-2014, the use of Video-Assisted Thoracoscopic Surgery among surgically treated cases increased from 24.6% to 42.3%, while the rate of conversions to open surgery decreased from 18.3% to 10.4%. Among stage IA non-small cell lung cancer patients treated with thoracic radiotherapy, the use of Stereotactic Body Radiotherapy increased from 53.4% to 73.0%. Overall, only 63.3% of subjects received standard of care. Receiving surgery for early-stage non-small cell lung cancer was less likely with increasing age (for those 80 and over: odds ratio [OR], 0.08; 95% confidence interval [95%CI], 0.07-0.09), for non-Hispanic Blacks (OR, 0.59; 95%CI, 0.57-0.62), and for squamous cell histology (OR, 0.46; 95%CI, 0.45-0.47). These disparities were also present in other stages.
8eea62084ca7e541d918e823422bd82e Conclusion
Particularly elderly lung cancer patients, non-Hispanic Blacks, and those with squamous cell histology are less likely to receive standard of care. These disparities may have consequences for lung cancer screening, as the effectiveness depends on adequate treatment of lung cancer.
6f8b794f3246b0c1e1780bb4d4d5dc53Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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P1.11 - Screening and Early Detection (Not CME Accredited Session) (ID 943)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 9/24/2018, 16:45 - 18:00, Exhibit Hall
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P1.11-06 - Lung Cancer Probability in New Perifissural Nodules Detected in a Lung Cancer Screening Study (ID 13427)
16:45 - 18:00 | Author(s): Harry J De Koning
- Abstract
Background
In incidence lung cancer screening rounds, new lung nodules are a regular finding, with a higher lung cancer probability than baseline nodules. A substantial number of screen-detected nodules is classified as perifissural nodule (PFN). Previous studies showed that baseline PFNs and PFNs in clinical settings represent non-malignant lesions such as intrapulmonary lymph nodes. Whether this is also the case for incident PFNs is unknown. This study evaluates all newly detected nodules in the Dutch-Belgian randomized-controlled NELSON study with respect to perifissural classification and lung cancer probability.
a9ded1e5ce5d75814730bb4caaf49419 Method
All NELSON participants with a new solid nodule detected in screening round 2, 3 or 4 (1, 3, and 5.5 years after baseline, respectively), were enrolled in this substudy. Nodules were classified into three groups: intraparenchymal, vessel attached or fissure attached. Screening CT scans of participants with lung cancer based on a nodule classified as fissure attached, were re-evaluated by two radiologists (4 and 6 years of experience) to check whether this nodule was a typical, atypical or non-PFN. The fissure-attached cancers were matched based on size with benign cases (1:4), and the radiologists were blinded for the final nodule outcome. In case of discrepancy, a third radiologist (13 years of experience) arbitered.
4c3880bb027f159e801041b1021e88e8 Result
1,484 new nodules were detected in the second, third and final NELSON screening round in 949 participants (77.4% male, median age 59 [interquartile range: 55-63]). 1,393 nodules (93.8%) were benign based on 2 year follow-up or pathology; 96 of these (6.9%) were fissure attached. Lung cancer diagnosis was made in 74 new nodules in 74 participants (7.8% of participants with a new nodule). Nine lung cancers (12.1%) were fissure attached and re-evaluated by the radiologists. None of the fissure attached malignant new nodules was classified as a typical or atypical PFN.
8eea62084ca7e541d918e823422bd82e Conclusion
None of the lung cancers that originated from a new nodule in the NELSON study was classified as a typical or atypical PFN. Our results suggest that also in the case of a new PFN, it is highly unlikely that these PFNs will be diagnosed as lung cancer.
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P2.11 - Screening and Early Detection (Not CME Accredited Session) (ID 960)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 3
- Moderators:
- Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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P2.11-02 - Direct Comparison of New Solid Nodules Detected in Women and Men During Incidence Screening Rounds of the NELSON Trial (ID 12512)
16:45 - 18:00 | Author(s): Harry J De Koning
- Abstract
Background
Low-dose computed tomography (LDCT) lung cancer screening is recommended by US guidelines. Women are commonly underrepresented in lung cancer screening trials and evidence is derived from a predominantly male population. New solid nodules that develop after baseline screening have a high lung cancer probability. There is very limited evidence concerning the potential differences of new solid nodules detected in women and men.
a9ded1e5ce5d75814730bb4caaf49419 Method
In the randomized Dutch-Belgian Lung Cancer Screening (NELSON) Trial, 7,557 participants (16% female) underwent baseline screening. Three incidence rounds took place after intervals of 1year, 2years and 2.5years respectively. We included participants with solid non-calcified nodules registered after baseline as new and not visible in retrospect on a previous screen. Continuous variables were compared using the Mann–Whitney U test or student's t test and are presented as medians with interquartile range (IQR) or means with standard deviation (±) respectively. Nominal variables were compared using the chi-squared test.
4c3880bb027f159e801041b1021e88e8 Result
In total, 699 participants (149 [21%] women, 550 [79%] men) with 1,130 new solid nodules (241 [21%] in women, 889 [79%] in men) were included. Eventually, 5.4% of women with a new solid nodule and 10.4% of men with a new solid nodule were diagnosed with lung cancer (P=0.063), corresponding to 3.3% of new solid nodules being malignant in women and 6.5% being malignant in men (P=0.060). The female participants were significantly younger than the male participants (58±5 years vs. 60±5 years, P=0.008), while there was no significant difference in smoking pack-years (39 years [IQR 30-49] vs. 39 years [IQR 30-52], P=0.696). Comparing new nodule size at initial detection in women and men, there was a significant difference for benign new nodules (51mm3, IQR: 29-128mm3 vs. 66mm3, IQR: 35-177mm3, P=0.019), but not for lung cancers (449mm3, IQR: 52-1050mm3 vs. 447mm3, IQR: 196-1135mm3, P=0.553). The currently advocated cutoff of ≥30mm3 (about 3.9mm) reached >95% sensitivity in both genders. At first follow-up after detection, new solid nodules in women had resolved significantly more frequent than in men (69% vs. 58%, P=0.003). Adenocarcinomas were significantly more common in women than in men (88% of lung cancers vs. 31% of lung cancers, P=0.002), whereas the stage I detection rate was comparable (67% of lung cancers vs. 63% of lung cancers, P=0.789).
8eea62084ca7e541d918e823422bd82e Conclusion
While there are significant differences between new solid nodules detected after baseline in women and men, there is no indication for a sex specific nodule management approach in LDCT lung cancer screening.
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P2.11-04 - Treatment Capacity Required for Implementing Lung Cancer Screening in the United States (ID 13825)
16:45 - 18:00 | Author(s): Harry J De Koning
- Abstract
Background
Implementing Low-Dose Computed Tomography screening for lung cancer will lead to an increased detection of early stages. The required resources to treat those cancers remains unknown.
a9ded1e5ce5d75814730bb4caaf49419 Method
We extended a well-established microsimulation model with data from the National Cancer Database to assess the number of lung cancer patients requiring surgery, radiotherapy, chemotherapy, and no therapy when implementing lung cancer screening in the United States in 2018. Three screening policies were assessed: the United States Preventive Task Force (USPSTF) recommendations; the Centers for Medicare & Medicaid Services (CMS) recommendations; and the most cost-effective policy from a study for Cancer Care Ontario (annual screening, ages 55-75, at least 40-pack year smoking history, currently smoking or quit within last 10 years). Base-case screening adherence was 50%. Sensitivity analyses assessed 20%, 35%, 65% and 80% adherence.
4c3880bb027f159e801041b1021e88e8 Result
Implementing the USPSTF recommendations with 50% screening adherence would require 35.3% more lung cancer surgeries in 2015-2040 compared to no screening. However, 2.1% less radiotherapy and 5.1% less chemotherapy treatments would be required. Furthermore, 6.2% fewer patients would receive no therapy. The required number of lung cancer surgeries would be 75,379 in 2018, 58,155 in 2023, 55,269 in 2028, and 45,007 in 2040. Compared to no screening, this is an increase of 92.7% in 2018, 44.3% in 2023, 36.8% in 2028, and 23.0% in 2040. Screening adherence strongly influenced results. By 2018, the required number of surgeries would range from 53,666 (with 20% adherence) to 96,953 (with 80% adherence). Results for the CMS and Ontario policies were similar to the USPSTF policy, although changes compared to no screening were smaller.
8eea62084ca7e541d918e823422bd82e Conclusion
Implementing lung cancer screening in the United States requires a major increase in surgical capacity. The current workforce of thoracic surgeons in the United States may not be able to cope with this increased demand.
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P2.11-24 - Impact of Screening Interval Length on New Nodules Detected in Incidence Rounds of CT Lung Cancer Screening: the NELSON Trial (ID 12511)
16:45 - 18:00 | Author(s): Harry J De Koning
- Abstract
Background
Low-dose computed tomography lung cancer screening is recommended by US guidelines. New solid nodules are regularly found in incidence screening rounds and have a higher lung cancer probability than baseline nodules. Contrary to baseline nodules, new nodules develop within a known screening interval (time between previous screen and new nodule detection). There is limited evidence concerning the impact of varying screening interval lengths on new solid nodules.
a9ded1e5ce5d75814730bb4caaf49419 Method
In the randomized Dutch-Belgian Lung Cancer Screening (NELSON) Trial, 7,557 participants underwent baseline screening. Three incidence rounds took place after intervals of 12months, 24months and 30months respectively and follow-up intervals ranged from 2-12months. We included solid non-calcified nodules registered after baseline as new and not visible in retrospect. Using logistic regression, screening interval length was assessed as predictor for lung cancer whilst adjusting for nodule size. The correlation of screening interval length and new nodule size was assessed with Spearman's rank correlation. Discriminative performance for lung cancer was quantified as area under the receiver operating characteristics curve (AUC).
4c3880bb027f159e801041b1021e88e8 Result
Overall, 1,130 new solid nodules were included with 6% being lung cancer. Of the nodules, 13% were detected after a screening interval of <10months, 28% after 10-14months, 4% after 15-21months, 37% after 22-26months, and 20% after >26months. While the proportion of new solid nodules that subsequently resolved until first follow-up decreased with longer screening interval (76%, 70%, 59%, 57%, 41% respectively, p<0.001), the lung cancer proportion significantly increased (2%, 3%, 3%, 7%, 11% respectively, p=0.001). The screening interval length was a significant predictor for lung cancer when assessed in all nodules (p=0.018). However, there was no significant association when only assessed in nodules that persisted on first follow-up (p=0.223). Compared to benign nodules, lung cancer size at initial detection correlated stronger with screening interval length (spearman's rho 0.106 vs. 0.320) and the discriminative performance of volume for lung cancer increased with screening interval length (AUC: 0.71 at 10-14months vs. 0.84 at >26months). Comparing malignant nodules detected after 10-14months, 22-26months or >26months, the proportion of stage IA lung cancers decreased (73%, 63%, 39% respectively, p=0.139) and all IIIb/IV cancers were found after >22months.
8eea62084ca7e541d918e823422bd82e Conclusion
The longer the screening interval prior to new nodule detection, the lower the nodule’s probability to resolve and the higher the nodule’s lung cancer probability. While a longer screening interval might facilitate the discrimination between benign and malignant new solid nodules, there was a trend for less favorable staging.
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PL02 - Presidential Symposium - Top 5 Abstracts (ID 850)
- Event: WCLC 2018
- Type: Plenary Session
- Track: Advanced NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 9/25/2018, 08:15 - 09:45, Plenary Hall
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PL02.05 - Effects of Volume CT Lung Cancer Screening: Mortality Results of the NELSON Randomised-Controlled Population Based Trial (ID 14722)
08:45 - 08:55 | Presenting Author(s): Harry J De Koning
- Abstract
- Presentation
Abstract
The NELSON-trial is a population-based RCT using nodule volume management for referral, initiated to show a 25% LC mortality reduction in males at 10-years of follow-up.
606,409 persons, aged 50-74, in the Netherlands and Leuven were sent a general questionnaire about risk factors, leading to 150,920 responders. 30,959 responders were eligible and invited to participate, of which 15,822 gave informed consent and were randomized (1:1). CT-screening was offered to study arm participants at baseline and 1, 3 and 5.5 years after randomization, whereas no screening was offered to control arm participants. Participant’s records were linked to national registries with 100% coverage regarding cancer diagnosis (Netherlands Cancer Registry), date of death (Centre for Genealogy) and cause of death (Statistics Netherlands). Medical files for deceased lung cancer patients up to 2013 were reviewed by an expert panel (blinded to study arm); cause of death reported by Statistics Netherlands was used thereafter. Follow up to 31.12.2015 comprised a minimum duration of 10 years for 98.7% enrolled (unless deceased). A pre-determined 9-year analysis was also considered due to dilution effects by screening design given growth rate of LC.
CT screening compliance was 94% on average, leading to a total of 29,736 scans. In 9.1% of the participants additional CT scans within 2 months were performed to estimate nodule Volume Doubling Time, leading to an overall referral rate of 2.1% for suspicious nodules. Detection rates across the rounds varied between 0.8-1.0%, and 69% of screen-detected LC were detected at stage IA or B. 261 lung cancers (52 interval cancers) were detected before the 4th round. In a subset of analyzed patients, surgical treatment was 3 times significantly more prevalent in study LC patients than in control arm patients (67.7% versus 24.5%, p<0,001). In total 934 participants have died in the control arm (NL), versus 904 in the study arm (NL). In the Dutch female enrolled participants, the rate-ratio of dying from lung cancer was 0.73 at 10-years, and 0.58 at 9-years FU.
The minimum 10-year FU for NELSON has been realized, and full data on incidence, mortality and cause of death are equally available for both arms. A (non- significant) 41.8% lung cancer mortality reduction has been achieved in the small subset of 2,382 Dutch women. Post-hoc analysis shows a 51.4% (p=0.04) LC mortality reduction at 8 years of FU. Data for the full cohort will be presented on behalf of NELSON-investigators.
e353dbe42c8654f33588d4da0b517469Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
