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Martin Tammemägi
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MA20 - Implementation of Lung Cancer Screening (ID 923)
- Event: WCLC 2018
- Type: Mini Oral Abstract Session
- Track: Screening and Early Detection
- Presentations: 2
- Moderators:
- Coordinates: 9/25/2018, 15:15 - 16:45, Room 206 F
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MA20.01 - Lung Cancer Screenee Selection by USPSTF versus PLCOm2012 Criteria – Preliminary ILST Findings (ID 14331)
15:15 - 15:20 | Presenting Author(s): Martin Tammemägi
- Abstract
- Presentation
Background
Background
The National Lung Screening Trial showed that lung cancer screening of high-risk individuals with low dose computed tomography can reduce lung cancer mortality by 20%. Critically important is enrolling high-risk individuals. Most current guidelines including the United States Preventive Services Task Force (USPSTF) and Center for Medicare and Medicaid Services (CMS) recommend screening using variants of the NLST eligibility criteria: smoking ≥30 pack-years, smoking within 15 years, and age 55-80 and 55-77 years. Many studies indicate that using accurate risk prediction models is superior for selecting individuals for screening, but these findings are based on retrospective analyses. The International Lung Screen Trial(ILST) was implemented to prospectively identify which approach is superior.
a9ded1e5ce5d75814730bb4caaf49419 Method
Methods
ILST is a multi-centred trial enrolling 4000 participants. Individuals will be offered screening if they are USPSTF criteria positive or have PLCOm2012 model 6-year risk ≥1.5%. Participants will receive two annual screens and will be followed for six years for lung cancer outcomes. Individuals not qualifying by either criteria will not be offered screening, but samples of them will be followed for lung cancer outcomes. Outcomes in discordant groups, USPSTF+ve/PLCOm2012-ve and USPSTF-ve/PLCOm2012+ve, are informative. Numbers of lung cancers, abnormal suspicious for lung cancer scans (a marker of future lung cancers) and individuals enrolled, and sensitivity and specificity and positive predictive values of the two criteria will be compared.
4c3880bb027f159e801041b1021e88e8 Result
Results
As of March 2018, ILST centers in Canada (British Columbia and Alberta), Australia, and the United Kingdom had enrolled and scanned 1938 individuals. Study results are summarized in Figure 1.
8eea62084ca7e541d918e823422bd82e Conclusion
Conclusion
Interim analysis of ILST data, suggests that classification accuracy of lung cancer screening outcomes support the PLCOm2012 criteria over the USPSTF criteria. Individuals who are USPSTF+ve and PLCOm2012-ve appear to be at such low baseline risk (0.46%) that they may be unlikely to benefit from screening.
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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MA20.06 - Lung Cancer Screening Pilot for People at High Risk: Early Results on Cancer Detection and Staging (ID 13890)
15:50 - 15:55 | Presenting Author(s): Martin Tammemägi
- Abstract
- Presentation
Background
In June 2017, Cancer Care Ontario initiated organized lung cancer screening for people at high risk of developing lung cancer, using annual low-dose computed tomography (LDCT), at three pilot sites in Ontario. A key indicator of pilot success is detection of lung cancers at early stages. Ontario Cancer Registry (OCR) is used to track lung cancer diagnosis, stage and histology.
a9ded1e5ce5d75814730bb4caaf49419 Method
Patient abstracts were created using Registry Plus CDC abstracting software for pilot participants and patient-level data were collected from hospital data submissions, hospital electronic medical records via remote access, OCR pathology database (eMaRC) and OCR clinical source records (Resolink). Confirmed lung cancer cases were reviewed by a team of cancer staging analysts to achieve consensus on stage group using AJCC TNM 8th edition. A post-staging review was conducted for all staged cases to ensure accuracy and completeness.
4c3880bb027f159e801041b1021e88e8 Result
As of February 2018, 1086 participants received a baseline LDCT scan. 37% (n=404) of participants had Lung-RADS™ scores of 1; 45% (n=487) had Lung-RADS™ scores of 2; 10% (n=112) had Lung-RADS™ scores of 3; and 8% (n=83) had Lung-RADS™ scores of 4A, 4B or 4X, which triggered additional follow-up or diagnostic workup. 18 lung cancers were confirmed and 11 were fully staged.
Of the 11 staged cases: 45% (n=5) was stage I; 9% (n=1) stage II; 9% (n=1) stage III; and 36% (n=4) stage IV. This represents a statistically significant increase in the proportion of early stage lung cancers (stage I and II) compared to historical proportions (p<0.05). 73% (n=8) were adenocarcinoma. The median risk score (i.e., PLCOm2012 risk prediction model probability of developing lung cancer in 6 years) was 8.1%, considerably higher than the median risk score of the overall pilot cohort (2.9%). 82% (n=9) had baseline Lung-RADS™ scores of 4X and 18% (n=2) had 4B. The average age at diagnosis was 67. 45% (n=5) were male; 55% (n=6) were current smokers; and 55% (n=6) had high school education or less. In addition, the screening pilot facilitated the successful transition by the OCR from AJCC TNM 7th to TNM 8th edition in lung cancer staging. Results will be updated in the conference presentation.
8eea62084ca7e541d918e823422bd82e Conclusion
Early pilot results demonstrate success in detecting early stage lung cancers and a statistically significant stage shift to earlier cancer stages. We anticipate a greater proportion of early stage lung cancers on annual recall LDCT scans. The OCR efficiently enabled capturing important incidence, staging and histological pilot data.
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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MS29 - Selection into Screening Programs: Interplay of Risk Algorithms, Genetic Markers and Biomarkers (ID 807)
- Event: WCLC 2018
- Type: Mini Symposium
- Track: Screening and Early Detection
- Presentations: 1
- Moderators:
- Coordinates: 9/26/2018, 13:30 - 15:00, Room 206 F
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MS29.01 - Assessment of Risk Prediction Algorithms for Entry into Screening Programs (ID 11525)
13:35 - 13:50 | Presenting Author(s): Martin Tammemägi
- Abstract
- Presentation
Abstract not provided
Only 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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OA09 - Prevention and Cessation (ID 909)
- Event: WCLC 2018
- Type: Oral Abstract Session
- Track: Prevention and Tobacco Control
- Presentations: 2
- Moderators:
- Coordinates: 9/24/2018, 15:15 - 16:45, Room 205 BD
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OA09.02 - Acceptance of Smoking Cessation Services in Cancer Care Ontario’s Lung Cancer Screening Pilot for People at High Risk (ID 13032)
15:25 - 15:35 | Author(s): Martin Tammemägi
- Abstract
- Presentation
Background
Participation in lung cancer screening can be a teachable moment for smoking cessation. Current smokers who attend for lung screening may also be motivated to quit. In June 2017, Cancer Care Ontario launched organized lung cancer screening at 3 pilot sites in Ontario with smoking cessation embedded in the screening pathway. Participants are recruited through primary care providers and public-facing messaging.
a9ded1e5ce5d75814730bb4caaf49419 Method
Smoking cessation services (SCS) are offered to all current smokers (anyone who smoked a cigarette in the past 30 days) interacting with the pilot. Individuals found ineligible for screening are offered a direct referral to the Canadian Cancer Society’s Smokers’ Helpline. Screen-eligible individuals are scheduled for smoking cessation counselling during their baseline low-dose computed tomography (CT) appointment, using an opt-out approach. Hospital-based SCS are provided by trained counsellors and consist of 10 minutes (minimum) of behavioural counselling, a recommendation or prescription for pharmacotherapy, and arrangements for proactive follow-up. The proportions of current smokers who accept referral to SCS and who attend hospital-based smoking cessation counselling are being monitored throughout the pilot. A participant satisfaction survey is completed after the screening appointment (if applicable). Data on quit rates, quit attempts, heaviness of smoking and relapse among screening participants is being captured.
4c3880bb027f159e801041b1021e88e8 Result
Between June and October 2017, 50% of the 1241 individuals who underwent risk assessment to determine eligibility for screening were current smokers. Of the 808 individuals eligible for screening, 63% were current smokers: 52% were male, (age 55-64, 61%; 65-74, 39%), 55% had a high school education or less. 27% of ineligible individuals were current smokers. 83% of all current smokers (regardless of screen-eligibility) accepted a referral to SCS. Of screen-eligible current smokers, 89% accepted hospital-based cessation counselling; 88% of those who had a baseline low-dose CT in the reporting period attended a hospital-based counselling session. 93% of survey respondents (response rate 56%) reported being satisfied with the smoking cessation counselling they received.
8eea62084ca7e541d918e823422bd82e Conclusion
Acceptance of SCS by current smokers in Cancer Care Ontario’s lung cancer screening pilot is very high. A large majority of screened current smokers have attended a hospital-based counselling session, and satisfaction with this service was high. These findings suggest that an opt-out approach is acceptable to individuals motivated to attend a lung screening program. The final pilot evaluation in spring 2020 will evaluate the success of the smoking cessation initiative by assessing quit attempts, quit rates and relapse among screening participants.
6f8b794f3246b0c1e1780bb4d4d5dc53Information from this presentation has been removed upon request of the author.
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OA09.07 - Association Between Outdoor Air Pollution And Lung Cancer in Female Never Smokers (ID 14485)
16:20 - 16:30 | Author(s): Martin Tammemägi
- Abstract
- Presentation
Background
Long term exposure to ambient particulate matter (PM2.5) has been associated with an increased risk of developing lung cancer, and is estimated to be responsible for ~23% of global lung cancer deaths. No current lung cancer screening risk prediction model uses air pollution as an individual risk factor in its risk calculation. As smoking rates decrease globally, and air pollution increases, it is important to assess the effect of long term outdoor air pollution exposure on lung cancer risk especially in never smokers.
a9ded1e5ce5d75814730bb4caaf49419 Method
We enrolled 421 patients with newly diagnosed lung cancer presenting to BC Cancer and conducted a detailed residential history from birth to estimate their air pollution exposure since 1996 when accurate high-resolution concentration estimates of PM2.5 particulate matter derived from satellite observations and ground measurements became available. The average PM2.5 exposure was quantified by combining residential histories with exposure data.
4c3880bb027f159e801041b1021e88e8 Result
The demographics of the 262(62%) ever smokers, and 159(38%) never smokers with lung cancer are shown in Table 1. Median exposure of all cancer patients was 7.1 PM2.5 ug/m3 (IQR 6.8-7.3; Range 4.3-65.8). Of the ever smokers, 6.1% had a PM2.5 >10 ug/m3 whereas 15.1% of the never smokers had a PM2.5 >10 ug/m3. Among never smokers with lung cancer with high PM2.5 exposure >10 ug/m3, 74% were female and 83% were of Asian descent. Using a logistic regression model, we demonstrated a significant association between air pollution exposure and never smokers compared to ever smokers in women: Odds Ratioper_1_LN-transformed unit = 12.05 (p<0.001). This association was absent in males (interaction p=0.006).
8eea62084ca7e541d918e823422bd82e Conclusion
6f8b794f3246b0c1e1780bb4d4d5dc53
In women with lung cancer, outdoor air pollution exposure was significantly higher in never smokers than in ever smokers. This association was not observed in men with lung cancer.Information from this presentation has been removed upon request of the author.
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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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P1.11-15 - Application of Lung-RADS vs. PAN-CAN Nodule Risk Calculation in the Alberta Lung Cancer Screening Study (ID 13052)
16:45 - 18:00 | Author(s): Martin Tammemägi
- Abstract
Background
False positive or negative examinations and high early recall rates are important factors in the performance of lung cancer screening programs. How low-dose chest tomography (LDCT) scans are interpreted and classified may impact these metrics.
a9ded1e5ce5d75814730bb4caaf49419 Method
LDCT examinations for participants in the Alberta Lung Cancer Screening Study (ALCSS) were interpreted by chest radiologist with information entered in a synoptic report. Baseline scans were classified according to highest risk of malignancy nodule as per the PAN-CAN nodule risk calculator (NRC) and according to the Lung-RADS scheme. A positive scan was any baseline LDCT requiring any intervention beyond an annual screening examination (NRC nodule with ≥5% malignancy risk; Lung-RADS category ≥3). In the calculation of sensitivity, false negative scans could include reader error or classification errors (NRC <5% or Lung-RADS <3 but cancer present regardless of perceived appropriateness of resulting management).
4c3880bb027f159e801041b1021e88e8 Result
Seven hundred and seventy-six participants in the ALCSS underwent LDCT screening and had no prior chest CT imaging on file. Median follow-up was 572 days (+/-205) with lung cancer confirmed in 16 (2.1%) participants. The early recall rate was 9.0% for NRC and 11.2% for Lung-RADS (p=0.044), with fair concordance between each approach (kappa 0.554). Sensitivity for malignancy was 87.5% vs. 87.5% (difference 0%, 95%CI -0.44%-0.44%) and specificity 92.6% vs. 90.4% (difference 2.2%, 95%CI 0.2%-4.3%) for NRC and Lung-RADS respectively. False negative screens were due to reader error (same case in both systems); and classification error (one different case for each system).
8eea62084ca7e541d918e823422bd82e ConclusionCancer +
Cancer -
Total
NRC +
14
56
70
NRC -
2
704
706
Lung-RADS +
14
73
87
Lung-RADS -
2
687
689
Total
16
760
776
Performance of both the NRC and Lung-RADS in the ALCSS was very good, with NRC resulting in a lower early recall rate. Application of the NRC demonstrated increased specificity over Lung-RADS without a change in sensitivity for lung cancer detection. Lung cancer program performance may be improved with the use of the PAN-CAN NRC classification.
6f8b794f3246b0c1e1780bb4d4d5dc53
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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: 1
- Moderators:
- Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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P2.11-23 - Risk Perception Among a Lung Cancer Screening Population (ID 13045)
16:45 - 18:00 | Author(s): Martin Tammemägi
- Abstract
Background
To make lung cancer screening feasible, populations with the highest risk of developing cancer need to be targeted. Furthermore, factors which motivate individuals to participate in lung cancer screening programs should be integrated into recruitment strategies. Among these motivators, an individual’s perception of their lung cancer risk is an important consideration. This paper analyzes factors associated with risk perception in subjects enrolled in the Pan-Canadian Early Detection of Lung Cancer Study (PanCan), and assesses the relationship between subjects’ risk perception and actual calculated risk.
a9ded1e5ce5d75814730bb4caaf49419 Method
The PanCan low-dose screening CT study recruited individuals from the general population who were current or former smokers age 50-75 having at least a 2% risk of developing lung cancer over 6 years as calculated by the PanCan model. Risk perception was captured at baseline with a 5-point Likert scale question asking the subject to assess their personal chances of being diagnosed with lung cancer compared with other smokers of the same age. Multivariate linear regression analysis was used to assess the relationship between risk factors and risk perception. Baseline risk variables in the model include demographics, smoking history, symptoms, medications, occupation, previous chest imaging, history of COPD, medical comorbidities, and family history of cancer.
4c3880bb027f159e801041b1021e88e8 Result
2514 patients were included in the analysis. Median age was 62.3, 55.3% were male, median pack-year smoking history was 50 years (range 2.2-230), and median calculated lung cancer risk was 3.4% over 6 years (range 2-38.2). Calculated lung cancer risk increased by 0.08% (SE 0.02, p-value=0.001) for each increase in Likert risk perception category. On multivariable analysis, the following variables were associated with risk perception category: cigarettes smoked per day (+0.003 increase in category / cigarette, p=0.083), presence of dyspnea (+0.192), presence of wheeze (+0.272), known COPD (+0.110), no family history of cancer (-0.476) and no family history of lung cancer (-0.385) (all p<0.001). Increased perception of risk was associated with intent to quit smoking within 6 months (p<0.001).
8eea62084ca7e541d918e823422bd82e Conclusion
In this lung cancer screening study, risk perception was positively associated with calculated risk for lung cancer, despite a minimum 2% risk in the cohort. Individual factors and family history of cancer predicted risk perception. Risk perception was also associated with a willingness to quit smoking. Self-risk perception and associated factors could be used to tailor recruitment strategies to screening programs. The link between risk perception and willingness to quit smoking could aid integrated tobacco cessation programs.
6f8b794f3246b0c1e1780bb4d4d5dc53
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P3.11 - Screening and Early Detection (Not CME Accredited Session) (ID 977)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 2
- Moderators:
- Coordinates: 9/26/2018, 12:00 - 13:30, Exhibit Hall
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P3.11-03 - Implementing Lung Cancer Screening in Canada: Evidence on Adherence and Budget Impact from the Pan-Canadian Early Detection Study (ID 13417)
12:00 - 13:30 | Author(s): Martin Tammemägi
- Abstract
Background
High-risk lung cancer screening has favourable cost-effectiveness ratios; making it an attractive intervention for lung cancer control. Relatively little is known, however, about the implementation of lung cancer screening in universal health care systems. To address this, we characterize screening adherence rates in the Pan-Canadian Early Detection of Lung Cancer Study (PanCan) and prepare a budget impact analysis for Canada.
a9ded1e5ce5d75814730bb4caaf49419 Method
We retrospectively characterized screening adherence to short-term (first-year) and long-term (year-four) annual screening rounds in the PanCan study and explored association with socio-demographic and screening characteristics with logistic regression models and Mann-Whitney rank sum and Chi square likelihood tests. We did a four-year budget impact analysis using published utilization rates for screening-related and incidental healthcare resources, smoking cessation, opportunistic screening and projected market dynamics for entrant treatments in Canada.
4c3880bb027f159e801041b1021e88e8 Result
The PanCan study screened 2537 participants with a baseline LDCT exam; of these, 2254 (88.9%) adhered to the second annual screening exam and 1,762 (69.5%) adhered to the year four exam. After adjusting for lung cancer incidences and other-cause mortality, we found significant associations between self-reported “current smoker” status and lower, second annual scan adherence rates (p<0.05); while variables related to the delivery of the intervention—such as the use of screening autofluorescence bronchoscopy and finding a lung nodule on the baseline LDCT—were significantly associated with greater adherence (p<0.05). Adherence to year-four screening exams was positively associated with age, family history of lung cancer, baseline quality of life and prior screening exam adherence (all p<0.05). Non-adherence was significantly associated with participants who had greater than 100 pack-years of smoking history and a lower level of formal education (p<0.05). Compared to participants who adhered to their scheduled, year-four annual screening exams, non-adherent participants had a higher predicted risk of developing lung cancer at baseline (p<0.05). The budget impact analysis indicates that the incremental program costs for screening an estimated 257, 914 eligible, high-risk, Canadians would be highly favourable compared to selection based on age and smoking history alone. The budget impact was also sensitive to uncertainty around the cost to treat actionable incidental findings and the adoption of entrant systemic therapy drugs.
8eea62084ca7e541d918e823422bd82e Conclusion
Study participants who were at the highest risk of developing lung cancer, were the least likely to adhere to screening. Using risk selection would enable affordable programs; however, programs may be compromised by barriers to participation for individuals who are at the greatest risk of developing lung cancer.
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P3.11-21 - The Development of a Robust Radiology Quality Assurance (QA) Program in a Provincial High-Risk Lung Cancer Screening Pilot (HRLCSP) (ID 13811)
12:00 - 13:30 | Author(s): Martin Tammemägi
- Abstract
Background
Lung cancer is the leading cause of cancer death in Ontario, with an estimated 7100 patient deaths occurring in 2016 (Canadian Cancer Society, 2016). Based on results from the National Institute of Health’s National Lung Screening Trial, Cancer Care Ontario (CCO) implemented the HRLCSP in 2017 to determine feasibility of provincial scale roll-out of an organized lung cancer screening program. An integral component of the HRLCSP is to ensure low-dose computed tomography (LDCT) scans would be performed, interpreted and reported in a standardized, and high-quality manner.
a9ded1e5ce5d75814730bb4caaf49419 Method
The HRLCSP project team coordinated with CCO’s Cancer Imaging Program (CIP) to gain insight into cancer imaging practices and protocols, and recruited clinical expertise through a Radiology QA Clinical Lead (RQACL). In collaboration with pilot site radiologists, a comprehensive QA program was developed to encompass all aspects of radiology including facility, educational, and reporting standards, in addition to defining quality improvement criteria.
4c3880bb027f159e801041b1021e88e8 Result
To ensure pilot centres were able to deliver high-quality LDCTs, the RQACL, site participants and clinical experts collaborated to define and implement quality parameters. Equipment standards were defined in The Radiology QA Program Manual, and agreement from pilot sites was confirmed. Collaboration with reading radiologists led to tailored educational workshops designed to ensure consistency in the reporting of lung nodules based on the Lung-RADS™ scoring criteria, adapted from the American College of Radiology. Scan interpretation considerations, scoring criteria, and reporting templates were implemented. Annual assessments have ensured compliance across pilot sites. A working group aiming to determine an algorithm to examine incidental findings is being created. LDCT scan Double Read minimums and Peer Review adjudication processes were developed to ensure expert opinion availability with radiologist discrepancies to ensure high quality scan interpretation.
8eea62084ca7e541d918e823422bd82e Conclusion
The design of the HRLCSP offered opportunities for implementing high quality standards around the LDCT scans. Implementation of a robust quality assurance program can ensure that the radiology component is delivered in a high-quality manner. Radiologist training programs, centre minimum requirements, and standardized reporting can ensure standards remain high. Lessons learned through the development of this comprehensive radiology QA program in the HRLCSP will allow for adoption of high-quality radiology standards on a larger provincial scale.
6f8b794f3246b0c1e1780bb4d4d5dc53
