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Martin Tammemagi



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    MA10 - Emerging Technologies for Lung Cancer Detection (ID 129)

    • Event: WCLC 2019
    • Type: Mini Oral Session
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
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      MA10.09 - Evaluation of the Clinical Utility of the PanCan, EU-NELSON and Lung-RADS Protocols for Management of Screen Detected Lung Nodules at Baseline (Now Available) (ID 2137)

      15:15 - 16:45  |  Author(s): Martin Tammemagi

      • Abstract
      • Presentation
      • Slides

      Background

      Several protocols are available to guide management of lung nodules identified by the first (baseline) low-dose screening CT. It is important to objectively assess their clinical utility, health care resource utilization and potential harms. We aim to compare the PanCan (NEJM 2013;369:908 & J Thorac Oncol 2018; 13(10): S362-S363), EU-NELSON (Lancet Oncol. 2017 Dec;18(12):e754-e766 & Lung Cancer 2006;54:177-184) and Lung-RADS(https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/Lung-Rads) lung nodule management protocols on our data set from two sites of the International Lung Screen Trial (ILST), in Vancouver, Canada and Perth, Western Australia.

      Method

      Ever smokers age 55 to 80 years were enrolled into ILST if they had a ≥30 pack-years smoking history and smoked within 15 years or if their PLCO m2012 6 year lung cancer risk was ≥1.51%. The participants were managed via the PanCan lung nodule risk based protocol. The NELSON and Lung-RADS nodule protocols were applied to the ILST data set. The potential difference in the proportion of the participants having an early recall CT scan (< 1 year) or referral to a clinical diagnostic pathway was compared between the PanCan, NELSON, Lung-RADS protocols. The participants were divided into 3 groups: Group 1 (next scheduled annual/biennial CT) included PanCan CAT 1, 2, NELSON NODCAT I, II, Lung-RADS CAT 1, 2. Group 2 (early recall CT <1 year) included PanCan CAT 3, NELSON NODCAT III, Lung-RADS CAT 3, 4A and Group 3 (Diagnostic Pathway) included PanCan CAT 4, 5, NELSON NODCAT IV (solid nodule), Lung-RADS CAT 4B, 4X. The number of participants and the lung cancer rate in each group was compared between the three protocols.

      Result

      A total of 1386 participants with a median follow-up of 10 months (ranging from 4-31 mos) were evaluated. The results are shown in Table 1.

      PanCan selected the fewest individuals to early recall (Group 2 & 3) versus NELSON p=0.004 and detected the same number of lung cancers as did the NELSON and more than by Lung-RADS.

      In addition, 81% of the PanCan group 1 participants were triaged to biennial repeat screening instead of annual screening in the NELSON and Lung-RADS protocols, which has substantial resource utilization and radiation exposure implications.

      presentation2.jpg

      Conclusion

      The personalized risk-based PanCan Protocol may decrease resource utilization and potentially minimize risk of screening for participants.

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    MS18 - Role of Biomarkers in Lung Cancer Screening (ID 81)

    • Event: WCLC 2019
    • Type: Mini Symposium
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
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      MS18.06 - Captive Audience, Teachable Moment - Integrating Tobacco Cessation in Lung Cancer Screening (Now Available) (ID 3549)

      14:30 - 16:00  |  Presenting Author(s): Martin Tammemagi

      • Abstract
      • Presentation
      • Slides

      Abstract

      Cigarette smoking causes more than 480,000 deaths each year in the United States.1Smoking has been causally linked to cancers of the oropharynx, larynx, esophagus, trachea, bronchus, lung, stomach, liver, pancreas, kidney, ureter, cervix, bladder and colorectum and acute myeloid leukemia, as well as to stroke, blindness, cataracts, age-related macular degeneration, periodontitis, aortic aneurysm, early abdominal aortic atherosclerosis, coronary heart disease, pneumonia, atherosclerotic peripheral vascular disease, chronic obstructive pulmonary disease, tuberculosis, asthma, diabetes, reproductive disorders, ectopic pregnancies, erectile dysfunction, hip fractures, rheumatoid arthritis and immune dysfunction.1Lung cancer screening is most effective when applied to individuals at high risk.2Using NLST data, Figure 1 describes how the number of competing-causes deaths, primarily smoking related, increases with lung cancer risk, primarily driven by smoking, and how competing-causes deaths exceeds lung cancer deaths. Successful smoking interventions have the potential to greatly reduce morbidity and mortality in lung cancer screenees. It is likely that smoking cessation interventions in lung cancer screening programs will be cost-effective and may lead to health benefits that exceed those of the lung cancer mortality reduction benefits. Current, U.S. guidelines recommend providing smoking cessation interventions for current smokers in lung cancer screening programs. However, which type of smoking cessation program in the lung cancer screening setting is most effective is unknown.

      Lung cancer screenees generally have longer and more intense smoking histories so they may be more intractable to cessation interventions. On the other hand, screening may provide a teachable moment, which may lead to greater rates of cessation.3The proportion of current smokers selected for screening is greater when selected by risk prediction model, than when selected by NLST-like criteria. The proportion of current smokers in the NLST was 48.2%, in PLCO NLST-eligible participants was 40.4%, and in the Pan-Canadian Early Detection of Lung Cancer Study and Cancer Care Ontario (CCO) pilot, both of which have eligibility criteria of PLCOm2012 6-year risks ≥2%, were 62.8% and 65.4%, respectively.

      Two recent reviews concluded that evidence is lacking to recommend specific tailored smoking cessation approach in the lung cancer screening setting and recommend more research.4,5Currently, in the U.S., 8 trials in the SCALE (Smoking Cessation within the Context of Lung Cancer Screening) collaboration are underway that are investigating different smoking cessation interventions within lung cancer screening programs.6Some of the factor under study in SCALE include the following6:participant eligibility criteria, baseline versus annual screen, participant’s interest in stopping smoking, treatment delivery method and dose, incorporation of positive and negative screening results, perceived risk of lung cancer, and costs of treatments.Results of SCALE are expected after 2021.

      Recently, Cadham and colleagues conducted a meta-analysis of smoking cessation interventions in samples that were similar to those in lung cancer screening programs.7At 6-month follow-up, smoking cessation had the following associations with interventions:

      Electronic/web-based (odds ratio [OR] 1.14, 95% CI 1.03-1.25)

      Telephone counseling (OR 1.21, 95% CI 0.98-1.50)

      In-person counseling (OR 1.46, 95% CI 1.25-1.70)

      Pharmacotherapy (OR 1.53, 95% CI 1.33-1.77).

      CCO’s Lung Cancer Screening Pilot for People at High Riskstarted low dose computed tomography screening in three sites on June 1, 2017. In the first year of screening, 1624 individuals received LDCT scans and current smokers were enrolled in an “opt-out” in-hospital smoking cessation programs. Of scanned participants 88.8% attended in-hospital smoking cessation counselling, and 95.2% were satisfied with their cessation services.

      In conclusion, several intervention approaches appear to be associated with smoking cessation. Multiple approaches appear better than single approaches. Pharmacotherapy and in-person counseling interventions appear to be superior to electronic/web-based or telephone counseling. Successful enrollment into in-person cessation programs is achievable.

      References

      1. United States. Public Health Service. Office of the Surgeon General., National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health. The health consequences of smoking--50 years of progress : a report of the Surgeon General.Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.

      2. Tammemagi MC, Katki HA, Hocking WG, et al. Selection criteria for lung-cancer screening. The New England journal of medicine. 2013;368(8):728-736.

      3. Taylor KL, Cox LS, Zincke N, Mehta L, McGuire C, Gelmann E. Lung cancer screening as a teachable moment for smoking cessation. Lung cancer (Amsterdam, Netherlands). 2007;56(1):125-134.

      4. Iaccarino JM, Duran C, Slatore CG, Wiener RS, Kathuria H. Combining smoking cessation interventions with LDCT lung cancer screening: A systematic review. Preventive medicine. 2019;121:24-32.

      5. Pineiro B, Simmons VN, Palmer AM, Correa JB, Brandon TH. Smoking cessation interventions within the context of Low-Dose Computed Tomography lung cancer screening: A systematic review. Lung cancer (Amsterdam, Netherlands). 2016;98:91-98.

      6. Joseph AM, Rothman AJ, Almirall D, et al. Lung Cancer Screening and Smoking Cessation Clinical Trials. SCALE (Smoking Cessation within the Context of Lung Cancer Screening) Collaboration. American journal of respiratory and critical care medicine. 2018;197(2):172-182.

      7. Cadham C. Systematic Review and Meta-Analysis of Smoking Cessation Interventions for Potential Use in Lung Cancer Screening Settings: 6- and 12-Month Outcomes. . American Society of Preventive Oncology Annual Meeting ASPO 2019; Monday, March 11, 2019, 2019; Tampa, Florida.

      8. Tammemagi MC, Church TR, Hocking WG, et al. Evaluation of the Lung Cancer Risks at Which to Screen Ever- and Never-Smokers: Screening Rules Applied to the PLCO and NLST Cohorts. PLoS medicine. 2014;11(12):e1001764.

      Figure 1. Lung cancer and competing causes deaths in the National Lung Screening Trial by PLCOm2012 model risk level (taken from 8)

      nlstdeathsbyintervention.png

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    P1.11 - Screening and Early Detection (ID 177)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Screening and Early Detection
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/08/2019, 09:45 - 18:00, Exhibit Hall
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      P1.11-03 - Disparities and National Lung Cancer Screening Guidelines in the U.S. Population (ID 1496)

      09:45 - 18:00  |  Author(s): Martin Tammemagi

      • Abstract

      Background

      Current U.S. Preventive Services Task Force (USPSTF) lung cancer (LC) screening guidelines are based on smoking history and age (55-80). These guidelines may miss those at higher risk, even at younger ages, due to other risk factors such as race or family history. In this study, we characterize the demographic/clinical profiles of those who are selected by risk-based screening criteria, but missed by USPSTF in younger (45-54) or older ages (71-80).

      Method

      We used data from the National Health Interview Survey, the CISNET Smoking History Generator, and logistic prediction models for non-smoking risk factors to simulate life-time LC risk-factor data for 100,000 men and women in the U.S. 1950-1960 birth cohorts. We calculated age-specific 6-year LC risk (r) for each individual from ages 45-90 using the PLCOm2012 model. We evaluated age-specific screening-eligibility by USPSTF guidelines and by risk-based criteria (varying thresholds between 1.3%-2.5%).

      Result

      In the 1950 cohort, 6.73% would be missed for screening in their younger ages by the USPSTF-criteria, but would have been screened by the risk-based criteria. Similarly, 13.97% of the cohort would be ineligible for screening by USPSTF in older ages. Notably, a higher proportion of African Americans will be ineligible for screening by USPSTF at younger (25.6%) or older (19.7%) ages, which is significantly higher than for Whites (7.7% and 15.75% respectively). Similar results were observed for other risk thresholds and for the 1960 cohort.

      fig1_wclc.png

      Conclusion

      Further consideration is needed to incorporate comprehensive risk factors, including race/ethnicity, into lung screening criteria to reduce potential racial disparities.

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    P2.10 - Prevention and Tobacco Control (ID 176)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Prevention and Tobacco Control
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.10-04 - Predicting Non-Compliance in Routine Lung Cancer Screening for High-Risk Adults (Now Available) (ID 2664)

      10:15 - 18:15  |  Presenting Author(s): Martin Tammemagi

      • Abstract
      • Slides

      Background

      Lung cancer is the most common cause of cancer-related deaths, which can be effectively reduced by routine screening. To detect lung cancer early, annual screening in high-risk adults aged 55-74 years using low-dose computed tomography (LDCT) is recommended by the Canadian Medical Association guidelines. High-risk adults are recommended an annual screen within 11-15 months of their baseline scan. However, screening compliance is a challenging area influenced by a series of complex biopsychosocial, behavioral and cognitive processes. This study aims to describe the participants and identify predictors of noncompliance in the Lung Cancer Screening Pilot for People at High Risk Program (HR LCSP) conducted in Ontario, Canada.

      Method

      During 2017-18, HR LCSP has recruited over 5,999 high-risk adults from 3 sites in Ontario, with 5,502 adults undergone risk assessment for screening eligibility, and 2,997 baseline scans conducted. Baseline and follow-up participant experience surveys assess satisfaction especially around test result communication. During risk assessment, all individuals who identify as current smokers are referred to smoking cessation services irrespective of their eligibility. The clinical data are collected using an internationally accepted standard, the Resident Assessment Instrument Minimum Data Set at each site. We hypothesize that participant compliance is predicted by the satisfaction of their first screening experience in additional to socio-demographic and clinical factors. A multivariable logistic regression model will be conducted to predict non-compliance, which is defined by a return interval >15 months or missing. The model will contain individual level factors including age, sex, aboriginal status, education, income estimates, geographic distance; system level factor includes physician-referral/ self-referral status; clinical factors include the risk prediction by PLCOm2012, which assesses smoking status including intensity and duration; other clinical factors include personal and family history of cancer, history of lung disease, body mass index; psychosocial/behavioral factors include smoking cessation program participation, baseline screening results including the presence of actionable incidental findings and appropriate follow-up of the abnormal results. Data linkage is under way and results will be presented at the conference.

      Result

      This study will provide a granular view on the predictors of routine screening compliance among high-risk adults, which will be used to improve the program recruitment and retention especially when designing targeted messages. Findings will have implications for health care professionals when communicating with high-risk individuals about routine screening for lung cancer.

      Conclusion

      Section not applicable.

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    P2.11 - Screening and Early Detection (ID 178)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Screening and Early Detection
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.11-22 - Comparison of the Sensitivity of USPSTF and PLCOm2012 Lung Cancer Screening Criteria in a Racially Diverse Population (ID 855)

      10:15 - 18:15  |  Author(s): Martin Tammemagi

      • Abstract

      Background

      Objective: To compare the sensitivity to detect lung cancer of two lung cancer screening selection criteria, the USPSTF (≥30 pack-years smoked, quit-time ≤15 years, age 55-80) and the PLCOm2012 model 6-year risk ≥1.5%, in a racially diverse population including a high proportion of Blacks.

      Method

      Lung cancer cases diagnosed at a Chicago academic hospital in 2010–2017 were retrospectively analyzed for whether they met lung cancer screening eligibility using the USPSTF and PLCOm2012 criteria. Contingency table analysis with McNemar’s odds ratios, confidence intervals and p-values evaluated comparisons.

      Result

      The race/ethnic distribution of the 823 lung cancer cases was 245 (29.8%) Whites, 435 (52.9%) Blacks, 75 (9.1%) Hispanics, 39 (4.7%) Asians, and 29 (3.5%) others. Overall, data on criteria risk factors were available for 770 (93.6%) individuals: 68.3% were positive by PLCOm2012 criteria and 49.9% were positive by the USPSTF (Table 1, McNemar’s odds ratio (ORM)=11.9, 95%CI 6.8-22.9, p<0.0001). Limited to Blacks, the USPSTF criteria identified 50.8% and the PLCOm2012 identified 74.9%. Only 3 individuals were USPSTF+ve/PLCOm2012-ve and 104 individuals were PLCOm2012+ve/USPSTF-ve (Table 2, ORM=34.7, 95%CI 11.5-170.8, p<0.0001).

      Conclusion

      Overall and especially in Blacks, compared to the USPSTF criteria, the PLCOm2012 criteria was significantly more sensitive at identifying lung cancer patients.

      Table 1. Lung cancer cases (N=770) stratified by USPSTF and PLCOm2012 selection criteria status, all races/ethnicities. Cells contain number, (row percent), [column percent].

      PLCOm2012 risk < 1.5%

      PLCOm2012 risk >1.5%

      Total

      USPSTF criteria -ve

      231

      (59.8%)

      [94.7%]

      155

      (40.2%)

      [29.5%]

      386

      (100.0%)

      [50.1%]

      USPSTF criteria +ve

      13

      (3.4%)

      [5.3%]

      371

      (96.6%)

      [70.5%]

      384

      (100.0%)

      [49.9%]

      Total

      244

      (31.7%)

      [100.0%)

      526

      (68.3%)

      [100.0%]

      770

      (100.0%)

      [100.0%]

      Table 2. Lung cancer cases (N=419) stratified by USPSTF and PLCOm2012 selection criteria status, Black race only. Cells contain number, (row percent), [column percent].

      PLCOm2012 risk < 1.5%

      PLCOm2012 risk >1.5%

      Total

      USPSTF criteria -ve

      102

      (49.5%)

      [97.1%]

      104

      (50.5%)

      [33.1%]

      206

      (100.0%)

      [49.2%]

      USPSTF criteria +ve

      3

      (1.4%)

      [2.9%]

      210

      (98.6%)

      [66.9%]

      213

      (100.0%)

      [50.8%]

      Total

      105

      (25.1%)

      [100.0%)

      314

      (74.9%)

      [100.0%]

      419

      (100.0%)

      [100.0%]

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    PL02 - Presidential Symposium including Top 7 Rated Abstracts (ID 89)

    • Event: WCLC 2019
    • Type: Plenary Session
    • Track:
    • Presentations: 1
    • Now Available
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      PL02.02 - Lung Cancer Screenee Selection by USPSTF Versus PLCOm2012 Criteria – Interim ILST Findings (Now Available) (ID 2804)

      08:00 - 10:15  |  Author(s): Martin Tammemagi

      • Abstract
      • Presentation
      • Slides

      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.

      Method

      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 PLCOm2012+ve/USPSTF-ve, are informative. Numbers of lung cancers and individuals enrolled, sensitivity, specificity and positive predictive values (PPV) of the two criteria will be compared.

      Result

      As of March 2019, ILST centers in Canada (British Columbia), Australia, Hong Kong, and the United Kingdom had enrolled and scanned 3673 individuals. Study results are summarized in Figure 1.

      presentation5.jpg

      Conclusion

      Interim analysis of ILST data, indicates that classification accuracy of lung cancer screening outcomes support the PLCOm2012 criteria over the USPSTF criteria. The PLCOm2012 criteria detected significantly more lung cancers. Individuals who are USPSTF+ve and PLCOm2012-ve appear to be at such low baseline risk (0.2%) that they may be unlikely to benefit from screening.

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