USPSTF Recommendations: Lung Cancer Screening

So, guideline season is still upon us, and I wanted to bring up something that kind of flew under the radar: Lung Cancer Screening.

You may remember a paper (and GR at UAB) from a few years ago that showed a mortality benefit for low dose CT scanning in smokers. The National Lung Screening Trial (NLST) This is the main study that drove the USPSTF to recommend CT screening in many smokers.

The guidelines are here. Here’s the scoop:

55-80 year olds with at least a 30pack year smoking history, currently smoking or quit within the last 15 years should receive Annual low dose chest CT. As with most screening guidelines, stop when life expectancy is “substantially limited” by another health problem, or when patients have been smoke free for more than 15 years.  Based on the wording above, it seems reasonable to stop at 80, sooner if there are significant comorbidities. They give this a Grade B recommendation.

Interestingly, the guidelines vary somewhat from the study itself.  The NLST enrolled patients 55-74, yet the guidelines recommend screening through age 80.  The study utilized 3 annual CT scans, and mortality benefit was seen after just those three scans. USPSTF recommended annual screening from 55-80 (potentially 25 scans if you start at 55 and the patient keeps smoking without developing some other health problem).

So the benefit of screening is obvious patients live longer, less likely to die from lung cancer.  The NLST enrolled >50,000 patients, screened them for 3 years, and then followed for an average of 6.5 years.  Overall mortality was reduced by 6.7% and lung cancer specific mortality was reduced by 20%.  NNS to prevent one lung cancer death is 320. In comparison, annual FOBT testing reduces colon cancer mortality by 15-20%, and the NNS 1173.

What about the harms?  Well, 39% of those in the CT group of the NLST had a positive test, and the majority of those led to more testing.  More testing may be more imaging, or may be a biopsy.  96% of the positive tests in the CT group were eventually proven to be false positives.  1.5% of those with a positive test had at least one complication from further testing.

Is this practice changing?  Maybe.  I have tried to order a low dose CT on a patient in the last few years, heavy smoker who I felt was high risk.  His insurance wouldn’t pay for it, but did pay for the regular CT when I told them I was worried about his weight loss.  The affordable care act mandates that all grade A or B USPSTF screening guidelines are covered without out-of-pocket cost to the patient.  In that case, we should be able to order these now without much pushback from the insurers.

Here are a few related stories:

What do you think?  Is the mortality reduction worth the huge number of false positives? Will you start ordering low dose CTs on your smoking patients? Would love to hear your thoughts in the comments.

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Chronic Pancreatitis

Guest Poster:  Chronic pancreatitis  by Dr. Josh Stripling

 Definition: Irreversible destruction of the pancreatic parenchyma causing varying degrees of endocrine and exocrine dysfunction

  •  most patients typically present with persistent abdominal pain and steatorrhea
  • exocrine dysfunction – chronic diarrhea and weight loss
  • approx 20% present with maldigestion without pain

Causes:

  • The most common cause of chronic pancreatitis is alcohol use (usually more than 10y and more than 50g/day)
  • TIGAR-O (Toxic-metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and severe acute pancreatitis, Obstructive)
  • tobacco also increase the risk of developing chronic pancreatitis

Diagnosis:  there are two specific entities: large- duct and small-duct (minimal change)

  • no consensus on gold standard for diagnosis: difficult testing and not always available
  • typical diagnosis is clinical based on symptoms and imaging
  • available testing includes: Secretin and CCK stimulation tests, fecal elastase, serum tripsinogen, stool sudan stain
  • most patients should undergo MRCP (not ERCP) or EUS to evaluate pancreatic ducts
  • patients can progress to development of pancreatic cancer

Plain film or CT can highlight pancreatic calcification to support the diagnosis

Management

  • avoidance of cause: EtOH cessation, pancreatic duct stenting, etc.
  • enteric coated pancreatic enzyme supplementation (40,000 units of lipase recommended) plus acid suppressant
  • fat-soluble vitamin replacement
  • monitor for endocrine dysfunction
  • pain management is difficult and theoretical improvement in pain with enzyme supplementation may occur
  • total pancreatectomy with islet cell transplantation is becoming more frequent

Resources: MKSAP 16, Harrison’s, “Chronic Pancreatitis” AFP 2007

Images: Medscape, http://www.meddean.luc.edu, healthcentral.com, drug3K.com