Lung cancer screening: advantages, controversies, and applications.

BACKGROUND: Lung cancer is the leading cause of cancer death in the United States. Results from the National Lung Screening Trial (NLST) have shown that low-dose computed tomography (CT) is capable of detecting lung neoplasms in individuals at high risk. However, whether it is advantageous to perform lung cancer screening on these patients is a significant concern, as are the potential adverse outcomes from screening. METHODS: A review of several randomized clinical trials, focusing on the NLST, was undertaken. Adverse outcomes and costs related to lung cancer screening were also examined. RESULTS: Lung cancer screening using low-dose CT in high-risk individuals reduced lung cancer deaths by more than 20% when compared with those screened by chest radiography. False-positive results were seen in both groups, but the number of adverse events from the screening test and subsequent diagnostic procedures was low. CONCLUSIONS: Lung cancer screening is controversial, but the NLST has demonstrated that such testing may reduce lung cancer deaths in high-risk individuals when performed with low-dose CT rather than chest radiography. Guidelines should be established to not only help identify an appropriate screening population, but also develop standards for radiological testing.

Pulmonary manifestations of the Churg-Strauss syndrome and related idiopathic small vessel vasculitis syndromes.

PURPOSE OF REVIEW: Pulmonary vascular involvement and the resulting clinical manifestations are prominent in several of the idiopathic systemic small vessel vasculitis syndromes. This group of syndromes, often referred to as the antineutrophil cytoplasmic antibody-associated vaculitis syndromes, is composed of the Churg-Strauss syndrome, Wegener's granulomatosis, microscopic polyangiitis, and several organ specific subsets of the latter. The former three syndromes form the basis of this review. RECENT FINDINGS: Because the presenting signs and symptoms are variable and because these are uncommon disorders, the clinical manifestations in different age groups, ethnic groups, sexes, stage of disease among others have been documented by way of a number of case series and case reports. The role of the antineutrophil cytoplasmic antibody in these disorders is being clarified. In diagnosis, the usefulness of the test depends on the sensitivity and specificity of testing in the population being studied. In pathogenesis, the antineutrophil cytoplasmic antibody may be causative or may merely be associated with the clinical manifestations. SUMMARY: These disorders, although distinctive, are often difficult to diagnose and commonly pose a perplexing clinical scenario for the clinician. A thorough history, physical examination, and a high index of suspicion is mandatory if these entities are to be recognized expeditiously.

Methodology for lung cancer evidence review and guideline development: ACCP evidence-based clinical practice guidelines (2nd Edition).

BACKGROUND: To assemble a geographically diverse panel of experts in the diagnosis and treatment of lung cancer, representative of multiple clinical specialties, with the intention of developing clinically relevant practice guidelines for chest medicine and primary care physicians, including recommendations covering the full spectrum of care of the patient with non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). METHODS: The Duke University Center for Clinical Health Policy Research was selected to review and summarize the current evidence in the treatment of NSCLC. The BlueCross BlueShield Association Technology Evaluation Center was chosen and funded by the Agency for Healthcare Research and Quality to review and synthesize the current evidence on treatment of SCLC. Other chapters received existing guidelines, systematic reviews, and metaanalyses that were published since the first edition of these guidelines, as collected by the Duke University Evidence-based Practice Center. The writing committees for these chapters conducted searches for the primary articles and additional evidence in their topic area. The expert panel established clinical recommendations founded on the synthesis of this evidence. CONCLUSIONS: This section describes the approach used to develop the guidelines, including identifying, evaluating, and synthesizing the evidence, assessing the strength of evidence and grading the individual recommendations, and suggestions for implementation of the guidelines.

Follow up and surveillance of the patient with lung cancer: what do you do after surgery?

Of the new cases of lung cancer discovered each year, it has been estimated that 50-55% have localized disease and are thus candidates for potentially curative treatment. Some of these patients will refuse surgery or will have co-morbidities that preclude surgery. The remainder will undergo an attempted curative resection. A common clinical question arises in these patients: how should this patient be followed after surgery? Post-treatment surveillance is indicated to monitor for recurrence of the original tumor and for the development of a metachronous tumor. The appropriate protocol is controversial and current recommendations are primarily expert opinion or consensus-based and await further study. A suggested clinically reasonable and cost-effective surveillance approach would include a history, physical examination and an imaging study (either chest radiograph or CT) every 6 months for 2 years and then annually. Patients should be counselled on symptom recognition and advised to contact their physician should such symptoms appear.

Improved survival in never-smokers vs current smokers with primary adenocarcinoma of the lung.

STUDY OBJECTIVES: Adenocarcinoma of the lung is now the most common histologic subtype of lung cancer in the United States. To determine if there are survival differences in never-smokers and current smokers with adenocarcinoma, we conducted an analysis of lung adenocarcinomas seen at the H. Lee Moffitt Cancer Center, and looked for demographic and survival differences in the two groups. DESIGN: Data were gathered through the tumor registry at the H. Lee Moffitt Cancer Center and confirmed by chart review. A total of 132 documented never-smokers and 522 current smokers with lung adenocarcinoma were included. Detailed demographic survival information were gathered and tabulated. Former smokers were not included in the study. Multivariate analyses were performed using the Cox regression method to identify variables with independent prognostic significance. Life table actuarial analyses were performed to determine survival. Differences between survival curves were estimated using the log-rank test. RESULTS: The mean age at diagnosis for never-smokers was higher as compared to current smokers: 63.5 years vs 59.4 years (p = 0.0005). In addition, there was an increased percentage of female subjects in the never-smoker category: 78% vs 54% (p < 0.0001). There was a statistically significant difference in survival between current smokers and never-smokers (p = 0.004). The Kaplan-Meier estimates at 5 years were 16% for current smokers and 23% for never-smokers. On multivariate analyses, smoking was identified as an independent negative prognostic factor. CONCLUSION: Our data show that never-smokers with adenocarcinoma are predominantly female, present at a higher mean age, and have improved survival when compared to current smokers. By multivariate analyses, the never-smoking status was found to be an independent predictor of improved survival. The survival difference may be partly influenced by less comorbidity among never-smokers. Nevertheless, owing to differences in the mechanism of carcinogenesis (in smokers vs nonsmokers), demographic factors, tumor behavior and survival, adenocarcinomas occurring in never-smokers may display a distinct natural history and may warrant further investigation as a separate entity with epidemiologic studies and clinical trials designed specifically for this category of non-small cell lung cancer.

Eosinophilic interstitial lung disease.

PURPOSE OF REVIEW: Although rare, the eosinophilic lung diseases are being increasingly identified as distinct clinical entities. These disorders are a heterogeneous group of disorders in which there is an increased number of eosinophils in the airways and/or lung parenchyma. These disease entities may be broadly separated into airway disorders (asthma, allergic bronchopulmonary mycosis, eosinophilic bronchitis, and bronchocentric granulomatosis) and parenchymal (interstitial) disorders. This review and update will concentrate on the latter group of entities. RECENT FINDINGS: Recent publications in the field have concentrated on expanding the list of causative agents and clinical situations. An especially promising number of articles report advancements in the understanding of the pathogenetic mechanisms behind the development of the clinical syndromes. SUMMARY: Whatever the function of the eosinophil in these disorders, it is important to remember that the disease processes lumped together as the eosinophilic lung diseases are a heterogeneous group of diseases. In an attempt to categorize these disorders, they have been connected, either appropriately or artificially, by their association with the eosinophil. Nevertheless, the eosinophilic connection may serve as a clue to pathogenesis and treatment.

Overview of methodology for lung cancer evidence review and guideline development.

A multidisciplinary panel was convened by the American College of Chest Physicians (ACCP) to develop clinical practice guidelines for lung cancer prevention, diagnosis, and treatment. The ACCP Expert Panel on Lung Cancer Guidelines produced 20 guidelines, each related to a distinct set of management decisions. This article describes the approach used to develop the guidelines, including identifying, evaluating, and synthesizing evidence, assessing the strength of evidence pertinent to individual guidelines, and grading guideline recommendations.

Lung cancer. Practice organization.

The management of patients with suspected or known lung cancer is becoming increasingly complex. State-of-the-art care often requires input from many sources, including pulmonology, thoracic surgery, medical oncology, radiation oncology, pathology, and radiology. Valuable contributions to care also come from nursing, social work, psychology, psychiatry, pastoral care, and palliative care, among others. As a result, multidisciplinary input into care is vital. Patients with suspected lung cancer should be expeditiously evaluated and referred for management. Clear and understandable information on the diagnosis, treatment options, and possible outcomes should be provided. Treatment recommendations should be based on locally agreed-on adaptations of clinical practice guidelines. Provisions for ongoing care should be apparent to all concerned

Occupational asthma.

Preview Patients affected by occupational asthma have respiratory symptoms that may persist for months, years, or even life. Hundreds of substances have been implicated in the disease, and the list is expected to grow. The authors discuss management of this sometimes life-threatening condition and emphasize the importance of environmental controls to prevent future cases.