Current Controversies in Cardiothoracic Imaging: Overdiagnosis at Lung Cancer Screening-Not So Bad After All-Counterpoint.

Initially introduced into the medical literature in research publications from "Special Project #1" of the Council for Tobacco Research, the concept of overdiagnosed lung cancer (OD LC) has consistently served to misinform and confuse the medical community, contributing to interminable delays in implementation of population lung cancer screening. Estimates of overdiagnosis vary enormously (9.5% to 75%). Careful, judicious application of diagnostic algorithms and clinical practice guidelines prevents overtreatment of potentially OD LC and offers a safe and effective method to prevent tens of thousands of LC-related deaths. Speculative concern over potential OD should not further block availability of computed tomography screening to those at risk.

Survival following lung resection in immunocompromised patients with pulmonary invasive fungal infection.

OBJECTIVES: Pulmonary invasive fungal infections (IFIs) are associated with high mortality in patients being treated for haematological malignancy. There is limited understanding of the role for surgical lung resection and outcomes in this patient population. METHODS: This is a retrospective cohort of 50 immunocompromised patients who underwent lung resection for IFI. Patient charts were reviewed for details on primary malignancy and treatment course, presentation and work-up of IFI, reasons for surgery, type of resection and outcomes including postoperative complications, mortality, disease relapse and survival. Analysis was also performed on two subgroups based on year of surgery from 1990-2000 and 2001-2014. RESULTS: The median age was 39 years (range: 5-64 years). Forty-seven patients (94%) had haematological malignancies and 38 (76%) underwent haematopoietic stem cell transplantation (HSCT). Surgical indications included haemoptysis, antifungal therapy failure and need for eradication before HSCT. The most common pathogen was Aspergillus in 34 patients (74%). Wedge resections were performed in 32 patients (64%), lobectomy in 9 (18%), segmentectomy in 2 (4%) and some combination of the 3 in 7 (14%) for locally extensive, multifocal disease. There were 9 (18%) minor and 14 (28%) major postoperative complications. Postoperative mortality at 30 days was 12% (n = 6). Acute respiratory distress syndrome was the most common cause of postoperative death. Overall 5-year survival was 19%. Patients who had surgery in the early period had a median survival of 24 months compared with 5 months for those who had surgery before 2001 (P = 0.046). At the time of death, 15 patients (30%) had probable or proven recurrent IFI. Causes of death were predominantly related to refractory malignancy, fungal lung disease or complications of graft versus host disease (GVHD). Patients who had positive preoperative bronchoscopy cultures had a trend towards worse survival compared with those with negative cultures (hazard ratio: 1.80, P = 0.087). CONCLUSIONS: Surgical resection of IFI in immunocompromised patients is associated with high perioperative mortality. Long-term survival is limited by recurrent malignancy, persistent fungal infection and GVHD but has improved in recent years. Selection for surgical resection is difficult in this patient population, but should be carefully considered in those who are symptomatic, or have failed antifungal treatment.

Non-Small Cell Lung Cancer, Version 6.2015.

These NCCN Guidelines Insights focus on recent updates to the 2015 NCCN Guidelines for Non-Small Cell Lung Cancer (NSCLC). Appropriate targeted therapy is very effective in patients with advanced NSCLC who have specific genetic alterations. Therefore, it is important to test tumor tissue from patients with advanced NSCLC to determine whether they have genetic alterations that make them candidates for specific targeted therapies. These NCCN Guidelines Insights describe the different testing methods currently available for determining whether patients have genetic alterations in the 2 most commonly actionable genetic alterations, notably anaplastic lymphoma kinase (ALK) gene rearrangements and sensitizing epidermal growth factor receptor (EGFR) mutations.

Natural history of typical pulmonary carcinoid tumors: a comparison of nonsurgical and surgical treatment.

BACKGROUND: The natural history of typical pulmonary carcinoid tumors has not been described and has important implications for counseling elderly patients or patients with high operative-risk about surgical resection. METHODS: Data from the Surveillance, Epidemiology, and End Results Program were used to identify 4,111 patients with biopsy specimen-proven lymph node-negative typical carcinoid tumor of the lung between 1988 and 2010; 306 had no resection, 929 underwent sublobar resection, and 2,876 underwent lobectomy. Overall survival and disease-specific survival (DSS) were analyzed using Kaplan-Meier plots. Multivariate analysis was used to determine predictors of survival. RESULTS: Five-year overall survival in patients who underwent lobectomy, sublobar resection, or no surgery was 93%, 92%, and 69%, respectively (P < .0001); 5-year DSS was 97%, 98%, and 88%, respectively (P < .0001). Among T1 tumors, DSS was 98% for patients who underwent lobectomy and sublobar resection and 92% for no surgery; among T2 tumors, DSS was 97%, 100%, and 87%, respectively, and among T3 and T4 tumors, it was 96%, 100%, and 75%, respectively. On multivariate analysis, nonoperative management was associated with an increased risk for disease-specific mortality compared with lobectomy (hazard ratio, 2.14; 95% CI, 1.35-3.40; P = .0013). CONCLUSIONS: In this population-based cohort, surgical resection of lymph node-negative carcinoid tumors is associated with a survival advantage over nonoperative treatment. However, the DSS at 5 years was still high without any treatment, suggesting that observation of asymptomatic peripheral typical carcinoid tumors or endoscopic management of symptomatic central carcinoid tumors may be considered in patients at high risk for surgical resection.

Non-small cell lung cancer, version 1.2015.

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer (NSCLC) focuses on the principles of radiation therapy (RT), which include the following: (1) general principles for early-stage, locally advanced, and advanced/metastatic NSCLC; (2) target volumes, prescription doses, and normal tissue dose constraints for early-stage, locally advanced, and advanced/palliative RT; and (3) RT simulation, planning, and delivery. Treatment recommendations should be made by a multidisciplinary team, including board-certified radiation oncologists who perform lung cancer RT as a prominent part of their practice.

National lung screening trial limitations and public health policy.

The completion of the National Lung Screening Trial (NLST), a randomized controlled trial (RCT) of lung cancer screening (LCS), in 2010 provided powerful RCT evidence of the efficacy and safety of computed tomography-based screening; nevertheless, the study had important limitations. Failure to understand these limitations has had substantial adverse effects. Misinterpretation or misrepresentation of the results has led to underestimation of benefits and overestimation of adverse effects. When factored into predictive models, inaccurate estimates have yielded falsely low projections of potential lives saved with national implementation of LCS, exaggerated projected costs, and underestimated cost-effectiveness. When extrapolated estimates were presented to guideline groups and payer panels by screening critics, results included delay in implementation of screening, recommendations to screen only a limited high-risk subgroup, and advice to restrict LCS to otherwise undefined "centers of excellence" able to enter data into a national registry. Finally, despite the formal endorsement of LCS by a large number of prestigious guideline groups, inaccurate extrapolation of NLST data has served to convince payer panels to recommend against insurance coverage for LCS. This article reviews limitations of the NLST study design and compares its results with screening data from many other RCTs and clinical programs, with the intention of providing more accurate and comprehensive information on the benefits, risks, costs, and cost-effectiveness of LCS.

Augmented meaningful use criteria to identify patients eligible for lung cancer screening.

BACKGROUND: Lung cancer screening (LCS) with low-dose-radiation (low-dose computed tomography [LDCT]) saves lives. Despite recent US Preventive Services Task Force (USPTF) draft endorsement of LCS, a minority of eligible patients get screened. Meaningful use is a set of standards for electronic health records (EHR) established by the Centers for Medicare and Medicaid Services and includes reporting of smoking status. We sought to improve rates of LCS among patients treated at our institution by identifying eligible patients using augmented smoking-related meaningful use criteria. METHODS: We launched an LCS program at our institution, a National Comprehensive Cancer Network (NCCN) cancer center, in January 2013. We developed a "tobacco screen," administered by clinic staff to all adult outpatients every 6 months and entered into the EHR. This contained smoking-related meaningful use criteria as well as a pack-year calculation and quit date if applicable. Weekly electronic reports of patients who met eligibility criteria for LCS were generated, and EHR review excluded patients who had had chest computed tomography (CT) within 12 months or who were undergoing cancer treatment. We then contacted eligible patients to review eligibility for LCS and communicated with the primary treating physician regarding the plan for LCS. RESULTS: During the first 3 months of the program, 4 patients were enrolled, 2 by physician referral and 2 by self-referral. We then began to use the tobacco screen reports and identified 418 patients potentially eligible for LCS. Over the next 7 months, we enrolled a total of 110 patients. Fifty-eight (53%) were identified from the tobacco screen, 32 (29%) were self-referred, and 20 (18%) were physician referrals. Three stage I lung cancers were detected and treated. The tobacco screen was easily implemented by clinic staff and took a median time of 2 minutes to enter for current and former smokers. Lack of response to attempts at telephone contact and objection to paying out-of-pocket costs were the most common reasons for failing to screen eligible patients. CONCLUSIONS: Use of augmented meaningful use criteria containing detailed tobacco exposure history is feasible and allows for identification of patients eligible for LCS in a medical center. Barriers to LCS include lack of insurance coverage and lack of systematic referral of patients at high risk.

Minimizing over-diagnosis in lung cancer screening.

Overestimation of the frequency and impact of over-diagnosis bias in lung cancer screening has contributed to long delays in implementation of lung cancer screening programs. Literature review reveals little evidence of substantial numbers of over-diagnosed non-lethal lung cancer. There is now strong evidence that lung cancers that would not cause symptoms or kill during normal anticipated survival are uncommon and mostly limited to in situ adenocarcinomas, identifiable as CT non-solid nodules. Prevention of overtreatment is possible within well-constructed diagnostic algorithms.

Non-small cell lung cancer, version 2.2013.

These NCCN Guidelines Insights focus on the diagnostic evaluation of suspected lung cancer. This topic was the subject of a major update in the 2013 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer. The NCCN Guidelines Insights focus on the major updates in the NCCN Guidelines and discuss the new updates in greater detail.

Thymomas and thymic carcinomas: Clinical Practice Guidelines in Oncology.

Masses in the anterior mediastinum can be neoplasms (eg, thymomas, thymic carcinomas, or lung metastases) or non-neoplastic conditions (eg, intrathoracic goiter). Thymomas are the most common primary tumor in the anterior mediastinum, although they are rare. Thymic carcinomas are very rare. Thymomas and thymic carcinomas originate in the thymus. Although thymomas can spread locally, they are much less invasive than thymic carcinomas. Patients with thymomas have 5-year survival rates of approximately 78%. However, 5-year survival rates for thymic carcinomas are only approximately 40%. These guidelines outline the evaluation, treatment, and management of these mediastinal tumors.

Longitudinal changes in function, symptom burden, and quality of life in patients with early-stage lung cancer.

BACKGROUND: Emerging evidence supports the integration of palliative care concurrently with disease-focused care in patients with serious illnesses, such as lung cancer. This paper describes how longitudinal changes in physical function, symptom burden, and QOL of patients with early-stage non-small cell lung cancer (NSCLC) informed the development of an interdisciplinary, tailored palliative care intervention. METHODS: Patients with early stage (I-IIIB) NSCLC were accrued into the usual care phase (Phase 1) of an NCI-funded Program Project Grant. Baseline and longitudinal (up to 52 weeks post-accrual) physical function, symptoms, and QOL were assessed in the thoracic ambulatory clinics of one NCI-designated Comprehensive Cancer Center. Outcome measures included geriatric assessments, psychological distress, symptoms, and QOL. The association between disease stage (I-II vs. III) and longitudinal changes in these domains was evaluated. RESULTS: A total of 103 patients were accrued. Stage I-II patients were significantly more likely to complete the study (p = 0.005). The stages (I-II vs. III) were equivalent at baseline on all demographic variables, clinical, and functional status. Physical function fluctuated longitudinally and was higher at 6 and 24 weeks than at baseline and 12 weeks. There was a longitudinal decrease in total number of symptoms (p < 0.001). Physical and social/family QOL fluctuated longitudinally (p < 0.001 and p = 0.016, respectively). CONCLUSIONS: Patients with early-stage NSCLC report a significant longitudinal decrease in physical QOL, and fluctuations in objective and subjective measures of physical function over time were observed regardless of disease stage category. An interdisciplinary palliative care intervention is currently being tested to decrease symptom burden and improve QOL.

Non-small cell lung cancer.

Most patients with non-small cell lung cancer (NSCLC) are diagnosed with advanced cancer. These guidelines only include information about stage IV NSCLC. Patients with widespread metastatic disease (stage IV) are candidates for systemic therapy, clinical trials, and/or palliative treatment. The goal is to identify patients with metastatic disease before initiating aggressive treatment, thus sparing these patients from unnecessary futile treatment. If metastatic disease is discovered during surgery, then extensive surgery is often aborted. Decisions about treatment should be based on multidisciplinary discussion.