“The European Society for Medical Oncology (ESMO) 2017 Congress is just around the corner, and we can already say with confidence that there will be many provocative presentations, including several that are poised to change practice. At this point, we can only rely on the abstracts and press releases for several of these, but here are my early impressions on the top five presentations in lung cancer for ESMO 2017.”
“Patients with recurrent lung cancer have better post-surgery survival rates if their management includes a follow-up programme based on computer tomography (CT) of the chest, according to new findings.
“The findings, presented at the ERS International Congress 2015 in Amsterdam today (27 September, 2015), is the first to show improved overall survival after surgery for a CT- based follow-up programme and could change the way patients are currently managed.
“Previous research has confirmed that after the introduction of the CT-based follow-up, most cases of recurrent lung cancer can be detected before the patient has any symptoms. This allows for earlier diagnosis and leads to an improved chance of having a radical treatment against the relapse. This new study aimed to assess whether this follow-up also improved survival rates.”
“Several factors, including the presence of a nodule on CT scan and persistent metaplasia, served as significant predictors of lung cancer recurrence or the development of secondary primary lung cancers, according to study results presented at the American Thoracic Society International Conference.
“ ‘This suggests that aggressive ongoing surveillance of lung cancer survivors may be needed for extended periods of time,’ Samjot Dhillon, MD, associate professor of oncology at Roswell Park Cancer Institute, and colleagues wrote.
“Lung cancer accounts for approximately 27% of all cancer deaths, and more than 158,000 Americans are expected to die of the disease this year, according to the American Lung Association. About half of patients with lung cancer have advanced disease at the time of diagnosis.”
“A recent study reported in The Journal of Nuclear Medicine compared use of the novel Ga-68-PSMA-ligand PET/CT with other imaging methods and found that it had substantially higher detection rates of prostate-specific membrane antigen (PSMA) in patients with biochemical recurrence after radical prostatectomy. Discovering a recurrence early can strongly influence further clinical management, so it is especially noteworthy that this hybrid PSMA-ligand identified a large number of positive findings in the clinically important range of low PSA-values (<0.5ng/mL).
“According to the CDC, prostate cancer is the most common cancer among men in the United States, after non-melanoma skin cancer. While many men with prostate cancer die from other causes, prostate cancer remains one of the leading causes of cancer death among men of all races. Treatment and survival after recurrence depend on many factors, but early detection of the recurrence is certainly key.
“Matthias Eiber, MD, corresponding author of the study, noted, ‘The study is the first to examine this highly promising PET tracer in the use of a homogeneous patient collective consisting of only those with biochemical recurrence after radical prostatectomy. It found superb detection rates compared to other tracers, like choline, or imaging modalities, like MRI. For patients, this means that the referring urologist can receive earlier and more precise information about the site and extent of metastatic disease. Physicians will also be better able estimate whether a PSMA-PET scan might be useful in a specific setting.’ “
“Researchers were able to demonstrate response to radiotherapy in breast cancer patients with osteolytic metastases by measuring increases in bone density using Hounsfield units (HU) in computed tomography (CT) scans, according to results of a recent study.
“ ‘In previous studies we demonstrated that radiotherapy is capable of improving stability in spinal bone metastases by facilitating re-ossification,’ wrote Robert Foerster, MD, of the department of radiation oncology at University Hospital Heidelberg, Germany, and colleagues in Radiation Oncology. ‘With our current analysis we were able to quantify the re-ossification after radiotherapy by measuring the change in mean bone density on the basis of x-ray absorption in CT scans and we found that mean bone density, as a local response, increased significantly in the metastases after radiotherapy.’ ”
“The researchers retrospectively analyzed 135 osteolytic spinal metastases taken from 115 women with metastatic breast cancer treated at their institution between January 2000 and January 2012. Bone density was measured at baseline, and 3 months and 6 months after radiotherapy.”
The gist: New research shows that four or more PET/CT scans can help guide care for patients who have been treated for lung cancer. This is significant in the light of a recent announcement from Medicaid and Medicare Services that only three FDG PET/CT scans would be routinely covered after treatment.
“New research from Johns Hopkins School of Medicine reveals a high value of scans which could lead to future change of reimbursement policies for follow-up positron emission tomography/computed tomography (PET/CT) studies in lung cancer. The study, featured in the February 2015 issue of the Journal of Nuclear Medicine, establishes the value of fourth and subsequent follow-up PET/CT scans in clinical assessment and management change in patients with the disease.
“According to the American Lung Association, lung cancer is the leading cancer killer in both men and women in the United States. Approximately 402,326 Americans living today have been diagnosed with lung cancer. In 2014, diagnoses of an estimated 224,210 new cases of lung cancer were expected, representing about 13 percent of all cancer diagnoses.
“In the retrospective study, a total of 1,171 patients with biopsy-proven lung cancer who had positron emission tomography with a radioactive tracer (18F-FDG were identified at a single tertiary center from 2001 to 2013. Among these, 85 patients (7.3%) had four or more follow up PET/CT scans with a total of 285 fourth and subsequent follow up PET/CT scans. Median follow up from the fourth scan was 31.4 months. The follow-up PET/CT scan results were correlated with clinical assessment and treatment changes.”
The gist: New criteria could keep CT scan screening tests from indicating that a person has lung cancer, when they really do not. So called “false-positives” can lead to unnecessary medical procedures and distress. The Lung-RADS criteria may lower the rate of false-positive screening tests. However, there are concerns that Lung-RADS might delay diagnosis for people with true lung cancer.
“The use of Lung Imaging Reporting and Data System criteria during interpretation of low-dose CT scan results may yield lower false-positive results than observed in the National Lung Screening Trial, according to results of a retrospective study.
“However, the Lung Imaging Reporting and Data System (Lung-RADS) criteria — developed by the American College of Radiology — also were associated with reduced sensitivity.
“ ‘The findings suggest that the implementation of Lung-RADS can substantially reduce the false-positive rate in CT screening for lung cancer,’ William C. Black, MD, study author and professor of radiology at the Dartmouth-Hitchcock Medical Center, told HemOnc Today. ‘However, the findings also suggest that the diagnosis of some lung cancers may be delayed with the implementation of Lung-RADS. Whether this delay will substantively reduce the effectiveness of CT screening is unknown and will have to be further studied.’ “
“As in the draft plan, individuals must still have a 30 pack-year history of smoking to qualify and must either be smoking currently or have quit in the past 15 years.
“Also, beneficiaries must obtain a written order from a physician for the first screening, stipulating that the patient underwent counseling on lung cancer screening and that it involved a shared decision-making process. Subsequent annual screenings will also require similar written orders.
“The counseling sessions must emphasize the importance of continued abstinence for ex-smokers and cessation for current smokers.”
“A new statistical analysis of results from the National Lung Screening Trial (NLST) concludes that performing low-dose computerized tomography screening can be cost-effective compared to doing no screening for lung cancer in aging smokers.
” ‘This provides evidence, given the assumptions we used, that it is cost-effective,’ said Ilana Gareen, assistant professor (research) of epidemiology in Brown University’s School of Public Health and second author on the new study in the New England Journal of Medicine.
“Four years ago, the vast NLST showed that low-dose helical CT scanning reduced mortality from lung cancer by 20 percent compared to chest X-rays. The study involved more than 53,000 smokers aged 55-74. Chest X-rays, meanwhile, have been shown to be no better than doing nothing to screen for the cancer.
“With the NLST’s trove of medical and cost data to work from, a research team including Gareen, senior author Constantine Gatsonis, professor of biostatistics, and lead author Dr. William Black at Dartmouth College’s Geisel School of Medicine, set out to determine the financial implications of conducting CT screening compared to not screening. The standard for this is to calculate a ratio of the costs of CT screening per person—including the test, any follow-up testing and treatment, and indirect costs—and the number of ‘quality-adjusted life-years added’ per person across the population. The quality adjustment distinguishes between living in good health and surviving but with major health problems.”