NELSON lung screening protocol beats NLST for CT Lung cancer detection

NELSON lung screening protocol beats NLST for cancer detection

By Frances Rylands-Monk, AuntMinnie.com contributing writer

August 7, 2022 — In a face-off between CT lung cancer screening trials, the protocol used to analyze lung nodules in the Dutch-Belgian Randomized Lung Cancer Screening (NELSON) trial proved more sensitive than that used in the U.S. National Lung Screening Trial (NLST).

That’s according to research presented on August 7 at the International Association for the Study of Lung Cancer (IASLC) World Conference on Lung Cancer (WCLC) 2022 in Vienna. In the presentation, researchers from Erasmus University Medical Center Rotterdam said that the NELSON protocol may increase the benefits of lung cancer screening, particularly for early-stage cancers, while reducing unnecessary follow-up procedures.

Koen de Nijs.

Koen de Nijs.

“We hope that these results will help inform decisions on nodule management in ongoing and future screening programs,” lead researcher Koen de Nijs, a PhD student at Erasmus, told AuntMinnieEurope.com. “Our results suggest that volume-based nodule management is likely to increase the benefits of lung cancer screening programmes.”

Both NELSON and NLST were landmark research studies that demonstrated the effectiveness of CT lung cancer screening for high-risk individuals. NELSON revealed a reduction in lung cancer mortality of 24% for screening with CT, compared to a 20% reduction in the NLST. But the trials differed in study population and trial design, he noted.

Specifically, the NELSON trial used a nodule management protocol that incorporated nodule volume and quantified volume growth as opposed to nodule diameter for determining whether to conduct follow-up procedures. The Erasmus group, therefore, evaluated how the difference in nodule management protocols affected CT sensitivity across stages and histology in the trials.

Using the MISCAN-Lung model, previously used to evaluate results from the NLST, to evaluate NELSON’s outcomes, the group found that the sensitivity in NELSON was estimated to be higher across all stages compared with the NLST. The model reproduced lung cancer incidence and mortality by method of detection (clinical or screen-detected), sex, histology, and stage; the researchers evaluated potential differences in CT sensitivity by stage and histology, accounting for characteristics of the study population, trial design, and epidemiology in each trial.

The comparison between the trials was as follows:

Sensitivity of CT lung cancer screening protocols
Sensitivity by cancer type NLST NELSON
Early-stage adenocarcinoma, stage 1A 57% 73%
Early-stage adenocarcinoma, stage 1B 64% 90%
Squamous cell carcinoma, stage 2 39% 75%

Specificity with the NELSON protocol was also superior to that of NLST. The Erasmus researchers stated that NELSON’s volumetric-based technique for evaluating lung nodules was superior to the technique used with NLST. Model-based comparison of the NELSON and NLST suggests that the differences in screening effectiveness may be explained by differences in the nodule management protocols, they pointed out.

Overall, they hope the new research will have an influence on nodule management protocol.

“Volume-based measurement may require investment and training, such as for the use of computer-aided detection systems. However, in a comparison of the volume-based NELSON trial and the diameter-based NLST, we find considerable differences in the probability of the detection of disease at an early stage,” said de Nijs.

The results may also have an impact on recommendations of future screening programs, he added. “Many published estimates of cost-effectiveness are still based on the results of the NLST. Any program employing volume-based nodule management may see greater benefits from the required investment, improving the cost-effectiveness of lung cancer screening on a population scale.”

IASLC: Air pollution exposure adds to lung cancer risk

IASLC: Air pollution exposure adds to lung cancer risk

By AuntMinnie.com staff writers

August 9, 2022 — Long-term exposure to air pollution should be considered a risk factor for lung cancer in patients who have never smoked, according to research presented August 9 at the International Association for the Study of Lung Cancer (IASLC) 2022 World Conference on Lung Cancer in Vienna, Austria.

After comparing cumulative three-year versus 20-year exposure to air pollution in over 200 females with newly diagnosed lung cancer who had never smoked, a team of researchers led by Dr. Renelle Myers of BC Cancer in Vancouver found that many foreign-born Canadian women had experienced long-term exposure to air pollution.

The researchers studied 236 female patients with newly diagnosed lung cancer who had never smoked and were invited to participate in the study. Of these, 190 (83.3%) were born outside of Canada and 71% were Asians. The patients had a mean age of lung cancer diagnosis of 66 years, and 92.8% had adenocarcinoma and 55.9% had stage III/IV lung cancer.

To assess both short- and long-term exposure to outdoor air pollution, the researchers used the International Agency of Research on Cancer’s carcinogenic benchmark level of particulate matter of 2.5 micrograms/meter3 (PM 2.5) in outdoor air pollution. After collecting detailed patient background and residential history, they linked residential locations to satellite-derived PM 2.5 exposure data beginning in 1996. A high spatial-resolution global exposure model was then used to quantify cumulative exposure to PM 2.5.

The researchers found that an assessment of three-year exposure to a carcinogenic level of outdoor air pollution significantly underestimated cumulative exposure to PM 2.5 prior to lung cancer diagnosis, especially among patients born outside of Canada.

Only four (2%) of the foreign-born patients had a three-year cumulative PM 2.5 exposure of more than 10 ug/m3, while 38 (20%) had a 20-year cumulative PM 2.5 of more than 10 ug/m3. The difference was statistically significant (p < 0.001). What’s more, all patients had a PMI 2.5 exposure greater than 5 ug/m3.

“Our study demonstrates the importance of incorporating long-term cumulative exposure to ambient air pollutants in the assessment of individual lung cancer risk in combination with traditional risk factors,” said Myers in a statement from the IASLC. “Our finding has important clinical implications in assessing lung cancer risk with global migration.”

CT lends itself to opportunistic screening for osteoporosis

CT lends itself to opportunistic screening for osteoporosis

By Kate Madden Yee, AuntMinnie.com staff writer

August 10, 2022 — Chest CT for indications such as lung cancer screening can also be used to screen for osteopenia or osteoporosis — especially when an artificial intelligence (AI) algorithm that identifies regions of interest is added, a study published August 6 in Osteoporosis International suggests.

The results are good news for patients both from the perspectives of both radiation exposure and fracture risk, wrote a team led by Jinrong Yang, PhD, of Huazhong University of Science and Technology in Wuhan, China.

“The routine chest CT with AI is of great value in opportunistic screening for osteopenia or osteoporosis, which can quickly screen the population at high risk of osteoporosis without increasing radiation dose, thus reducing the incidence of osteoporotic fracture,” the group noted.

Osteoporosis causes loss of bone mass and density, the authors explained. But it can be difficult to detect, and if it isn’t identified in a timely fashion, it can cause serious fractures.

“Osteoporosis is still seriously underestimated at present, and more than 50% of patients with osteoporotic fracture have never received screening for osteoporosis,” they wrote. “Therefore, it is imperative to identify individuals at high risk of osteoporosis early and intervene as soon as possible, which can not only avoid fracture and reduce personal pain, but also save medical costs and reduce economic burden.”

Current standard for diagnosing osteoporosis is dual-energy x-ray absorptiometry (DEXA). But this technology has its limits, since it is a 2D image, according to Yang’s team. That’s where CT could come in: It’s used for lung cancer screening in a population similar to those who benefit from osteoporosis screening, and it can provide data on the health of a patient’s vertebrae with little or no additional cost to the initial exam.

“Opportunistic CT screening systematically leverages the wealth of data embedded in routine CT scans, which are often unrelated to clinical indications, to screen for potential disease or risk factors beyond clinical indications in a single imaging examination,” the group wrote.

Yang’s and colleagues explored whether chest CT used for lung cancer screening and combined with an artificial intelligence algorithm could also identify osteoporosis. (The algorithm measured bone mineral density using automatic region of interest profiling on CT images.)

The study included 836 individuals who underwent dual-energy x-ray absorptiometry (DEXA) as well as chest CT (and had images of both thoracic and first lumbar vertebrae) between August 2018 and August 2019. The patients were categorized according to DEXA results into three groups: those with healthy bones, those with osteopenia, and those with osteoporosis.

The group found that CT attenuation values of thoracic and first lumbar vertebrae decreased with age, particularly in menopausal women, and showed a high predictive and diagnostic capability for osteopenia and osteoporosis. Those patients with higher CT attenuation values had a lower chance of developing these conditions, with the risk of osteopenia decreasing by 32% to 44% and the risk of osteoporosis decreasing by 61% to 80% with every 10 Hounsfield units increase of CT attenuation values.

The study authors said that the study results don’t indicate that CT should replace DEXA for diagnosing osteoporosis, but the group suggests that it could be an effective, additional screening tool.

“Chest CT combined with artificial intelligence automated tools has important implications for opportunistic screening of osteoporosis,” Yang et al wrote. “The purpose of opportunistic screening [is] not to demonstrate that low-dose CT can replace DEXA in the diagnosis of osteopenia or osteoporosis, but to investigate the value of CT values as an auxiliary means in screening for [these conditions].”

Lung CT NELSON lung screening protocol beats NLST for cancer detection

NELSON lung screening protocol beats NLST for cancer detection

By Frances Rylands-Monk, AuntMinnie.com contributing writer

August 8, 2022 — In a face-off between CT lung cancer screening trials, the protocol used to analyze lung nodules in the Dutch-Belgian Randomized Lung Cancer Screening (NELSON) trial proved more sensitive than that used in the U.S. National Lung Screening Trial (NLST).

That’s according to research presented on August 7 at the International Association for the Study of Lung Cancer (IASLC) World Conference on Lung Cancer (WCLC) 2022 in Vienna. In the presentation, researchers from Erasmus University Medical Center Rotterdam said that the NELSON protocol may increase the benefits of lung cancer screening, particularly for early-stage cancers, while reducing unnecessary follow-up procedures.

“We hope that these results will help inform decisions on nodule management in ongoing and future screening programs,” lead researcher Koen de Nijs, a PhD student at Erasmus, told AuntMinnieEurope.com. “Our results suggest that volume-based nodule management is likely to increase the benefits of lung cancer screening programmes.”

Both NELSON and NLST were landmark research studies that demonstrated the effectiveness of CT lung cancer screening for high-risk individuals. NELSON revealed a reduction in lung cancer mortality of 24% for screening with CT, compared to a 20% reduction in the NLST. But the trials differed in study population and trial design, he noted.

Specifically, the NELSON trial used a nodule management protocol that incorporated nodule volume and quantified volume growth as opposed to nodule diameter for determining whether to conduct follow-up procedures. The Erasmus group, therefore, evaluated how the difference in nodule management protocols affected CT sensitivity across stages and histology in the trials.

Using the MISCAN-Lung model, previously used to evaluate results from the NLST, to evaluate NELSON’s outcomes, the group found that the sensitivity in NELSON was estimated to be higher across all stages compared with the NLST. The model reproduced lung cancer incidence and mortality by method of detection (clinical or screen-detected), sex, histology, and stage; the researchers evaluated potential differences in CT sensitivity by stage and histology, accounting for characteristics of the study population, trial design, and epidemiology in each trial.

The comparison between the trials was as follows:

Sensitivity of CT lung cancer screening protocols
Sensitivity by cancer type NLST NELSON
Early-stage adenocarcinoma, stage 1A 57% 73%
Early-stage adenocarcinoma, stage 1B 64% 90%
Squamous cell carcinoma, stage 2 39% 75%

Specificity with the NELSON protocol was also superior to that of NLST. The Erasmus researchers stated that NELSON’s volumetric-based technique for evaluating lung nodules was superior to the technique used with NLST. Model-based comparison of the NELSON and NLST suggests that the differences in screening effectiveness may be explained by differences in the nodule management protocols, they pointed out.

Overall, they hope the new research will have an influence on nodule management protocol.

“Volume-based measurement may require investment and training, such as for the use of computer-aided detection systems. However, in a comparison of the volume-based NELSON trial and the diameter-based NLST, we find considerable differences in the probability of the detection of disease at an early stage,” said de Nijs.

The results may also have an impact on recommendations of future screening programs, he added. “Many published estimates of cost-effectiveness are still based on the results of the NLST. Any program employing volume-based nodule management may see greater benefits from the required investment, improving the cost-effectiveness of lung cancer screening on a population scale.”

CT Scan Lung screening evens out gender disparity in lung cancer mortality

CT screening evens out gender disparity in lung cancer mortality

By Brian Casey, AuntMinnie.com staff writer

August 3, 2022 — Men with lung cancer have a much higher risk of mortality compared with women, says a new paper published August 1 in Lung Cancer. But this difference disappears if they got CT lung screening, suggesting that screening can even out gender disparities.

Researchers found that among individuals with lung cancer who got screened and those who didn’t, men had a 62% higher mortality rate than females. But there was no statistically significant difference in mortality rates between men and women when data was analyzed based on who got screened and who didn’t.

CT lung screening has been demonstrated to reduce mortality by 20% among high-risk individuals like heavy smokers. But much of the recent research into CT lung cancer screening has focused on racial and gender disparities in screening.

For example, a July 24 paper in Cancer Medicine found that while the recent expansion of CT lung screening guidelines doubled the number of eligible individuals, many might not be able to get to a screening facility due to socioeconomic factors. And a July 28 study in JAMA Oncology questioned whether existing guidelines are missing many at-risk people.

With respect to women, part of the problem with recent research is that females have been somewhat underrepresented. The landmark National Lung Screening Trial consisted of 59% males versus 41% females, while the Dutch-Belgian Lung Cancer Screening (NELSON) saw an even greater disparity, with only 16% of participants being women. At the same time, the incidence of lung cancer has fallen 35% in men over the last four decades, but it has increased 87% in women.

In the current study, a team led by Adriana Rodriguez Alvarez of Boston University wanted to focus more closely on gender disparities in CT lung screening. The group analyzed data from the Boston Lung Cancer Study acquired from 2013-2021. In all, 1,216 individuals diagnosed with lung cancer were included in their analysis; of these, 9.4% had undergone CT lung cancer screening.

The researchers separated the study subjects into four groups, defined by gender and screening status. They also classified individuals by stage of cancer at diagnosis. Alvarez and colleagues then used propensity score matching to create a study cohort that was balanced between men and women.

They found that the only category with a statistically significant difference was in mortality rates for men versus women in the group that included both screened and unscreened individuals.

Lung cancer mortality by CT lung cancer screening status and gender
Screening status and gender Hazard ratio for mortality p-value
Men vs. women (screened and unscreened) 1.62 p = 0.00022
Screened — all genders (vs. unscreened) 1.14 p = 0.79
Unscreened men (vs. unscreened women) 1.6 p = 0.54
Screened men (vs. screened women) 0.57 p = 0.46

Statistics are after adjustment for sex, age, smoking history, and stage.

In other findings, the researchers noted that early-stage cancer (stage 1A) was the most common diagnosis in the screened individuals, while late-stage cancer (stage IV) and extensive-stage cancer were more common in those who were not screened. Also, 27.5% of unscreened men died, versus 17.8% of unscreened women.

The researchers noted that their findings correlated with previous studies that pointed to a better prognosis for women with lung cancer than men, particularly with those who were not screened. But the difference disappeared among those who were screened.

“However, when screened women were compared to screened men, there were no differences in survival probability,” the authors concluded. “These findings could suggest that screening, regardless of sex, is effective to reduce sex disparities in lung cancer survival.”

Do CT lung cancer screening rules need to be expanded again?

Do CT lung cancer screening rules need to be expanded again?

By Kate Madden Yee, AuntMinnie.com staff writer

July 28, 2022 — Current guidelines on CT lung cancer screening from the U.S. Preventive Services Task Force (USPSTF) may not cover many current and former smokers who remain vulnerable to developing lung disease, a study published July 28 in JAMA Oncology has found.

The USPSTF’s current recommendation focuses mostly on people between the ages of 50 and 80 who are long-term current smokers, or who quit recently. For example, it doesn’t cover former long-term smokers if they quit 15 or more years ago, or even current smokers if they have smoked for 20 pack years or less.

That’s leaving out a lot of people who might still be at risk of lung cancer but who aren’t eligible for low-dose CT (LDCT) screening, noted a team led by Dr. Charles Faselis of the VA Medical Center in Washington, DC. And this gap could be dangerous, the group wrote.

“The findings of this cohort study suggest that there is a high risk of lung cancer among smokers for whom LDCT screening is not recommended,” Faselis and colleagues noted.

Last year, the USPSTF amended its lung cancer screening recommendation, lowering the starting age and reducing the length of pack-year smoking required. But the updated recommendation still doesn’t include large groups of individuals:

  • Adults between 50 and 80 who are former heavy smokers (more than 20 pack years of smoking) who quit more than 15 years ago
  • Current smokers who aren’t classified as heavy smokers (less than 20 pack years of smoking)

Therefore, Faselis and colleagues sought to investigate lung cancer risk among these two groups not covered by the USPSTF screening guidance via research that used data from the Cardiovascular Health Study from the National Heart, Lung, and Blood Institute. It included information from 4,279 people with no cancer but with baseline data on pack-year smoking history and duration of stopping smoking. The mean age of the 4,279 individuals was 72.8 years; 15.5% were Black Americans, 83.8% were white, and 0.7% were of other race or ethnicity.

The researchers found that, despite not falling under the USPSTF screening guidelines, the individuals they studied had more than 10 times the risk of incident lung cancer compared with never-smokers, and 18% to 53% higher risk of all-cause death.

Morbidity and mortality for individuals outside USPSTF CT lung screening guidelines
Outcome Never smokers* (control) Nonheavy smokers Former heavy smokers with 15 or more years of smoking cessation
Incident lung cancer 1 10.06 10.22
All-cause death 1 1.53 1.18

*Never smokers hazard ratio is reference, at 1; ratios adjusted for age, sex, and race.

The authors conceded that the absolute risk of lung cancer in the population they studied remains small, at 5%. This highlights the need to assess potential harms of annual screening among older smokers, perhaps using machine learning or artificial intelligence (AI) technology.

“[Our] findings …provide new evidence of a high risk of lung cancer among smokers for whom LDCT screening is not recommended,” the group wrote. “These findings suggest that future studies should determine whether annual LDCT screening could reduce lung cancer mortality in these smokers.”

Did new CT lung cancer screening guidelines really improve access?

Did new CT lung cancer screening guidelines really improve access?

By Kate Madden Yee, AuntMinnie.com staff writer

July 26, 2022 — New guidelines issued last year on who should get CT lung cancer screening nearly doubled the number of people eligible for the scans. But that doesn’t necessarily mean they will get them, due to healthcare disparities, according to a study published July 24 in Cancer Medicine.

Many Black individuals may not be able to get access to CT lung screening due to demographic factors like lacking access to transportation and appointment wait times — despite the fact that they are now eligible for screening, wrote a team led by Kristin Maki, PhD, of the University of Texas MD Anderson Cancer Center in Houston.

“Our results suggest that despite increasing the number of Black individuals who are eligible for lung cancer screening, the 2021 USPSTF recommendation highlights ongoing socioeconomic disparities that need to be addressed to ensure equitable access,” the group wrote.

Last year, the U.S. Preventive Services Task Force (USPSTF) updated its lung cancer screening recommendation, lowering the age of eligibility from 55 to 50 and adjusting smoking history from 30 pack years to 20 pack years. The change was an attempt to expand the screening eligibility pool, particularly to include more Black Americans, and it immediately prompted debate on whether the attempt was effective — with some arguing that it is and others arguing that it isn’t.

In yet another exploration of the issue, Maki and colleagues used data from the 2015 National Health Interview Survey to investigate the impact of the USPSTF 2021 lung cancer screening eligibility criteria on racial disparities between Black and white people, tracking factors such as education and socioeconomic level and employment and insurance status. The team also assessed individuals’ use of preventive care and reasons for delayed medical care.

The study included data from those who would have been eligible for CT lung cancer screening according to the USPSTF’s 2013 recommendation. The authors found that the 2021 update had a dramatic effect on expanding the eligibility pool, in line with previous studies: The number of eligible individuals grew from 7.9 million under the 2013 guidelines to 14.2 million under the 2021 recommendation, a relative increase of 81.4%.

Under the 2021 guidance, the proportion of eligibility expanded for all racial and ethnic groups except white individuals; the share of women eligible for screening also grew.

Eligibility for CT lung cancer screening by race and sex, by year of USPSTF recommendation 
Factor 2013 2021 
Non-Hispanic white 87.0% 83.7%
Non-Hispanic Black 6.9% 7.7%
Hispanic 3.5% 4.1%
Non-Hispanic Asian 2% 3.7%
Males 57.5% 55.4%
Females 42.5% 44.6%

But despite expanding the pool of eligibility, the 2021 recommendation doesn’t make healthcare disparity between Black and white individuals disappear.

For example, Black patients were more likely to report of lack transportation to a medical site compared with their white counterparts (11.1% vs. 3.6%); could not get an appointment soon enough (10.5% compared with 6.6%); and that the wait in the office was too long (10.4% vs. 4.9%).

“The 2021 USPSTF recommendation update will dramatically increase the number of adults in the U.S. who are eligible for lung cancer screening, yet this may not address drivers of inequities related to lung cancer screening,” the authors explained.

How can these disparities be mitigated? Maki’s group offered a number of ideas.

“Increasing accessibility through mobile clinics, telehealth, and other innovations in care delivery may help to reduce some barriers to screening,” the team concluded. “At the patient level, integrating patient navigators, interventions to address health literacy, and efforts to reduce medical mistrust may help in reducing barriers to screening and improving lung cancer outcomes among minority populations.”

Detecting Coronary Calcium in Young Adults: Are We There yet?

Detecting Coronary Calcium in Young Adults: Are We There yet?

Gregory S. Thomas, MD, MPH; Nathan D. Wong, PHD

DISCLOSURES

J Am Coll Cardiol. 2022;79(18):1887-1889.

Atherosclerosis begins before birth and progresses throughout life.[1] Calcific atherosclerosis has been demonstrated in human cultures for at least 5,300 years[2] and was commonplace in many ancient cultures.[3] The modern day Tsimane tribe of the Bolivian Amazon demonstrates the potential preventive power of a lifetime of minimal atherosclerotic cardiovascular disease (ASCVD) risk factors. They live a subsistence lifestyle of hunting, gathering, fishing, and farming and have an estimated lifetime low-density lipoprotein cholesterol (LDL-C) of ≈71 mg/dL. Coronary artery calcium (CAC) scanning of 705 Tsimane adults found their CAC to be approximately one-fifth the level observed in a U.S. industrialized population.[4]

CAC is a well-established marker of coronary atherosclerosis burden and strongly predicts ASCVD events in young[5] and in middle-aged and older[6]adults. It is useful for patients undergoing CAC imaging and their clinicians to know how their score compares to others of similar age, sex, and race/ethnicity. In 2006, McClelland et al[7] provided clinicians with a calculator to estimate an individual’s age, sex, and race/ethnicity-based CAC profile by comparing them with a database of 6,110 subjects aged 45–84 years from the MESA (Multiethnic Study of Atherosclerosis) study who did not have known ASCVD or diabetes. In this issue of the Journal of the American College of Cardiology, Javaid et al[8] utilized CAC values from 3 populations younger than those in MESA to develop a calculator for individuals aged 30–45 years. The 3 populations totaled 19,725 predominantly White and Black individuals and included participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study,[9] the CAC Consortium cohort,[10] and the Walter Reed Cohort.[11] Each cohort was weighted equally, and the authors smoothed the raw data to prevent overfitting, using a method similar to that of McClelland et al.[7]

These 3 populations include the bulk of U.S. White and Black 30- to 45-year-old patients in published CAC datasets. As the authors note, their risk factor prevalence is similar to that of National Health and Nutrition Examination Survey participants. The CARDIA dataset was community-based, CAC Consortium participants were self or physician referred, and the Walter Reed Cohort was physician referred, although it was in a medical setting in which CAC testing was widely encouraged. Typically, physician-referred individuals would be expected to have a greater risk factor and thus CAC burden. On the other hand, individuals who would enroll in a study such as CARDIA are potentially subject to healthy study responder bias. Both calculators intersect at age 45 years, at which point CAC scores at each percentile are only slightly higher in the young adult than the MESA calculator. On balance, the authors succeeded in assembling a dataset and a calculator that is generalizable to the U.S. White and Black populations.

An important implication of the young adult calculator lies in its potential clinical utility. Should young adults aged 30–45 years be considered for assessment of CAC, and if so, who? The 2018 American Heart Association/American College of Cardiology/multisociety guideline for cholesterol management[12] recommends consideration of CAC scores to further inform treatment decisions beyond risk-scoring and risk-enhancing factors. This recommendation, however, is based primarily on adults aged ≥45 years in MESA in which a CAC score of >100 identified those with a favorable net clinical benefit for statin use.[13] Such an analysis is not available for younger adults, nor is the guideline recommended Pooled Cohort Equation score for 10-year ASCVD risk calculation applicable to those aged <40 years.

Although universal screening for CAC in young adults should not be endorsed, we suggest certain “CAC benefit groups” in which ASCVD risk may be sufficiently high to warrant assessment of CAC assessment from a shared-decision discussion between clinician and patient, including consideration of other risk enhancing factors. These groups include the following: 1) those with suspected or diagnosed familial hypercholesterolemia; 2) those with a family history of premature ASCVD; 3) those with multiple risk factors; and 4) those aged 40–45 years who are identified as borderline-intermediate risk by the current Pooled Cohort Equation.

 

 

 

 

Regular screening of people at high risk for pancreatic cancer pays off

Regular screening of people at high risk for pancreatic cancer pays off

Study finds most patients with pancreatic cancer diagnosed through regular screenings had early-stage disease and long-term survival

Date:
July 13, 2022
Source:
Johns Hopkins Medicine
Summary:
Surveillance programs for people at high risk of developing pancreatic cancers can help detect precancerous conditions and cancers early, when they are most treatable, according to a new multicenter study.
FULL STORY

Surveillance programs for people at high risk of developing pancreatic cancers can help detect precancerous conditions and cancers early, when they are most treatable, according to a new multicenter study directed by experts at the Johns Hopkins Kimmel Cancer Center.

A total of 1,461 individuals at high risk of developing pancreatic cancer were enrolled in the Cancer of Pancreas Screening-5 (CAPS5) study at Johns Hopkins Medicine and seven other medical centers, and underwent annual pancreatic imaging tests. Of these participants, 10 were diagnosed with pancreatic cancer, including one participant who was diagnosed four years after dropping out of recommended surveillance. Seven of the remaining nine patients (77.8%) were diagnosed with stage I disease, and the other two had progressed to higher stage cancer (one had stage IIB, and one had stage III disease). Seven of these patients were alive after a median follow-up of 2.6 years.

These findings were published online in the June 2022 issue of the Journal of Clinical Oncology.

“A clear majority of patients in the CAPS program who were diagnosed with pancreatic cancer were detected at the first stage of the disease if they maintained their surveillance,” says senior study author Michael Goggins, M.B.B.Ch., M.D., Sol Goldman Professor of Pancreatic Cancer Research and director of the Pancreatic Cancer Early Detection Laboratory.

In general, Goggins says, most patients presenting with symptoms already have later-stage pancreatic cancer; very few have their disease detected at stage I. Combining the CAPS5 data with statistics from previous Johns Hopkins Medicine CAPS studies that began in 1998, led by Marcia Canto, M.D., director of clinical research for the gastroenterology division, investigators found that in the entire CAPS cohort of 1,731 patients, 19 of the 26 cases of pancreatic cancer were diagnosed in patients who maintained their pancreas surveillance. Of those, 57.9% had stage I cancers, 15.8% had stage II cancers, 21.1% had stage III cancers and 5.2% had stage IV disease. By contrast, six of the seven pancreatic cancers detected in patients who had stopped their annual surveillance (85.7%) were stage IV. The five-year survival to date of patients with a surveillance-detected pancreatic cancer is 73.3%, and median overall survival is 9.8 years, compared with 1.5 years for patients diagnosed with pancreatic cancer outside surveillance.

“Many of those diagnosed with pancreatic cancer under surveillance can be potentially cured. By contrast, people who dropped off their surveillance had poor survival rates. Our results support the CAPS surveillance recommendation that those who meet the criteria should undergo regular screenings,” says Goggins.

In the CAPS5 study, investigators enrolled individuals between 2014-2021 who had a genetic variant that made them susceptible to pancreatic cancer or who had more than one first-degree relative with pancreatic cancer. Nearly half (48.5%) had a genetic variant predisposing them to cancer, including 18.4% with a mutation in the BRCA2 gene and 6.4% with a variant in the ATM gene. About a third of the group had a personal history of cancer, with breast cancer being the most commonly reported (15.8% affected). Patients received annual screenings with magnetic resonance imaging or endoscopic ultrasound.

Eight other participants had pancreatic surgeries for concerning lesions detected during surveillance. Of these, three were found to have high-grade dysplasia precancerous conditions, and five were found to have low-grade dysplasia. Also, during the study period, 73 patients were diagnosed with other cancers, including 17 cases of breast cancer, 11 cases of prostate cancer and seven cases of melanoma.

Pancreatic surveillance is best done at expert centers by multidisciplinary teams, Goggins says, because some abnormalities that show up in pancreatic imaging are of uncertain significance. Researchers are working on blood tests that could be combined with imaging for early detection of cancers, he says.

Study co-authors were Mohamad Dbouk, Alison P. Klein, Ihab Kamel, Ralph H. Hruban, Jin He, Eun Ji Shin, Anne Marie Lennon, and Marcia Canto of Johns Hopkins. Other institutions participating in the study were the University of Pennsylvania Perelman School of Medicine, Philadelphia; University of Pittsburgh Medical Center; University Hospitals Cleveland Medical Center; Dana-Farber Cancer Institute, Boston; Yale Center for Pancreatic Disease, New Haven, Connecticut; Columbia University Irving Medical Center, New York, New York; and the University of Michigan, Ann Arbor.

The work was supported by the National Cancer Institute (grants CA210170, CA176828, CA62924, and P30CA013696); the Pancreatic Cancer Action Network; the V Foundation; Susan Wojcicki and Dennis Troper; the Lustgarten Foundation; the Smith Family Research Fund; the Bowen-Chapman Fund; and a Stand Up To Cancer-Lustgarten Foundation Pancreatic Cancer Interception Translational Research Grant.

Goggins receives royalties related to licensing as a co-discoverer of PALB2 as a pancreatic cancer susceptibility gene to Myriad Genetics. Klein is a consultant for OptumInsight and Merck, and receives research funding from OptumLabs. Kamel receives research funding from Siemens Healthineers. Hruban receives research funding from Applied Materials Inc. and has the potential to receive royalty payments from Thrive Earlier Detection Corp for the TERT in bladder cancers and GNAS inventions in an arrangement reviewed and approved by The Johns Hopkins University. Shin is a consultant for Boston Scientific. Lennon holds a patent for CancerSEEK. Canto is a consultant for Castle Biosciences and Bluestar Genomics; she receives research funding from Pentax Medical Corp. and Endogastric Solutions; and receives royalties from UpToDate, online. These arrangements are being managed by The Johns Hopkins University in accordance with its conflict-of-interest policies.


Story Source:

Materials provided by Johns Hopkins Medicine. Note: Content may be edited for style and length.


Journal Reference:

  1. Mohamad Dbouk, Bryson W. Katona, Randall E. Brand, Amitabh Chak, Sapna Syngal, James J. Farrell, Fay Kastrinos, Elena M. Stoffel, Amanda L. Blackford, Anil K. Rustgi, Beth Dudley, Linda S. Lee, Ankit Chhoda, Richard Kwon, Gregory G. Ginsberg, Alison P. Klein, Ihab Kamel, Ralph H. Hruban, Jin He, Eun Ji Shin, Anne Marie Lennon, Marcia Irene Canto, Michael Goggins. The Multicenter Cancer of Pancreas Screening Study: Impact on Stage and Survival. Journal of Clinical Oncology, 2022; DOI: 10.1200/JCO.22.00298

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Johns Hopkins Medicine. “Regular screening of people at high risk for pancreatic cancer pays off: Study finds most patients with pancreatic cancer diagnosed through regular screenings had early-stage disease and long-term survival.” ScienceDaily. ScienceDaily, 13 July 2022. <www.sciencedaily.com/releases/2022/07/220713114610.htm>.

PSMA-PET/CT comparable to MRI Scans for detecting prostate cancer

PSMA-PET/CT comparable to MRI for detecting prostate cancer

By Kate Madden Yee, AuntMinnie.com staff writer

July 6, 2022 — Prostate-specific membrane antigen (PSMA)-PET/CT imaging is comparable to MRI for detecting clinically significant prostate cancer. But MRI is still the more accurate modality for detecting the grade of disease, according to research presented on July 3 at the European Association of Urology (EAU) in Amsterdam, the Netherlands.

The findings suggest that PSMA-PET/CT shows promise as an alternative for prostate cancer detection — good news for patient care, wrote a team led by Dr. Lih-Ming Wong of St. Vincent’s Hospital in Melbourne, Australia.

“This study confirms that the existing ‘gold standard’ of prebiopsy detection — MRI — is indeed a high benchmark,” Wong said in a statement released by the society. “Even with fine-tuning, we suspect PSMA-PET/CT won’t replace the MRI as the main method of prostate cancer detection. But it will likely have application in the future as an adjunct to the MRI, or for people for whom an MRI is unsuitable, or as a single combined ‘diagnostic and staging’ scan for appropriately selected patients.”

The U.S. Food and Drug Administration (FDA) cleared the imaging agent gallium-68 (Ga-68) PSMA-11 for PSMA-PET/CT scans in 2020; a second agent, Pylarify, was cleared in 2021. Previous studies have suggested that PSMA-PET is a comparable tool to MRI for detecting clinically significant tumors in patients with prostate cancer.

Wong’s group sought to investigate this theory further via a study that included 240 patients at risk of prostate cancer. Each underwent an MRI exam and a PSMA-PET/CT scan; if imaging indicated that prostate cancer was present, patients had a biopsy.

MRI found abnormalities suggestive of prostate cancer in 141 patients, and the PSMA-PET/CT scans found abnormalities in 198 patients. Of the 240 individuals who were included in the study, 181 (75%) underwent biopsy, and 82 of those were confirmed to have “clinically significant” prostate cancer, as defined by the relatively new International Society of Urologic Pathologists (ISUP) grading system for cancer severity.

Although PSMA-PET/CT imaging found more abnormalities than MRI exams did, MRI was more accurate in identifying the grade of prostate cancer than PSMA-PET/CT, at 75% compared with 62%, the team noted. But the two modalities were comparable when it came to identifying clinically significant prostate cancer, Wong noted.

“Our analysis found that MRI scans were better than PSMA-PET for detecting any grade of prostate cancer … [but] when we looked only at clinically significant prostate cancers, there was no difference in accuracy,” he said.

PSMA-PET/CT offers a good alternative to MRI for prostate cancer diagnosis, but more research is necessary, said Dr. Peter Albers of Heinrich-Heine-University Düsseldorf in Germany and chair of the EAU’s chief scientific officer, in the statement.

“More research will be needed to explore the PSMA-PET/CT correlation between the standard uptake value and cancer aggressiveness, but the first steps down the road in finding the best diagnostic approach to clinically significant prostate cancer have been taken,” he said.