Chapter 8: Pulmonary Disorders

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Population

• –Adults, asymptomatic.

Recommendation

USPSTF 2016

• –Do not screen asymptomatic adults for COPD.

Source

• –JAMA. 2016;315(13):1372-1377.

Comments

1. Detection while asymptomatic doesn’t alter disease course or improve outcomes.

2. Several symptom-based questionnaires have high sensitivity for COPD.

3. In symptomatic patients (ie, dyspnea, chronic cough, or sputum production with a history of exposure to cigarette smoke or other toxic fumes), diagnostic spirometry to measure FEV1/FVC ratio is indicated.

LUNG CANCER

Population

• –Asymptomatic persons with >30 pack-year smoking history.

Recommendations

USPSTF 2013 , ASCO 2013, ACCP 2018

• –Screen for lung cancer annually with low-dose chest CT in adults ages 55–80 y who have at least a 30 pack-year smoking history.

  • USPSTF: age 55–80 y

  • ASCO: age 55–74 y

  • ACCP: age 55–77 y

• –Stop screening if a person has not smoked for 15 y, or if they develop a significant medical problem that would limit ability to receive treatment for an early stage lung cancer.

• –Do not screen routinely with chest x-ray and/or sputum cytology.

Sources

• –https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening

• –JAMA. 2012;307(22):2418-2429. https://www.asco.org/practice-guidelines/quality-guidelines/guidelines/thoracic-cancer#/10211

• –CHEST. 2018;153(4):954-985. https://www.ncbi.nlm.nih.gov/pubmed/29374513

Recommendations

American Cancer Society, NCCN 2018

• –Screen with low-dose chest CT if

  • age 55–74 y, a 30 pack-year smoking history, and cessation <15 y ago, or

  • age 50+, a 20 pack-year smoking history, and additional risk factors that raise the risk of cancer by 1.3% per the Tammegami lung cancer risk calculator (PLOS Med 2014;11;1-13).

• –Screen for at least 3 consecutive years.

• –Only screen if a highly skilled support team is available to evaluate CT scans, schedule appropriate follow-up, and perform lung biopsies safely when indicated.

• –Employ shared decision-making.

Sources

• –J Natl Compr Canc Netw. 2018;16:412-441.

• –https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html

Comments

1. Less than 1 in 1000 patients with a false-positive result experience a major complication resulting from diagnostic workup.

2. Clinical insight:

   1. Counsel all patients against tobacco use, even when age >50 y. Smokers who quit gain ~10 y of increased life expectancy and have maximum reduction in risk of lung cancer after 15 y of no tobacco use. (Br Med J. 2004:328)

   2. Spiral CT screening can detect greater number of lung cancers in smokers with a >10-pack-year exposure. (N Engl J Med. 2006;355: 1763-1771)

   3. The NCI has reported data from the National Lung Screening Trial (NLST), a randomized controlled trial comparing LDCT and CXR yearly × 3 with 8-y follow-up. A total of 53,500 men and women age 50–74 y, 30 pack-year smokers were randomized. A 20.3% reduction in deaths from lung cancer was reported for the LDCT group (estimated that ...