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All About Lung Cancer 
Andrea Borondy Kitts 
@findlungcancer 
November 20, 2014
Agenda 
• Dan’s Story 
• Lung Cancer Statistics 
• What is Lung Cancer 
• Lung Cancer Risk Factors 
• Natural History and ...
Lung Cancer Is Personal 
© 2014 Free to Breathe 
Dan’s Story
Lung Cancer is the 2nd Leading Cause of Death in the US 
• Lung cancer is the leading cause of 
cancer deaths in both men ...
© 2014 Free to Breathe 
Lung Cancer Facts
© 2014 Free to Breathe 
Lung Cancer Risk
© 2014 Free to Breathe 
• Lung Cancer Risk
© 2014 Free to Breathe 
Lung Cancer Facts
Global Lung Cancer Incidence and Mortality 
Most common cancer worldwide 
• 1.6 million deaths in 2012 
Fifty eight percen...
Lung Cancer is a Non-Infectious Chronic Disease 
http://www.nccn.org/patients/guidelines/nscl/index.html#8 
Most are carci...
87% Non-Small Cell Lung Cancer (NSCLC); 13% 
Small Cell Lung Cancer (SCLC) Histology 
Molecular Challenges in Lung Cancer ...
Over 80% of Lung Cancers are caused by Tobacco 
U.S. Department of Health and Human Services. (2014). The Health Consequen...
Lung Cancer Risk 
Other than smoking, what else can cause lung 
cancer? 
- Secondhand exposure to smoke 
- Radon 
- Having...
Natural History of Lung Cancer 
DNA 
damage to 
cells 
Abnormal 
cell growth 
Lesion 
Pathological 
Evidence 
Approximatel...
Surgical Treatment in Early Stages; Systematic 
Treatment in Late Stages 
Surgical Options include wedge resection, 
lobec...
© 2014 Free to Breathe 
• Lung Cancer Symptoms
80% of Lung Cancers Diagnosed after the 
Cancer has Spread When Chance of Cure Small 
Stage IV NSCLC 
<1% = 5 year OS 
11/...
Annual Low Dose CT Scan Screening Finds Lung 
Cancer Early When Chance for Cure High 
Stage T1AN0 
92% 5-year Overall Surv...
National Lung Screening Trial Design Overview 
• 53,456 participants 
– LDCT scan 
or 
– CXR 
• Enrolled 2002 – 2004 
• 3 ...
National Screening Trial Results 
The National Lung Screening Trial Research Team . N 
Engl J Med 2011;365:395-409. 
More ...
Stage shift seen with LDCT screening in NLST shifts back 
after screening stopped - greater than 20% mortality 
improvemen...
Annual Lung Cancer Screening 
Recommended For the High Risk Population 
Age 
55 to 80 (age 74 for Medicare) 
Smoking Histo...
• More than 10 million Americans in the recommended population 
to screen 
• Estimated to save more than 20,000 lives a ye...
Stigma due to Strong Link with Smoking 
People with lung cancer blamed and/or blame themselves for their disease 
http://c...
Deadliness of disease and images of horrible death 
Lack of survivors and advocates = less research $’s 
11/20/2014 29
Tobacco Company Marketing Targets Youth – Every adult who dies 
early because of smoking is replaced by two new young smok...
Smoking is The Cancer Trigger 
Smoking is now known to cause 
13 different types of cancer— 
almost everywhere in the body...
Smoking is The Breath Blocker 
Chronic Obstructive Pulmonary Disease (COPD) 
Smoking causes most 
cases of COPD. 
There is...
Smoking is the Heart Stopper 
• Smoking causes cells lining veins and arteries to swell. 
• Narrower arteries mean 
reduce...
Government Policies and Social Context 
Warning Labels on Tobacco Products 
• Many now advocating for “plain 
packaging” 
...
Primary Prevention: States Have Failing Grades 
for Most Tobacco Control Measures 
Spending 
Cessation 
Excise Taxes 
Smok...
Summary 
• Lung Cancer is a Non-Infectious Chronic Disease 
– More than 80% of cases caused by tobacco use 
– 90% of regul...
Back Up Slides 
11/20/2014 37
Lung Cancer Incidence and Mortality Rates Decreasing 
in the US 
11/20/2014 38 
http://seer.cancer.gov/statfacts/html/lung...
Public Health Policy Implications 
Improve lung cancer survivability via USPSTF recommended low dose CT 
(LDCT) lung cance...
Tobacco Control Policies Stigmatize Smokers 
Tobacco Industry Response to 1964 Surgeon General Report: 
deny addictive nat...
Lung Cancer Stigma has Adverse Impacts on Depressive 
Symptoms, Quality of Life and Physical Symptoms 
• People with lung ...
LUNG CANCER (LC) STIGMA CONCEPTUAL MODEL 
Tobacco Control Policies 
Decreased Smoking Prevalence 
Reduced LC Incidence 
Re...
© 2014 Free to Breathe 
Lung Cancer Facts
Lung cancer is the leading cause of cancer deaths for 
both men and women 
© 2014 Free to Breathe
Lung Cancer is the Leading Cause of Cancer Deaths in the US 
• The leading cause of cancer deaths in both men and women 
–...
© 2014 Free to Breathe 
• Why You Should Care
Overall Lung Cancer Incidence in US is 60.1 cases per 100,000; 
Highest in African American Men at 93.0 per 100,000 
Avera...
Lung Cancer Screening with LDCT now Recommended for the 
Population at High Risk 
“The USPSTF recommends annual screening ...
All  About Lung Cancer
All  About Lung Cancer
All  About Lung Cancer
All  About Lung Cancer
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All About Lung Cancer

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Overview of Lung Cancer Statistics, Causes, Symptoms, Natural Disease History, Treatment, Screening, Stigma and Tobacco Control

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All About Lung Cancer

  1. 1. All About Lung Cancer Andrea Borondy Kitts @findlungcancer November 20, 2014
  2. 2. Agenda • Dan’s Story • Lung Cancer Statistics • What is Lung Cancer • Lung Cancer Risk Factors • Natural History and Treatment • Lung Cancer Screening • Tobacco Control • Summary 11/20/2014 2
  3. 3. Lung Cancer Is Personal © 2014 Free to Breathe Dan’s Story
  4. 4. Lung Cancer is the 2nd Leading Cause of Death in the US • Lung cancer is the leading cause of cancer deaths in both men and women in the US – 160,000 die each year, more than breast, colon, prostate and pancreatic cancer combined – 5 year survival at 16.8% essentially unchanged since 1975 • Most common cancer worldwide – 1.6 million deaths in 2012 11/20/2014 4
  5. 5. © 2014 Free to Breathe Lung Cancer Facts
  6. 6. © 2014 Free to Breathe Lung Cancer Risk
  7. 7. © 2014 Free to Breathe • Lung Cancer Risk
  8. 8. © 2014 Free to Breathe Lung Cancer Facts
  9. 9. Global Lung Cancer Incidence and Mortality Most common cancer worldwide • 1.6 million deaths in 2012 Fifty eight percent of new cases in underdeveloped regions Highest incidence and mortality in men • Central and Eastern Europe • Eastern Asia Women have lower incidence and mortality • Highest in North America – cultural differences in smoking prevalence • Lag in when women started smoking 11/20/2014 13 http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx
  10. 10. Lung Cancer is a Non-Infectious Chronic Disease http://www.nccn.org/patients/guidelines/nscl/index.html#8 Most are carcinomas and initiate in the lining of the airways • Bronchi • Bronchiole • Alveoli Today’s smokers are more likely to develop lung cancer than smokers 50 years ago. 11/20/2014 14
  11. 11. 87% Non-Small Cell Lung Cancer (NSCLC); 13% Small Cell Lung Cancer (SCLC) Histology Molecular Challenges in Lung Cancer Ben Leach Published Online: December 17, 2012 http://www.targetedonc.com/publications/targeted-therapy-news/ 2012/November-2012/Molecular-Challenges-in-Lung-Cancer NSCLC further characterized histologically into: • Adenocarcinoma • Squamous Cell • Large Cell 11/20/2014 15
  12. 12. Over 80% of Lung Cancers are caused by Tobacco U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking – 50 Years of Progress A Report of the Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/reports/50- years-of-progress/50-years-of-progress-by-section.html 11/20/2014 16
  13. 13. Lung Cancer Risk Other than smoking, what else can cause lung cancer? - Secondhand exposure to smoke - Radon - Having had smoking related cancer - Family History - Environmental pollutants (pollution, dust, © 2014 Free to Breathe asbestos) - COPD or Pulmonary Fibrosis
  14. 14. Natural History of Lung Cancer DNA damage to cells Abnormal cell growth Lesion Pathological Evidence Approximately 85% of diagnoses at a late stage 5 year survival 16.8% Localized – 54% Distant – 4% Metastasis Diagnosis Treatment Death Damage accumulates with age and exposure to agents e.g. tobacco. Average age of diagnosis is 70 Few symptoms in early stages Screening test (LDCT) not generally available until 2015 Early stage – Surgery and possible adjuvant chemo/radiation Late stage – palliative and life extension CT PET/CT Biopsy MRI Staging http://www.nccn.org/patients/guidelines/nscl/index.html 11/20/2014 18 http://seer.cancer.gov/statfacts/html/lungb.html
  15. 15. Surgical Treatment in Early Stages; Systematic Treatment in Late Stages Surgical Options include wedge resection, lobectomy, bilobectomy, and pneumonectomy via traditional, minimally invasive (VATS) or robotic surgery • sometimes preceded by, or followed with, adjuvant chemotherapy and/or radiation Systematic treatments include chemotherapy, radiation, targeted molecular treatments, and immunotherapy • Approximately 67% of NSCLC have an identified genetic mutation http://www.onclive.com/publications/Oncology-live/2013/January- 2013/Targeting-Tumors-Early-Trials-Push-Novel-Agents-to-Forefront/2 11/20/2014 19
  16. 16. © 2014 Free to Breathe • Lung Cancer Symptoms
  17. 17. 80% of Lung Cancers Diagnosed after the Cancer has Spread When Chance of Cure Small Stage IV NSCLC <1% = 5 year OS 11/20/2014 Low Dose Lung Cancer Screening 21
  18. 18. Annual Low Dose CT Scan Screening Finds Lung Cancer Early When Chance for Cure High Stage T1AN0 92% 5-year Overall Survival Goldstraw P, Crowley J, Chansky K, et al. (2007) The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2:706–714. 11/20/2014 Low Dose Lung Cancer Screening 22
  19. 19. National Lung Screening Trial Design Overview • 53,456 participants – LDCT scan or – CXR • Enrolled 2002 – 2004 • 3 Annual Screenings National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409. 11/20/2014 Low Dose Lung Cancer Screening 23
  20. 20. National Screening Trial Results The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409. More Lung Cancers found in LDCT Arm • Total Cases • LDCT 1060 • CXR 941 • Cases per 100k person years • LDCT 645 • CXR 572 Difference primarily early stage disease More Lung Cancer Deaths in CXR Arm • Total Deaths • LDCT 356 • CXR 443 • Deaths per 100k person years • LDCT 247 • CXR 309 20% Reduction in mortality with LDCT 11/20/2014 Low Dose Lung Cancer Screening 24
  21. 21. Stage shift seen with LDCT screening in NLST shifts back after screening stopped - greater than 20% mortality improvement possible 67.1 VS 33.2 20.5 VS 52.5 The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409
  22. 22. Annual Lung Cancer Screening Recommended For the High Risk Population Age 55 to 80 (age 74 for Medicare) Smoking History 30 pack years or more • 1 pack a day for 30 years/2 packs per day for 15 years etc. Current or Former Smoker Quit within the last 15 years 11/20/2014 26
  23. 23. • More than 10 million Americans in the recommended population to screen • Estimated to save more than 20,000 lives a year • Additional benefit for smoking cessation – Published smoking cessation rates in lung cancer screening trials and studies show 2 to 3 times the cessation rate as compared to the general population (11 to 22% vs 5 to 7%) "This has the biggest impact on lung cancer that we have ever seen in our lifetime," he said. "This will do more to save lives than anything else we have done to date in lung cancer, from a clinical perspective.” Reginald Munden, MD MD Anderson Cancer Center in Houston Principal site investigator in the NLST 11/20/2014 Low Dose Lung Cancer Screening 27
  24. 24. Stigma due to Strong Link with Smoking People with lung cancer blamed and/or blame themselves for their disease http://cancergeek.wordpress.com/2013/11/16/cancer-the-harsh-story-of-lung-cancer-vs-breast-cancer/ 11/20/2014 28
  25. 25. Deadliness of disease and images of horrible death Lack of survivors and advocates = less research $’s 11/20/2014 29
  26. 26. Tobacco Company Marketing Targets Youth – Every adult who dies early because of smoking is replaced by two new young smokers. • $8.4 Billion spent on advertising annually • $23 million every day • 90% of regular smokers start smoking by age of 18 • Smoking harder to quit than heroin Blakeslee, Sarah. (1987). Nicotine: Harder To Kick...Than Heroin. Retrieved October 29, 2014 from The New York Times website: http://www.nytimes.com/1987/03/29/magazine /nicotine-harder-to-kickthan-heroin.html Centers for Disease Control and Prevention. (2014). Economic Facts About U.S. Tobacco Production and Use, Retrieved on October 24, 2014 from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm BeTobaccoFree.gov. (2014). Nicotine Addiction and Your Health. Retrieved on October 29, 2014 from http://betobaccofree.hhs.gov/health-effects/ nicotine-health/index.html 11/20/2014 30
  27. 27. Smoking is The Cancer Trigger Smoking is now known to cause 13 different types of cancer— almost everywhere in the body.  1 out of 3 U.S. cancer deaths are tobacco-related.
  28. 28. Smoking is The Breath Blocker Chronic Obstructive Pulmonary Disease (COPD) Smoking causes most cases of COPD. There is NO CURE for COPD
  29. 29. Smoking is the Heart Stopper • Smoking causes cells lining veins and arteries to swell. • Narrower arteries mean reduced blood flow to the heart, brain, and organs. • Clots can block narrowed arteries, causing heart attack, stroke, and even sudden death. • Even occasional smoking damages blood vessels.
  30. 30. Government Policies and Social Context Warning Labels on Tobacco Products • Many now advocating for “plain packaging” Ban on Cigarette and Smokeless Tobacco Advertising on TV and Radio Smoking Restrictions in Public Places Increased Cigarette Taxes • 10% increase reduces consumption 3 to 5% Tobacco Master Settlement Agreement • Dollars go into general fund. Not being used for original intent of tobacco control Graphic CDC Anti-smoking Campaign Lung cancer incidence reduced from 42% in 1965 to 18% in 2012 Decline in teen smoking incidence leveling off. 5.6 million youths will die prematurely of tobacco related illness New threat E-cigarettes Unintended consequence is stigmatization of people with lung cancer increasing the disease burden Large tax revenues and strong lobbying stymie will to make tobacco illegal http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-progress- by-section.html 11/20/2014 34 http://www.cdc.gov/tobacco/data_statistics/by_topic/policy/legislation/
  31. 31. Primary Prevention: States Have Failing Grades for Most Tobacco Control Measures Spending Cessation Excise Taxes Smoke Free Air Laws 11/20/2014 35 http://www.stateoftobaccocontrol.org/state-grades/state-rankings/
  32. 32. Summary • Lung Cancer is a Non-Infectious Chronic Disease – More than 80% of cases caused by tobacco use – 90% of regular tobacco use starts by age 18 – Smoking harder to quit than heroin – Cigarettes more addictive now than in 1960’s • Lung cancer is the most common cancer worldwide and the leading cause of cancer deaths in men and women in the US – Mortality rate high due late stage at diagnosis • USPSTF and CMS now recommend LDCT screening annually for the high risk population – 10 million Americans eligible – Estimate more than 20,000 lives saved per year – Need to raise awareness with primary care physician community and the population at risk • Tobacco control efforts, although resulting in some success, have failed to eliminate smoking – E-cigarettes threaten to erode smoking incidence reduction achieved to date • Increased research funding needed for improved screening and treatment modalities 11/20/2014 36
  33. 33. Back Up Slides 11/20/2014 37
  34. 34. Lung Cancer Incidence and Mortality Rates Decreasing in the US 11/20/2014 38 http://seer.cancer.gov/statfacts/html/lungb.html
  35. 35. Public Health Policy Implications Improve lung cancer survivability via USPSTF recommended low dose CT (LDCT) lung cancer screening. Improved survival leads to positively reinforcing loops of reduced stigma, increased advocacy, increased research, increased survival Need CMS to cover LDCT lung cancer screening. Continuation of tobacco control policies should add lung cancer screening as a teachable moment for smoking cessation. Also, switch focus from negative portrayal of smokers and focus on tobacco and e-cigarette industry actions targeting addiction & marketing to youths 11/20/2014 39
  36. 36. Tobacco Control Policies Stigmatize Smokers Tobacco Industry Response to 1964 Surgeon General Report: deny addictive nature of smoking portray smoking as lifestyle choice Tobacco control policies de-normalized smoking and stigmatized smokers smoking as environmental health issue (2nd hand smoke) legislation of smoke free public areas and work places portraying smoking as a personal choice leading to a horrible death 11/20/2014 40 Stuber J, Galea S, Link BG. Smoking and the emergence of a stigmatized social status. Social Science in Medicine. 2008;67(3):420–430.
  37. 37. Lung Cancer Stigma has Adverse Impacts on Depressive Symptoms, Quality of Life and Physical Symptoms • People with lung cancer experience dual burdens of their disease and stigma • Lung cancer stigma is an independent factor – 2.1% impact on quality of life (QOL) – 3% of the impact on depressive symptoms – 1.3% increase in severity of symptoms • Depression impacts QOL and QOL prognostic factor for survival (ref below) Ediebah DE, Coens C, Zikos E.,Qinten C., Ringash J., King MT., Schmucker von Kich J., Gotay C., Greimel E., Fletchner H., Weis J., Reeve BB., Smit EF., TaphoornMJ., Bottomley A.Does change in health-related quality of life score predict survival? Analysis of EORTC 08975 lung cancer trial.Br J Cancer. 2014 Apr 17. doi: 10.1038/bjc.2014.208. (Epub ahead of print) 11/20/2014 41
  38. 38. LUNG CANCER (LC) STIGMA CONCEPTUAL MODEL Tobacco Control Policies Decreased Smoking Prevalence Reduced LC Incidence Reduced LC Advocacy Reduced LC Research Low Survivability Andrea Borondy Kitts April 2014 Increased LC Stigma Adverse LC patient impacts Stigmatized smokers Tobacco control policies effective at decreasing smoking prevalence however stigmatized smokers and people with lung cancer. Reduction in incidence of lung cancer offset by low survivability due to stigma resulting in negatively reinforcing loops of increased stigma, adverse patient impacts, less advocacy and reduced research. 11/20/2014 42
  39. 39. © 2014 Free to Breathe Lung Cancer Facts
  40. 40. Lung cancer is the leading cause of cancer deaths for both men and women © 2014 Free to Breathe
  41. 41. Lung Cancer is the Leading Cause of Cancer Deaths in the US • The leading cause of cancer deaths in both men and women – 160,000 die each year, more than breast, colon, prostate and pancreatic http://apps.nccd.cdc.gov/uscs/toptencancers.aspx cancer combined – 5 year survival at 16.8% essentially unchanged since 1975 http://www.cancer.org/acs/groups/content/@research/documents/webco ntent/acspc-042151.pdf
  42. 42. © 2014 Free to Breathe • Why You Should Care
  43. 43. Overall Lung Cancer Incidence in US is 60.1 cases per 100,000; Highest in African American Men at 93.0 per 100,000 Average age at diagnosis 70 http://seer.cancer.gov/statfacts/html/lungb.html 11/20/2014 47
  44. 44. Lung Cancer Screening with LDCT now Recommended for the Population at High Risk “The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery." http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm • More than 10 million Americans in the recommended population to screen • Estimated to save more than 20,000 lives a year • Additional benefit for smoking cessation – Published smoking cessation rates in lung cancer screening trials and studies show 2 to 3 times the cessation rate as compared to the general population (11 to 22% vs 5 to 7%) Sifferlin, Alexandra. 2013. "Surviving Lung Cancer." Time 182, no. 7: 15. Academic Search Premier, EBSCOhost (accessed October 28, 2014). Moyer VA, on behalf of the U.S. Preventive Services Task Force. Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement. (2014). Annals of Internal Medicine, 160:330-338. doi:10.7326/M13-2771 Townsend, C. O., Clark, M. M., Jett, J. R., Patten, C. A., Schroeder, D. R., Nirelli, L. M., Swensen, S. J. and Hurt, R. D. (2005). Relation between smoking cessation and receiving results from three annual spiral chest computed tomography scans for lung carcinoma screening. Cancer, 103:, 2154–2162. doi: 10.1002/cncr.21045 Tammemagi, M.C., Berg, C.D., Riley, T.L., Cunningham, C.R., Taylor, K.L. (2014). Impact of Lung Screening Results on Smoking Cessation. Journal of the National Cancer Institute, 10:6, DOI:10.1093/jnci/dju84 11/20/2014 48

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