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Pulmonary Journal Club

(Click on title to be directed to posting, most recent listed first)

May 2017 Phoenix Pulmonary/Critical Care Journal Club
October 2015 Phoenix Pulmonary Journal Club: Lung Volume Reduction
September 2015 Tucson Pulmonary Journal Club: Genomic Classifier
   for Lung Cancer
April 2015 Phoenix Pulmonary Journal Club: Endo-Bronchial Ultrasound in
   Diagnosing Tuberculosis
February 2015 Tucson Pulmonary Journal Club: Fibrinolysis for PE
January 2015 Tucson Pulmonary Journal Club: Withdrawal of Inhaled
    Glucocorticoids in COPD
January 2015 Phoenix Pulmonary Journal Club: Noninvasive Ventilation In 
   Acute Respiratory Failure
September 2014 Tucson Pulmonary Journal Club: PANTHEON Study
June 2014 Tucson Pulmonary Journal Club: Pirfenidone in Idiopathic
   Pulmonary Fibrosis
September 2014 Phoenix Pulmonary Journal Club: Inhaled Antibiotics
August 2014 Phoenix Pulmonary Journal Club: The Use of Macrolide
   Antibiotics in Chronic Respiratory Disease
June 2014 Phoenix Pulmonary Journal Club: New Therapies for IPF
   and EBUS in Sarcoidosis
March 2014 Phoenix Pulmonary Journal Club: Palliative Care
February 2014 Phoenix Pulmonary Journal Club: Smoking Cessation
January 2014 Pulmonary Journal Club: Interventional Guidelines
December 2013 Tucson Pulmonary Journal Club: Hypothermia
December 2013 Phoenix Pulmonary Journal Club: Lung Cancer
   Screening
November 2013 Tucson Pulmonary Journal Club: Macitentan
November 2013 Phoenix Pulmonary Journal Club: Pleural Catheter
   Infection
October 2013 Tucson Pulmonary Journal Club: Tiotropium Respimat 
October 2013 Pulmonary Journal Club: Pulmonary Artery
   Hypertension
September 2013 Pulmonary Journal Club: Riociguat; Pay the Doctor
August 2013 Pulmonary Journal Club: Pneumococcal Vaccine
   Déjà Vu
July 2013 Pulmonary Journal Club
June 2013 Pulmonary Journal Club
May 2013 Pulmonary Journal Club
March 2013 Pulmonary Journal Club
February 2013 Pulmonary Journal Club
January 2013 Pulmonary Journal Club
December 2012 Pulmonary Journal Club
November 2012 Pulmonary Journal Club
October 2012 Pulmonary Journal Club
September 2012 Pulmonary Journal Club
August 2012 Pulmonary Journal Club
June 2012 Pulmonary Journal Club
June 2012 Pulmonary Journal Club
May 2012 Pulmonary Journal Club
April 2012 Pulmonary Journal Club
March 2012 Pulmonary Journal Club
February 2012 Pulmonary Journal Club
January 2012 Pulmonary Journal Club
December 2011 Pulmonary/Sleep Journal Club
October, 2011 Pulmonary Journal Club
September, 2011 Pulmonary Journal Club
August, 2011 Pulmonary Journal Club
July 2011 Pulmonary Journal Club
May, 2011 Pulmonary Journal Club
April, 2011 Pulmonary Journal Club
February 2011 Pulmonary Journal Club 
January 2011 Pulmonary Journal Club 
December 2010 Pulmonary Journal Club

 

Both the Phoenix Good Samaritan/VA and the Tucson University of Arizona fellows previously had a periodic pulmonary journal club in which current or classic pulmonary articles were reviewed and discussed. A brief summary was written of each discussion describing thearticle and the strengths and weaknesses of each article.

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Entries in thoracic CT scan (2)

Tuesday
Dec312013

December 2013 Phoenix Pulmonary Journal Club: Lung Cancer Screening

During this month’s pulmonary journal club we reviewed several of the sentinel studies looking at lung cancer screening. Since the National Lung Screening Research Team (NLSRT) (1) published the impressive results showing a 20% reduction in lung cancer mortality, the debate on when and if to initiate a national lung cancer screening program has been at the forefront of debate. The American Lung Association and American Cancer Society have issued statements that are not guidelines, but did offer insight on the price we pay for earlier lung cancer detection and reduction in mortality…which is the increased rates of false positives detected and increased rates of biopsies.

The US Task Force on Lung Cancer Screening has yet to decide on a screening program and have yielded a statement that neither supports nor refutes the current level of evidence. Prior to the NLSRT study there were others that showed conflicting results on lung cancer screening. The PLCO Cancer Screening Trial (2) was a large randomized prospective trial that recruited 77,464 patients and used chest X-rays at yearly intervals for 3 years in patients aged 55-74. This study included nonsmokers. The results are ongoing but the preliminary data showed that a total of 564 cancers were detected with 87% as non-small cell. Further data on outcomes will be reported in 2015.

The PANCAN and BCCA Study were 2 prospective cohort studies (3) done to see which CT detected incident nodules on more likely to be malignant. The results of the 2 combined studies showed that out of the 12029 incident nodules detected only 142 were biopsy proven malignant.  Nodules were more likely to be malignant if the size was greater than 1cm, spiculated, multiple nodules, and more upper lobe predominant. In addition a nodule along the perifissure region was highly unlikely to be cancer. The study also noted that biopsy of the largest nodule was often not the malignant nodule in 20% of cases. Subsequent image with volumetric imaging may help with this.

The results of the 2 year incidence screening results (4) demonstrated that the low dose CT screening was superior to chest radiography in detecting earlier stage cancers as well as showing lower incidence rates of lung cancer when the initial CT screening was negative. The highest rates of lung cancer were detected at the T2 interval screening due detection of enlarging nodules. Overall the 2 year incidence study showed that the use of CT screening was superior to chest Radiography in detecting earlier stage non-small cell lung cancers.

The review of the prior papers yielded a healthy discussion on where do we go as clinicians in offering lung cancer screening to patients. There was a consensus that nearly all curable lung cancers have been found incidentally, and that it makes sense to have a screening process. What this screening process should be is still uncertain.  By limiting the screening option to smokers with a significant 30 pack year history and limiting the initial screening age to 55 we have set initial targets to look at.  The price of CT screening will inevitably result in higher costs and higher rates of false positives. Future algorithms will need to be adjusted to limit rates of false positives by looking more at volumetric analysis and nodule characteristics to limit unnecessary biopsies.

Manoj Mathew, MD FCCP MCCM

References

  1. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. [CrossRef] [PubMed]
  2. Hocking WG, Hu P, Oken MM, Winslow SD, Kvale PA, Prorok PC, Ragard LR, Commins J, Lynch DA, Andriole GL, Buys SS, Fouad MN, Fuhrman CR, Isaacs C, Yokochi LA, Riley TL, Pinsky PF, Gohagan JK, Berg CD; PLCO Project Team. Lung cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. J Natl Cancer Inst. 2010;102(10):722-31. [CrossRef] [PubMed]
  3. McWilliams A, Tammemagi MC, Mayo JR, Roberts H, Liu G, Soghrati K, Yasufuku K, Martel S, Laberge F, Gingras M, Atkar-Khattra S, Berg CD, Evans K, Finley R, Yee J, English J, Nasute P, Goffin J, Puksa S, Stewart L, Tsai S, Johnston MR, Manos D, Nicholas G, Goss GD, Seely JM, Amjadi K, Tremblay A, Burrowes P, MacEachern P, Bhatia R, Tsao MS, Lam S. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-9. [CrossRef] [PubMed]
  4. Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR, Clingan KL, Duan F, Fagerstrom RM, Gareen IF, Gatsonis CA, Gierada DS, Jain A, Jones GC, Mahon I, Marcus PM, Rathmell JM, Sicks J; National Lung Screening Trial Research Team. Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med. 2013;369(10):920-31. [CrossRef] [PubMed] 

Reference as: Mathew M. December 2013 Phoenix pulmonary journal club: lung cancer screening. Southwest J Pulm Crit Care. 2013;7(6):363-4. doi: http://dx.doi.org/10.13175/swjpcc180-13 PDF

Saturday
Jun292013

June 2013 Pulmonary Journal Club

National Lung Screening Trial Research Team, Church TR, Black WC, Aberle DR, Berg CD, Clingan KL, Duan F, Fagerstrom RM, Gareen IF, Gierada DS, Jones GC, Mahon I, Marcus PM, Sicks JD, Jain A, Baum S. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368(21):1980-91. [CrossRef]  [PubMed]

This paper serves as a follow up on the results of the first round of testing using low dose computed tomography in screening for lung cancer.  A full review on the initial results can be referenced from the August 2011 Pulmonary Journal Club (1).

The study was performed at 33 centers from 2002 – 2004. A total of 53454 patients were enrolled. Inclusion criteria were age 55-74 and a 30 pack-year smoking history. All patients were randomized to receive either low dose screening CT scan (LDCT) or a chest x-ray.

The results of the first year of screening showed that the LDCT group had 7191 patients with a positive result. Out of these 7191 patients 270 patients (3.75%) were diagnosed with lung cancer. In the chest x-ray group a total of 2387 patients had a positive result and 136 patients (5.7%) were diagnosed with lung cancer. There were more stage 1A cancers diagnosed in the LDCT group (132 patients) compared to the chest x-ray group (46 patients).

The results of the study support that there is a higher prevalence in stage 1A lung cancer within the LDCT screening arm. However this comes at a cost of a substantial number of false positives which often result in additional tests, procedures and costs. In addition when we look at the overall prevalence of lung cancer between the LDCT and chest x-ray groups the difference is only 1% in the LDCT group compared to 0.7% in the chest x-ray group.  

Further information as the screening process continues will be needed to see if CT scanning is cost effective in screening for lung cancer.

Manoj Mathew, MD MCCM, FCCP

Reference

  1. Mathew M. August 2011 pulmonary journal club. Southwest J Pulm Crit Care. 2011;3:52-3.

Reference as: Mathew M. June 2013 pulmonary journal club. Southwest J Pulm Crit Care. 2013;6(6):308. doi: http://dx.doi.org/10.13175/swjpcc086-13 PDF