Worker Health Protection Program - Early Lung Cancer Detection Program

WORKER HEALTH PROTECTION PROGRAM – EARLY LUNG CANCER DETECTION PROGRAM Occupational lung carcinogens among DOE workers: • • • • • • • Uranium Asbestos Beryllium Nickel Silica Transuranics Cigarette smoking Current Lung Cancer Statistics • Leading cause of cancer death for both men and women • Deaths from lung cancer (estimated, 2002) World United States 1.18 million 160,000 CA 53:1-2003 Globoscan, IARC Lung cancer: Diagnosis and Survival 1. 2. Current stage at diagnosis – localized disease 15% No change in five year survival of lung cancer in 30 years: • • 1975 - 1977 – 13% five year survival 1996 - 2002 – 16% five year survival 3. Five year survival of Stage I lung cancer: 70%-80% Comparison of Survival Rates, Major Cancer Sites* 1975-1977 vs. 1984-1986 vs. 1996-2002 100 1975-1977 90 1984-1986 1996-2002 100 89 80 Five Year Survival Rate (%) 79 70 60 75 69 65 59 76 50 40 30 20 10 0 Breast 51 13 13 16 Colon Prostate Lung Type of Cancer *Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer Statistics, 2007. CA Cancer J Clin 2007;2007 57; 43-66 Estimated Cancer Deaths, U.S., 2007 Men 89, 510 Prostate 27, 050 Colon/Rectum 26, 000 Pancreas 16, 840 Leukemia 12, 320 Lung Women Lung 70, 880 Breast 40,460 Colon/Rectum 26,180 82,210 66,640 Total Lung Cancer Deaths = 160,390 Total “Other Cancer” Deaths = 148,850 Average age of people with lung cancer: 60 Screening, Leading Causes of Cancer Deaths, U.S. (> 30,000 deaths/year) Is screening available? Yes Lung Colon/Rectum Breast Prostate Pancreas No USW/Queens College Worker Health Protection Program Early Lung Cancer Detection Program CT Scanner Mobile Unit Low-Dose High-Resolution CT Scanner Visit of former Assistant DOE Secretary John Shaw to ELCD CT scanner Oak Ridge, TN April 15, 2005 Early Lung Cancer Detection Unit, ORNL/Y-12 Oak Ridge, TN Early Lung Cancer Detection Unit, ORNL/Y-12 Oak Ridge, TN Early Lung Cancer Detection Ribbon-cutting Ceremony August 16, 2006 Oak Ridge, TN Early Lung Cancer Detection Ribbon-cutting Ceremony August 16, 2006 Oak Ridge, TN GDP ELCD Eligibility Criteria ANY AGE SCARRING OF LUNG or PLEURA RELATED TO ASBESTOS/SILICA 45 – 49 YEARS OLD SMOKED FOR > 20 YEARS AND QUIT 15 YEARS AGO OR LESS > 50 YEARS OLD SMOKED FOR > 10 YEARS AND QUIT 15 YEARS AGO OR LESS AND/ OR AND/ OR AT LEAST ONE POSITIVE Be LPT DOE PROD., MAINT. OR LAB WORKER >5 YEARS (EXPOSURE BEGAN PRIOR TO 1986) DOE PROD., MAINT. OR LAB WORKER >5 YEARS AND AND AND % PREDICTED FEV1 >40%, NO CA UNDER ACTIVE OBSERVATION % PREDICTED FEV1 >40%, NO CA UNDER ACTIVE OBSERVATION % PREDICTED FEV1 >40%, NO CA UNDER ACTIVE OBSERVATION Current ATLC ELCD Eligibility Criteria ≥ 45-85 YEARS OLD ≥ 50-85 YEARS OLD SCARRING OF LUNG OR PLEURA RELATED TO ASBESTOS/SILICA SMOKING HISTORY OF AT LEAST 10 PACK-YEARS AND QUIT 20 YEARS AGO OR LESS AND/ OR AT LEAST ONE POSITIVE Be LPT DOE PROD., MAINT. OR LAB WORKER ≥ 2 YEARS (EXPOSURE BEGAN PRIOR TO 1992) AND % PREDICTED FEV1 >40%, NO CA UNDER ACTIVE OBSERVATION AND % PREDICTED FEV1 >40%, NO CA UNDER ACTIVE OBSERVATION ELCD Productivity at GDP’s November 2000 – July 2006 # people with Initial Scans # people with Incidence Scans # scans total # CT scanner coach trips # miles on CT scanner coach 6,224 3,116 16,807 139 50,029 Helical CT Scan for Lung Cancer Screening Elements 1. 2. 3. Low dose full chest helical CT scan Suspicious nodules sent for diagnosis and treatment High resolution follow-up scan of indeterminate nodules at 3 or 6 months Repeat low dose full chest helical CT scan at periodic intervals (eg – 12 or 18 months) 4. Full CT Scan Protocol for Participants with Indeterminate Nodules Initial Scan • 3 or 6 month scan Incidence Scan (12-18 months) • Follow-up scans for new nodules Stage of Lung Cancers Detected Through the Early Lung Cancer Detection Program, Gaseous Diffusion Plant Workers Stage I Stage II Limited stage: small cell carcinoma Stage III or IV TOTAL 26 6 4 9 45 58% 13% 9% 20% 100% Early Lung Cancer Detection Program, Gaseous Diffusion Plant Workers (November 1st, 2000 – July 31st , 2006) Number of People Scanned Total Lung Cancers Detected Number of Lung Ca Detected at Stage I, Stage II or Limited Small Cell Cancer 7 (88%) Site Paducah, Kentucky Portsmouth, Ohio Oak Ridge, Tennessee 1,738 8 2,048 18 14 (78%) 2,438 19 15 (79%) TOTAL 6,224 45 36 (80%) Early Lung Cancer Detection Program, Gaseous Diffusion Plant Workers (November 1st, 2000 – July 31st , 2006) Number of People Initially Scanned 1,738 Site Number of People Who Received Incidence Scan 911 Number of Follow-up CT Scans Completed 1,983 Total Number of Scans Completed 4,632 PAD POR OAK TOTAL 2,048 1,031 2,550 5,629 2,438 6,224 1,174 3,116 2,934 7,467 6,546 16,807 Early Lung Cancer Detection Program, Gaseous Diffusion Plant Workers (November 1st, 2000 – July 31st , 2006) Number of Lung Cancers Detected on Initial vs. Follow-up Scan(s) Number of Initial Scans Number of Lung Cancers on Initial Scan or f/u Scan Number of Incidence Scans 911 Number of Lung Cancers on Incidence Scan or f/u Scan Total Lung Cancers PAD POR OAK TOTAL 1,738 5 12 16 33 3 6 3 12 8 18 19 45 2,048 1,031 2,438 6,224 1,174 3,116 USW/QUEENS COLLEGE WORKER HEALTH PROTECTION PROGRAM R.C. 61 year old man, ex-smoker, 40 years K-25 chemical operator, 5 years 7/99 WHPP Chest x-ray Negative 7/00 PMD CT scan, chest Negative 6/01 PMD Chest x-ray Negative 10/01 WHPP low-dose helical CT Scan 1.7 cm x 1.4 cm nodule,RUL 11/01 R.C. undergoes right lobectomy Stage 1A lung cancer R.C. – 1.6 cm RUL mass USW/QUEENS COLLEGE WORKER HEALTH PROTECTION PROGRAM M.W. 57 year old woman, smoker, 40 years K-25, Y-12 controller, 26 years 5/01 12/01 1/02 WHPP Chest x-ray WHPP low-dose helical CT Scan WHPP conventional dose thin section CT scan PET scan Surgery; left upper lobectomy Negative 1.2 x 0.8 cm mass, LUL 1.3 x 1.0 cm mass; “relatively suspicious appearing” Positive; no metastases Negative lymph nodes; “no need for chemotherapy or radiotherapy” 1/02 1/02 M.W. M.W., RO, Mass, Left Upper Chest USW/QUEENS COLLEGE WORKER HEALTH PROTECTION PROGRAM J.W. 68 year old man, ex-smoker, 50 years Paducah GDP Cascade Operator, 35 years 7/99 5/01 8/01 10/01 WHPP Chest x-ray WHPP low-dose helical CT Scan WHPP 3 month CT scan Surgery; Right lower lobectomy Negative 0.9 x 0.9 cm mass 1.4x 1.4 cm mass; Negative lymph nodes; “no chemo or radiation needed” J.W., Initial WHPP CT Scan, May 2001 J.W., Initial WHPP CT Scan, May 2001 J.W., 3 Month WHPP CT Scan, August 2001 J.W., 3 Month WHPP CT Scan, August 2001 Early Lung Cancer Detection Program Oak Ridge National Laboratory (ORNL) and Y-12 Workers August 8, 2006 to January 31, 2008 Site Number of People Who Received Baseline Scan 408 Number of People Who Received Annual Scan 215 Number of Follow-up CT Scans Completed 148 Total Number of Scans Completed 771 ORNL Y-12 TOTAL 1305 1713 499 714 432 580 2236 3007 Early Lung Cancer Detection Program Oak Ridge National Laboratory (ORNL) and Y-12 Workers August 8, 2006 to January 31, 2008 Site Number of People Who Received Baseline Scan 408 Number of People with Suspicious Nodules 8 Number of Lung Cancer Cases 2 Number of Early Lung Cancers* 0 of 6 ORNL Y-12 TOTAL 1305 13 4 4 of 6 1713 21 6 4 of 6 *Early cancer is defined as Stage I or II non-small cell, or limited small cell. Stage of Lung Cancers Detected Through the Early Lung Cancer Detection Program ORNL and Y-12 Workers August 6th, 2006 to January 31, 2008 Stage I Stage II Limited stage: small cell carcinoma Stage III or IV TOTAL 4 0 0 2 6 67 % 0% 0% 33% 100% ATLC/QUEENS COLLEGE WORKER HEALTH PROTECTION PROGRAM J.H.W., 74 year old man pipefitter for 24 years, Y-12 exposed to radiation, asbestos, beryllium ex-smoker, quit in 1980 September 2005 WHPP Chest x-ray Limited pleural scarring; heart surgery 1.8 cm suspicious nodule; pleural plaques Positive Stage I lung cancer October 2006 WHPP CT Scan November 2006 January 2007 PET Scan Surgery; one lung lobe removed J.H.W., Baseline WHPP CT Scan, October 2006 1.4 cm mass in right upper lung J.H.W., WHPP X-Ray, September 2005 ATLC/QUEENS COLLEGE WORKER HEALTH PROTECTION PROGRAM I.H., 72 year old man utilities worker for 45 years, Y-12 exposed to radiation, asbestos, beryllium current smoker, 52 years September 2005 October 2006 November 2006 WHPP Chest x-ray WHPP CT Scan Surgery; one lung lobe removed Emphysema 1.4 cm suspicious nodule Stage I lung cancer I.H., Baseline WHPP CT Scan, September 2005 1.4 cm mass in right upper lung I.H., WHPP X-Ray, September 2005 Longitudinal Follow-up of Indeterminate Nodules Identified at Baseline • 764 participants with at least one indeterminate nodule (11/00 – 3/03) 751 (98.3%) participants with 12 month follow-up (95.9% with 12 month CT scan follow-up) • • 3 of the 751 people (0.39%) subsequently developed a lung cancer during the 12 month follow-up. All 3 > 5 mm in size at baseline. All 3 lung cancers were Stage I disease. • Conclusions 1. Helical CT screening can detect early stage lung cancers in a real world setting. Occupational cohorts with exposure to lung carcinogens allow a coherent and feasible method to enroll highly motivated people in rational screening programs. Indeterminate lung nodules are uncommonly malignant and can be managed with limited interval CT scanning. 2. 3. Conclusions (continued) 4. Radiologists can designate nodules that are suspicious for lung cancer with a high degree of sensitivity and specificity. Radiation exposure of low dose CT scanning and follow-up scans is limited. Problem of false positives in low dose helical CT scanning is limited and, in combination with PET scanning, can be rationally managed. 5. 6. Helical CT Scanning for Early Lung Cancer Detection Risks and Benefits Risks: 1. 2. 3. 4. Radiation exposure Anxiety Costs Unnecessary surgery Benefits: May reduce lung cancer mortality ELCD: Estimated radiation dose Initial and incidence low dose full chest CT scans: 125 mrem for men 150 mrem for women Thin section interval CT scans: 20 mrem per nodule examined Helical CT Scanning for Early Lung Cancer Detection Risks and Benefits Risks: 1. 2. 3. 4. Radiation exposure Anxiety Costs Unnecessary surgery Benefits: May reduce lung cancer mortality USW/Queens College Worker Health Protection Program Costs ELCD Program costs, 2000-2004:$6.4 million Cost per scan: Cost per person: Cost per lung cancer: $525 $1,300 $194,000 Ten Year Survival for 484 Participants of Early Lung Cancer Action Program with Lung Cancer Detected on Screening CT Scan.