1. Early Detection of Lung Cancer & Beyond
GUIA ELENA IMELDA R. LADRERA, MD
Lung Center of the Philippines

2. Objectives Present available statistics on Lung Cancer.
Present data on the early detection of lung cancer.
Present the LCP Algorithm in the approach to lung cancer suspect.
Present LCP research results in the treatment & prevention of Lung Cancer.

3. Incidence of Lung Cancer
Lung Cancer is the most common cause of cancer related death worldwide
Overall 5 year survival - < 15%
CANCER Principles and Practice of Oncology DeVita et al 8th Edition p896
Philippines
- 15,881 deaths are expected this year
- Median survival of 6 months
- Five-year survival of 5.28% & a 10-year survival of 2.68%
2005 Philippine Cancer Facts & Estimates

4. Estimated Five Leading Cancer Sites in 2005, Both Sexes 2005 Philippine Cancer Facts & Estimates
Number of Cases

5. Five Leading Causes of Cancer Deaths in 2005, Both Sexes 2005 Philippine Cancer Facts & Estimates

6. Lung Center of the Philippines Tumor Registry

7. Patients with Diagnosis of Bronchogenic Cancer at the Lung Center of the Philippines 2000 - 2004
Histology
2000
2001
2002
2003
2004
BCA Unspecified NSCLC or SCLC 20 21 31 36 57
NSCLC
AdenoCA
Squamous CA
Large cell CA
Unspecified
Others
TOTAL NSCLC 88 50 4 39
181
117 44 54
215
142 87 14
2 *
333
168 65 3 67 1+
304
167 72 84
326
SCLC 26 40 48 46
TOTAL
227
276
412
386
429
* Adeno-Squamous CA
+Neuroendocrine CA

8. Number of Patients with Lung Cancer (NSCLC & SCLC) 2000 – 2004 Lung Center of the Philippines Tumor Registry

9. Histopathologic Types of NSCLC Lung Center of the Philippines Tumor Registry

10. Distribution of Patients with Lung Cancer 2000 – 2004 Lung Center of the Philippines Tumor Registry

11. Distribution of NSCLC According to Stage of the Disease Lung Center of the Philippines Tumor Registry

12. Survival of Patients with Lung Cancer
Lung Center Tumor Registry

13. Lung Center of the Philippines
Bronchogenic Carcinoma (152 cases)
1 Year Survival by Stage
Stage 1 (T1-2 N0 M0) %
Stage II (T1-2 N1 M0) 94%
Stage IIIA (T1-2 N2 M0) %
LCP Tumor Registry 1994

14. Average 1 Year Survival for all Types 93.2%
Lung Center of the Philippines
Bronchogenic Carcinoma (152 cases)
Average 1 Year Survival for all Types
93.2%
LCP Tumor Registry 1994

15. Overall 5 year survival is LESS THAN 15%
Philippines
- 15,881 deaths are expected this year
- Median survival of 6 months
- Five-year survival of 5.28% &
a 10-year survival of 2.68%
2005 Philippine Cancer Facts & Estimates

16. Diagnostic Algorithm for Lung Cancer Lung Center of the Philippines 2008

17. ALGORITHM IN THE GENERAL APPROACH IN THE
DIAGNOSIS OF SUSPECTED LUNG CANCER
SPECIAL SITUATIONS
Follow-up every 3 months *
Negative or low suspicion of neoplasm
Positive for
pulmonary mass
Establish diagnosis
Central
lesion
TTNAB/ Sputum cytology
High risk
Bronchoscopy with cytology and biopsy
Positive
Negative
Further testing:
TTNA/TBNA
EBUS-NA
VATS
Bronchoscopy with Biopsy / Sputum cytology
Confirm
diagnosis
Negative for malignancy
or Non-specific
Do staging
Low suspicion/ risk
High suspicion/ risk
Exploratory thoracoscopy
other invasive procedures
Increase in mass size
No change in
mass size
Repeat biopsy
No further testing
Unresolved pneumonia of >1 month with abnormal CXR or asymptomatic with abnormal CXR
CT of chest/MRI
CXR and
ENT
Exam
Normal ENT examination with negative or positive CXR
Abnormal ENT examination
Refer to ENT
Follow-up evaluation B
Presence of extrapulmonary lymph node
Pleural effusion
Multiple pulmonary nodules
Atelectasis
Biopsy of lymph node, if accessible
Diagnostic thoracentesis
Pleural fluid cytology or pleural biopsy
Thoracoscopy
Video-assisted Thoracic Surgery (VATS)
Open lung biopsy
CT guided biopsy
Fiberoptic bronchoscopy (FOB)
* * *
Definition: *Low risk – age < 40 years old, non-smoker with (-) family History.
*High risk – age > 40 years old, smoker/ passive (+) family History.
RAD/jbl06
CLINICAL PRESENTATION
Peripheral
Cough or dyspnea
CXR
Pulmonary mass A
Hemoptysis
(1)
(2)
(3)
Treat other diseases as indicated or follow up visit every
1 mo.
Low risk
Go to B **
Inconclusive
Follow-up
Appropriate treatment

18. Treatment of Lung Cancer
Lung Center of the Philippines

19. Total no. Of 0perations - 152 (4.55%)
Lung Center of the Philippines
Bronchogenic Carcinoma
Total no. Of cases ,338
Total no. Of 0perations (4.55%)
LCP Tumor Registry 1994

20. Lung Center of the Philippines
Bronchogenic Carcinoma
Resection Rate of Operated cases
1982 – %
1986 – %
LCP Tumor Registry 1994

21. Percentage of Patients with Early Stage NSCCA who Underwent Surgery – Lung Center of the Philippines Tumor Registry
Number of Patients (%)
Stage I
TOTAL
With Surgery 58
22 (38%)
Stage II 44
8 (18%)
Stage IIIA
128
14 (11%)

22. Lung Center of the Philippines Early Lung Cancer Detection Program Lung Center OF THE Philippines Program, R. Montevirgen, MD
Study period:
Subjects
120 initial participants enrolled
High risk individuals
Q 6 months CXR until age 75
Results
- 3/120 (+) to have lung cancer.
- 2 patients presented with late stage disease upon enrolment.
- 1 patient detected with early disease (0.83%)

23. Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytology L.L. Humphrey MD et al Ann Intern Med 2004;140:
Study
Sample
Intervention
Prevalence
n (%)
Mortality rate per 1000 Person-Yrs
Northwest London Mass Radiography Service (1960)
29,733
Men of >40 yrs; 19% former smokers; 67% current smokers
CXR & sputum cytology
IG: 31 (0.10)
CG: 20 (0.08)
3 yr ff up
IG: 0.7
CG: 0.8
Kaiser Permanente Study (1964)
10, 713
Age yrs; 17% smokers
CXR NR
16 yr ff up
IG: 8.6
CG: 7.6
Mayo L ung Project (1971)
10,933
Male smokers age ≥ 45 yrs
CXR & sputum cytology vs usual care
91 (0.83)
20 yr ff up
IG: 4.4
CG: 3.9
Johns Hopkins Lung Project (1973)
10,387
Male smokers age ≥ 45yrs
DSG: 39 (0.75)
CxG:40 (0.78)
5 to 8 yr ff up
DSG: 3.4
CxG: 3.8

24. Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytology L.L. Humphrey MD et al Ann Intern Med 2004;140:
Study
Sample
Intervention
Prevalence
n (%)
Mortality rate per 1000 Person-Yrs
Memorial Sloan Kettering Study (1974)
10,040
Male smokers age ≥ 45yrs
CXR & sputum cytology
DSG:30 (0.6)
CxG: 23 (0.46)
5 to 8 yr ff up
DSG: 2.7
CxG: 2.7
Czech Study (1975)
6,345
Male smokers yrs
CXR
19 (0.30)
15 yr ff up

25. Summary
Two RCTs (JHLP & MSKLP) which used sputum cytology for screening. No mortality benefit was found.
MLP used CXR & sputum cytology compared to usual care. No mortality benefit was found.
CLP used q 6m CXR for 3 years, then yearly CXR for 3 years compared to annual CXR. No mortality benefit was found.

26. Cohort Trials of Low Dose CT Screening CANCER Principles and Practice of Oncology DeVita et al 8th Edition p 685 Table III
Project name
Enrolled Baseline Annual
Lung Cancer Prevalence
Baseline Annual
% of Stage I
Survival Rate
ELCAP
( )
>60y, >10Pk-yr
1000
1184
2.9%
0.6%
85%
86%
Nagano, Japan
( )
>40y, Pk-yr not req’d
5,483
8,303
0.4%
100%
ALCA-NCC,Japan
(1993 – 2000)
1,611
7,891
0.9%
0.3%
79%
82%
5 yr OS baseline : 71%
Hitachi, Japan
(2001 – 2002)
>40 y Pk-yr not req’d
7,956
5,568
0.5%
0.1%

27. Cohort Trials of Low Dose CT Screening CANCER Principles and Practice of Oncology DeVita et al 8th Edition p 685 Table III
Project name
Enrolled Baseline Annual
Lung Cancer Prevalence
Baseline Annual
% of Stage I
Survival Rate
Mayo Clinic
(1999 – 2004)
Age>50,Pk yrs >20, quit < 10 y
1520
4,472
2.0%
0.8%
77%
71%
72%
Instituto Tumori, Italy
(2000 – 2001)
Age >50y,Pk yrs >20
1,035
996
1.7%
0.5%
100%
85%
I-ELCAP
( )
Age>40y, Pk yrs not req’d
31, 567
27,456
1.3%
0.3%
86%
10yr OS : 80%

28. Summary
The lung cancer prevalence rate depends on risk characteristics.
The ratio of baseline to annual cancers is much higher for CT scan than it was for CXR. Or sputum cytology.
High proportion of finding Stage I disease.

29. No major medical professional organization currently recommends screening for lung cancer

30. Alternatives to Lung Cancer
Screening ?????

31. National Smoking Prevalence Study Research & Development, Lung Center of the Philippines Phil. Journal Int. Medicine 27: 133 – 156, May – June 1989
Adult population % smokers
Urban population – 40.92%
Rural population – 49.94%
Young Population %
Urban population – 18.98%
Rural population – 26.20%

32. Manila, Philippines Prevalence of ever smoking in population1 ages >40 by sex
Men
Women
83%
31%
1 Unweighted data for the sample of responders
Overall = 55%
Philippine BOLD Study . AS Buist et al, The Lancet 2007, Vol 370 pp
21 February 2008

33. Cigarette Smoking Among Hospitalized Patients in Metro Manila JCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp
Results :
1. 34% current smokers
43% former smokers
2. Of all current smokers <30y, 65% NEVER thought of attempting to quit. For those >30y, 66% attempted to quit
3. Of those who attempted to quit, 52% had 5-10x attempts.

34. Attitudes & Beliefs of Smokers
More than half of population thought seriously about quitting x serious attempts to quit – Urban group 1 serious attempt to quit - Rural group
Cigarette Smoking Among Hospitalized Patients in Metro Manila JCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp

35. Young People as Smokers
Overall – 22.70%
- Urban : 18.98%
- Rural : 26.20%
Mean age for starting is 11 – 12 y
Major reason for starting – Peer group pressure
Cigarette Smoking Among Hospitalized Patients in Metro Manila JCAlonzo MD, I.Fabic, MD Scientific Proceedings (LCP) 1996 Vol.4 pp

36. Teaching Lung Cancer Prevention to the Filipinos: an Inter-Agency Collaboration Department of Research & Development, Lung Center of the Philippines Scientific Proceedings 1995 Vol 3 pp47- 52
Aim is to develop a curriculum material on both elementary and HS levels on Lung Cancer prevention.
Modules are designed to develop awareness among students of the health hazards of smoking and its direct link to lung cancer.

37. SUMMARY
Lung cancer is the leading cause of cancer diagnosis and deaths worldwide and locally.
Lung cancer screening is currently not advocated even for high risk population.
Standardization of diagnostic evaluation for patients with suspected lung cancer is recommended.
Prevention of smoking through education, implementation of tobacco regulation law may help curb the incidence of lung cancer.