Screening and Early Detection: We Can Do Better with Lung Cancer
Presentation by Dr Jason Porter, West Cancer Center
At the Total Health 2023 Diversity, Equity, Inclusion Dinner held in Memphis, Tennessee, Dr Jason Porter from West Cancer Center discussed the current diagnostic standards for ruling out some of the top cancers in the US population, specifically, breast, prostate, colon, and lung. Dr Porter emphasized that lung cancer remains at the bottom of the list for good reason, because both recommendations, and uptake for lung cancer screening remains suboptimal compared to other cancers for which regular screening is available, such as breast, colon, and prostate. For this reason, he suggested that lung cancer will continue to be a major source of cancer related death, even among non-smokers. In this regard, he noted that 1 of 5 lung cancer patients is a ‘never smoker’, and “that’s not a trivial number… that’s 20%... if you’re sitting at a table with five, one of you, even though you never smoked, will get lung cancer”.
Dr Porter outlined the ‘SDMT’ approach for cancer: Screening, Diagnosis, Molecular evaluation, and Treatment. He noted that, if any steps in the SDMT approach are missed, that is a failure for the patient. For example, while diagnosis, molecular evaluation and treatment can be done for any lung cancer patient, if the screening step is missed, more than 75% of lung cancer patients will have locally advanced or metastatic disease at diagnosis, and even for Stage I patients, Dr Porter noted, the survival is only 65% at 5 years.
Breast Cancer
Dr Porter reviewed some of the key breast cancer symptoms, including, most notably, a lump or mass in the breast or armpit, as well as breast skin changes, dimpling or puckering on the breast, nipple discharge or nipple changes and swelling of the breast. He noted that, in general, patient uptake of mammography as a screening procedure has been good. He briefly reviewed the current indications for breast cancer screening with a clinical breast exam and mammography for those women 25 to 39 years with average risk every one to three years, and yearly for those over 40.
Prostate Cancer
Symptoms of prostate cancer, as noted by Dr Porter, include problems with urination, blood in the urine or semen, erection problems, as well as symptoms associated with more advanced disease, such as pain in the hips, back, or chest that can indicate spread to the bones, or weakness/numbness in the legs and feet, which could result from prostate cancer pressing on the spinal cord. Dr Porter noted that, with regular screening, generally conducted starting at age 50 for men at average risk, prostate cancer can be caught earlier. Screening for prostate specific antigen (PSA) levels using a blood test, is generally the method of choice, although PSA levels can be impacted by factors such as older age, ejaculation, and prostatitis, as well as medications and herbal supplements. Digital rectal exam (DRE) is less sensitive than PSA, but may also be performed if there is high suspicion of prostate cancer with normal PSA levels; for example, PSA may not be elevated in some prostate cancer subtypes such as small cell prostate cancer.
Colorectal Cancer
Dr Porter outlined some of the key symptoms of colon cancer which include either diarrhea or constipation, abdominal discomfort and bloating, blood in the stool, and/or weight loss without dieting. Because symptoms such as these can be non-specific and potentially attributable to other causes, he emphasized the role of the primary care provider and a need for a shift in the culture whereby patients should see their physicians while they are feeling well, instead of waiting until they develop signs and symptoms that could indicate more advanced disease. Colon cancer screening using colonoscopy, is generally indicated every 10 years for men and women with an average colon cancer risk, beginning at age 45.
Lung Cancer
In the final portion of his presentation, Dr Porter outlined some of the key statistics for lung cancer, being the number one cause of cancer-related death in the US. For early-stage non-small cell lung cancer, the 5-year survival is 60%, and 80% of lung cancer related deaths are caused by smoking (which means 20% of deaths occur in non-smokers), and there will be nearly 230,000 lung cancer cases reported this year, according to the American Cancer Society. He outlined the current standards for lung cancer screening, which is for adults 50 to 80 years old, who are current or former smokers (quitting within the last 15 years) and having at least a 20-pack/year smoking history. Dr Porter noted that the screening process, using a low dose computed tomography (CT) scan is simple, completely non-invasive, and quick.
A Case for Screening
Dr Porter provided a case example of a woman in his practice, previously diagnosed with lung cancer who came in for an evaluation and upon screening had no evidence of disease. The patient’s husband however, had never been screened and had no history of lung cancer despite a 45-year smoking history. At Dr Porter’s recommendation, the husband came in for screening and they detected a small tumor that was able to be completely removed with a limited surgery. As a result of the screening, they were able to remove the cancer at a very early stage and the patient will likely have a much better outcome than if he had waited for more obvious symptoms like cough to occur which would have indicated much more advanced disease.
Summary
Dr Porter concluded his presentation with a call to action for lung cancer screening. While not all individuals need to be screened yearly for lung cancer, he suggested that screening should be risk-modified, or risk-adapted, similar to colorectal cancer, where screening colonoscopies are indicated every 10 years for those with low risk, and every 5 years for those with higher risk. He noted that, while established screening methods for breast, prostate, and colon cancer are effective, lung cancer is, on average, killing more patients per year than all of these cancers (breast, prostate, and colorectal) combined, and that even patients who never smoked may still have had exposure to second-hand smoke, or other occupational exposures that put them at risk for lung cancer. As such, the current lung cancer screening recommendations, which are limited to smokers are clearly inadequate to catch all the possible lung cancer cases at an earlier and more curable stage. Dr Porter emphasized that, at present, lung cancer screening is largely underutilized, and campaigns to encourage lung cancer screening are therefore urgently needed, particularly for minority populations.
Quick Summary
Breast, prostate, colon, and lung cancers are some of the most commonly diagnosed cancers for which regular screening is available.
A benefit of regular screening for breast (mammography), prostate (PSA blood testing), and colon (colonoscopy) cancers is detection of cancer at earlier and more curable stages of disease.
Although lung cancer is the leading cause of cancer death, regular screening for lung cancer has been sub-optimal and is limited to current or former smokers, despite the fact that 20% of lung cancer patients are never-smokers.
Screening for lung cancer is simple, quick and non-invasive, and can help to detect cancers at a much earlier and more curable stage.
Campaigns to encourage regular screening for lung cancer are urgently needed.
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