Incidence and Management of Cardiothoracic Relevant Extrapulmonary Findings Found on Low-Dose Computed Tomography.

BACKGROUND: We aimed to investigate the incidence of extrapulmonary findings identified on low-dose computed tomography (CT) that may warrant evaluation by cardiothoracic surgeons and describe their management and referral patterns at our institution. METHODS: We conducted a retrospective cohort study of patients who underwent low-dose CT through a centralized Lung Cancer Screening Program at Thomas Jefferson University Hospital between January 2018 and December 2022. An electronic medical record review was performed for patients with incidental findings. Demographic, workup, referral, and management data were collected. RESULTS: Of 2285 patients who underwent low-dose CT, 368 (16%) had an extrapulmonary finding that may have an indication for clinical evaluation by a cardiothoracic surgeon. The most common incidental finding was a hiatal hernia, with a prevalence of 6.3% (144 of 2285), followed by ascending thoracic aneurysms, with a prevalence of 3.6% (82 of 2285), and small pericardial effusions, with a prevalence of 1.2% (28 of 2285). Of the patients with symptomatic hiatal hernias, 29% (14 of 48) were referred to a cardiothoracic surgeon compared with only 6.25% (6 of 96) in the asymptomatic group. Of the patients with thoracic aneurysms, 48% (39 of 82) had aneurysms ≥4.2 cm. Of the ≥4.2 cm group, 18% (7 of 39) were monitored by a cardiothoracic surgeon compared with 11.6% (5 of 43) in patients with aneurysms <4.2 cm. CONCLUSIONS: Hiatal hernias and ascending thoracic aneurysms were the 2 most prevalent incidental findings identified on low-dose CT during lung cancer screening. We demonstrated potential gaps in hiatal hernia referral patterns. Referring patients with thoracic aneurysms to cardiothoracic surgeons may not be initially warranted.

Individual- and neighborhood-level characteristics of lung cancer screening participants undergoing telemedicine shared decision making.

BACKGROUND: Although lung cancer screening (LCS) for high-risk individuals reduces lung cancer mortality in clinical trial settings, many questions remain about how to implement high-quality LCS in real-world programs. With the increasing use of telemedicine in healthcare, studies examining this approach in the context of LCS are urgently needed. We aimed to identify sociodemographic and other factors associated with screening completion among individuals undergoing telemedicine Shared Decision Making (SDM) for LCS. METHODS: This retrospective study examined patients who completed Shared Decision Making (SDM) via telemedicine between May 4, 2020 - March 18, 2021 in a centralized LCS program. Individuals were categorized into Complete Screening vs. Incomplete Screening subgroups based on the status of subsequent LDCT completion. A multi-level, multivariate model was constructed to identify factors associated with incomplete screening. RESULTS: Among individuals undergoing telemedicine SDM during the study period, 20.6% did not complete a LDCT scan. Bivariate analysis demonstrated that Black/African-American race, Medicaid insurance status, and new patient type were associated with greater odds of incomplete screening. On multi-level, multivariate analysis, individuals who were new patients undergoing baseline LDCT or resided in a census tract with a high level of socioeconomic deprivation had significantly higher odds of incomplete screening. Individuals with a greater level of education experienced lower odds of incomplete screening. CONCLUSIONS: Among high-risk individuals undergoing telemedicine SDM for LCS, predictors of incomplete screening included low education, high neighborhood-level deprivation, and new patient type. Future research should focus on testing implementation strategies to improve LDCT completion rates while leveraging telemedicine for high-quality LCS.

The Philadelphia Lung Cancer Learning Community: a multi-health-system, citywide approach to lung cancer screening.

BACKGROUND: Lung cancer screening uptake for individuals at high risk is generally low across the United States, and reporting of lung cancer screening practices and outcomes is often limited to single hospitals or institutions. We describe a citywide, multicenter analysis of individuals receiving lung cancer screening integrated with geospatial analyses of neighborhood-level lung cancer risk factors. METHODS: The Philadelphia Lung Cancer Learning Community consists of lung cancer screening clinicians and researchers at the 3 largest health systems in the city. This multidisciplinary, multi-institutional team identified a Philadelphia Lung Cancer Learning Community study cohort that included 11 222 Philadelphia residents who underwent low-dose computed tomography for lung cancer screening from 2014 to 2021 at a Philadelphia Lung Cancer Learning Community health-care system. Individual-level demographic and clinical data were obtained, and lung cancer screening participants were geocoded to their Philadelphia census tract of residence. Neighborhood characteristics were integrated with lung cancer screening counts to generate bivariate choropleth maps. RESULTS: The combined sample included 37.8% Black adults, 52.4% women, and 56.3% adults who currently smoke. Of 376 residential census tracts in Philadelphia, 358 (95.2%) included 5 or more individuals undergoing lung cancer screening, and the highest counts were geographically clustered around each health system's screening sites. A relatively low percentage of screened adults resided in census tracts with high tobacco retailer density or high smoking prevalence. CONCLUSIONS: The sociodemographic characteristics of lung cancer screening participants in Philadelphia varied by health system and neighborhood. These results suggest that a multicenter approach to lung cancer screening can identify vulnerable areas for future tailored approaches to improving lung cancer screening uptake. Future directions should use these findings to develop and test collaborative strategies to increase lung cancer screening at the community and regional levels.

Characterizing Lung Cancer Burden Among Asian-American Communities in Philadelphia.

Lung cancer (LC) is the leading cause of cancer death among Asian-Americans. However, there are differences in LC incidence and mortality among Asian racial subgroups. The objective of this study was to describe LC burden and disparities among race/ethnic groups (White, Black, Asian, and Hispanic) across US census tracts (CT) in Philadelphia using the Pennsylvania Cancer Registry dataset (N=11,865). ArcGIS Pro was used to geocode patient addresses to the CT level for linkage to US Census data. Despite being diagnosed more frequently with advanced-stage lung cancer compared with other race and ethnic groups in Philadelphia, Asian patients were most likely to be alive at the time of data receipt. Among Asian subgroups, Korean patients were the oldest (median age 75, p=0.024). Although not statistically different, distant stage disease was the most prevalent among Asian Indian (77.8%) and Korean (73.7%) and the least prevalent among Chinese patients (49.5%). LC was the cause of death for 77.8% of Asian Indian, 63.2% of Korean, 52.9% of other Asian, 48.5% of Chinese, and 47.5% of Vietnamese patients. CTs where Asian individuals were concentrated had lower socioeconomic status and greater tobacco retailer density compared to the entire city. Compared to all of Philadelphia, heavily Asian CTs experienced a greater age-standardized LC incidence (1.48 vs. 1.42) but lower age-standardized LC mortality (1.13 vs. 1.22). Our study suggests that LC disparities exist among Asian subgroups, with Asian Indian and Korean Philadelphians most likely to present with advanced disease. Additional studies are needed to investigate LC among high-risk racial and ethnic groups, including Asian subgroups.

Smoking Cessation Interventions Among Asian Americans: a Scoping Review.

BACKGROUND: Tobacco use is the leading cause of morbidity and mortality in the USA, with smoking rates remaining disproportionately high among Asian-Americans, particularly in males with limited English proficiency, including Vietnamese (43%), Korean (37%), and Chinese (29%) Americans. Barriers to smoking cessation in this population include high social acceptability of smoking in participants' countries of origin, low quit intention, and limited use of linguistically appropriate smoking cessation resources. This paper aims to conduct a systematic review of studies evaluating the effectiveness of smoking cessation interventions targeting Asian-Americans. METHODS: The researchers conducted a thorough search of Scopus, Medline, Cochrane Central, and Google Scholar from 2006 through March 2022, as well as reference lists of relevant articles. The inclusion criteria for the studies were that they described smoking cessation interventions for Asian-Americans and Asian immigrants, and reported outcomes related to feasibility, acceptability, usability, and smoking-related outcomes. RESULTS: The review identified 14 studies with a total of 5607 participants, with participant numbers ranging from 26 to 2277. The interventions varied across 14 distinct approaches, with individual counseling being a prominent component. These interventions were found to be feasible and culturally acceptable. All studies reported positive smoking-related outcomes, including abstinence rates ranging from 26.7 to 68% and an increase in quit attempts. Culturally sensitive components and linguistically tailored content played a significant role in promoting participant engagement. The retention rates in the studies ranged from 42 to 100%, highlighting the importance of partnership with the Asian community, cultural and ethnic congruence, and family involvement and support. CONCLUSION: The review highlighted the lack of direct in-language treatment as a disadvantage for Asian-American smokers in accessing evidence-based treatments. Despite this, the review reported the feasibility, acceptability, and effectiveness of a limited number of culturally targeted interventions for Asian-Americans, who are the fastest-growing racial-ethnic group. Future research should focus on exploring novel community-based and culturally adapted approaches for hard-to-reach and high-risk ethnic Asian subgroups to further improve smoking cessation outcomes in this population.

Evaluation of variables predicting PFT changes for lung cancer patients treated on a prospective 4DCT-ventilation functional avoidance clinical trial.

PURPOSE: Functional avoidance radiotherapy uses functional imaging to reduce pulmonary toxicity by designing radiotherapy plans that reduce doses to functional regions of the lung. A phase-II, multi-center, prospective study of 4DCT-ventilation functional avoidance was completed. Pre and post-treatment pulmonary function tests (PFTs) were acquired and assessed pulmonary function change. This study aims to evaluate which clinical, dose and dose-function factors predict PFT changes for patients treated with 4DCT-ventilation functional avoidance radiotherapy. MATERIALS AND METHODS: 56 patients with locally advanced lung cancer receiving radiotherapy were accrued. PFTs were obtained at baseline and three months following radiotherapy and included forced expiratory volume in 1-second (FEV1), forced vital capacity (FVC), and FEV1/FVC. The ability of patient, clinical, dose (lung and heart), and dose-function metrics (metrics that combine dose and 4DCT-ventilation-based function) to predict PFT changes were evaluated using univariate and multivariate linear regression. RESULTS: Univariate analysis showed that only dose-function metrics and the presence of chronic obstructive pulmonary disease (COPD) were significant (p<0.05) in predicting FEV1 decline. Multivariate analysis identified a combination of clinical (immunotherapy status, presence of thoracic comorbidities, smoking status, and age), along with lung dose, heart dose, and dose-function metrics in predicting FEV1 and FEV1/FVC changes. CONCLUSION: The current work evaluated factors predicting PFT changes for patients treated in a prospective functional avoidance radiotherapy study. The data revealed that lung dose- function metrics could predict PFT changes, validating the significance of reducing the dose to the functional lung to mitigate the decline in pulmonary function and providing guidance for future clinical trials.

Characterizing Pulmonary Function Test Changes for Patients With Lung Cancer Treated on a 2-Institution, 4-Dimensional Computed Tomography-Ventilation Functional Avoidance Prospective Clinical Trial.

Purpose: Four-dimensional computed tomography (4DCT)-ventilation-based functional avoidance uses 4DCT images to generate plans that avoid functional regions of the lung with the goal of reducing pulmonary toxic effects. A phase 2, multicenter, prospective study was completed to evaluate 4DCT-ventilation functional avoidance radiation therapy. The purpose of this study was to report the results for pretreatment to posttreatment pulmonary function test (PFT) changes for patients treated with functional avoidance radiation therapy. Methods and Materials: Patients with locally advanced lung cancer receiving chemoradiation were accrued. Functional avoidance plans based on 4DCT-ventilation images were generated. PFTs were obtained at baseline and 3 months after chemoradiation. Differences for PFT metrics are reported, including diffusing capacity for carbon monoxide (DLCO), forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC). PFT metrics were compared for patients who did and did not experience grade 2 or higher pneumonitis. Results: Fifty-six patients enrolled on the study had baseline and posttreatment PFTs evaluable for analysis. The mean change in DLCO, FEV1, and FVC was -11.6% ± 14.2%, -5.6% ± 16.9%, and -9.0% ± 20.1%, respectively. The mean change in DLCO was -15.4% ± 14.4% for patients with grade 2 or higher radiation pneumonitis and -10.8% ± 14.1% for patients with grade <2 radiation pneumonitis (P = .37). The mean change in FEV1 was -14.3% ± 22.1% for patients with grade 2 or higher radiation pneumonitis and -3.9% ± 15.4% for patients with grade <2 radiation pneumonitis (P = .09). Conclusions: The current work is the first to quantitatively characterize PFT changes for patients with lung cancer treated on a prospective functional avoidance radiation therapy study. In comparison with patients treated with standard thoracic radiation planning, the data qualitatively show that functional avoidance resulted in less of a decline in DLCO and FEV1. The presented data can help elucidate the potential pulmonary function improvement with functional avoidance radiation therapy.

Surgical Outcomes in the National Lung Screening Trial Compared With Contemporary Practice.

BACKGROUND: The National Lung Screening Trial (NLST) established a role for lung cancer screening. Mortality benefits with screening are predicated on successful treatment with low surgical mortality. Given variations observed in perioperative outcomes after lung cancer resection, it remains unknown whether benefits observed in the NLST are generalizable to a broader population. We sought to determine whether NLST perioperative outcomes are reflective of contemporary practice in a national cohort. METHODS: We identified patients diagnosed with non-small cell lung cancer who underwent lung resection in the 2014 to 2015 National Cancer Database (NCDB) and the NLST. We compared demographic and cancer characteristics in both datasets. We used hierarchical logistic regression to compare 30-day and 90-day postoperative mortality across facilities in both datasets. RESULTS: In all, 65054 patients in NCDB and 1003 patients in the NLST treated across 1119 NCDB hospitals and 33 NLST hospitals were included. After risk and reliability adjustment, mean 30-day and 90-day mortality were significantly higher among NCDB hospitals (mean 30-day, 2.2 [95% confidence interval (CI), 2.2 to 2.2] vs 1.8 [95% CI, 1.8 to 1.8], P < .001; mean 90-day, 4.2 [95% CI, 4.2 to 4.3] vs 2.9 [95% CI, 2.9 to 2.9], P < .001). Variation in risk- and reliability-adjusted 30-day mortality (95% CI, 1.1% to 4.9%) and 90-day mortality (95% CI, 2.6% to 9.7%) was observed among NCDB hospitals. Adjusted mortality was similar among NLST facilities (30 days, 1.8% to 1.8%; 90 days, 2.9% to 2.9%). CONCLUSIONS: Risk- and reliability-adjusted postoperative mortality varies widely in a national cohort compared with outcomes observed in the NLST. Efforts to minimize this variation are needed to ensure that benefits of lung cancer screening are fully realized in the United States.

Race is a Risk Factor for the Deferral of Resection and Radiation for Early-Stage Lung Cancer.

PURPOSE: There remain profound race-related disparities in the treatment of non-small cell lung cancer (NSCLC). Deferral of operative management for early-stage disease is recognized as driver of this disparity. Black race has been associated with higher rates of surgical deferral. It remains unclear how race impacts likelihood of receiving radiation therapy after declining surgical management of NSCLC. PATIENTS AND METHODS: A retrospective cohort analysis was completed using data from the National Cancer Database (NCBD) for patients 18 and over with stage I NSCLC offered surgical resection from 2004 to 2015 (N = 89,462). Multivariable logistic regression identified predictors of surgical deferral and predictors for deferral of radiation after deferral of surgery. Kaplan-Meier survival analysis with log-rank tests and multivariable Cox proportional hazards regressions were performed. RESULTS: 87,293 (97.6%) patients underwent surgery, 2169 (2.4%) deferred. Patients who deferred had 2.1 times higher hazard ratio for mortality, (HR = 2.08, [1.97, 2.29], P < .001). Of those that deferred, 1250 (57.6%) received postdeferral radiation. Compared to White patients, Black patients had OR of 1.82 for deferring both surgery and radiation (aOR: 1.82, [1.31, 2.53], P < .001) and Asian and Pacific Island (API) patients had an OR of 2.67 (aOR: 2.67, [1.27, 4.64], P = .008). Other predictors of deferral of therapy included: Medicare or lack of insurance, and treatment at nonacademic medical centers. CONCLUSION: Insurance status and Black race, and API race are associated with deferring surgical therapy and radiation therapy for NSCLC. These findings are consistent with the large body of work showing worse outcomes for treatment of NSCLC in minority patients.

Volume Doubling Time of Pulmonary Carcinoid Tumors Measured by Computed Tomography.

INTRODUCTION: Pulmonary carcinoid tumor (PCT) is a rare neuroendocrine lung neoplasm comprising approximately 2% of lung cancer diagnoses. It is classified as either localized low-grade (typical) or intermediate-grade (atypical) subtypes. PCT is known clinically to be a slow-growing cancer, however few studies have established its true growth rate when followed over time by computed tomography (CT). Therefore, we sought to determine the volume doubling time for PCTs as visualized on CT imaging. MATERIALS AND METHODS: We conducted a retrospective analysis of all PCTs treated at our institution between 2006 and 2020. Nodule dimensions were measured using a Picture Archiving and Communication System or retrieved from radiology reports. Volume doubling time was calculated using the Schwartz formula for PCTs followed by successive CT scans during radiographic surveillance. Consistent with Fleischner Society guidelines, tumors were considered to have demonstrated definitive growth by CT only when the interval change in tumor diameter was greater than or equal to 2 mm. RESULTS: The median volume doubling time of 13 typical PCTs was 977 days, or 2.7 years. Five atypical PCTs were followed longitudinally, with a median doubling time of 327 days, or 0.9 years. CONCLUSIONS: Typical pulmonary carcinoid features a remarkably slow growth rate as compared to more common lung cancers. Our analysis of atypical pulmonary carcinoid included too few cases to offer definitive conclusions. It is conceivable that clinicians following current nodule surveillance guidelines may mistake incidentally detected typical carcinoids for benign non-growing lesions when followed for less than 2 years in low-risk patients.

Racial difference in BMI and lung cancer diagnosis: analysis of the National Lung Screening Trial.

BACKGROUND: The inverse relationship between BMI and lung cancer diagnosis is well defined. However, few studies have examined the racial differences in these relationships. The purpose of this paper is to explore the relationships amongst race, BMI, and lung cancer diagnosis using the National Lung Screening Trial (NLST) data. METHODS: Multivariate regression analysis was used to analyze the BMI, race, and lung cancer diagnosis relationships. RESULTS: Among 53,452 participants in the NLST cohort, 3.9% were diagnosed with lung cancer, 43% were overweight, and 28% were obese. BMI was inversely related to lung cancer diagnosis among Whites: those overweight (aOR = .83, 95%CI = .75-.93), obese (aOR = .64, 95%CI = .56-.73) were less likely to develop lung cancer, compared to those with normal weight. These relationships were not found among African-Americans. CONCLUSION: Our findings indicate that the inverse relationship of BMI and lung cancer risk among Whites is consistent, whereas this relationship is not significant for African-Americans. In consideration of higher lung cancer incidence among African Americans, we need to explore other unknown mechanisms explaining this racial difference.

Molecular lung cancer: How targeted therapies and personalized medicine are re-defining cancer care.

Lung cancer remains the leading cause of cancer death in the United States and is unfortunately still frequently diagnosed in the metastatic setting, where the disease is considered incurable. Nearly 30% of these cancers may be driven by specific mutations that promote tumor growth and proliferation. These mutations are observed more frequently in young patients without significant smoking history and in certain racial and ethnic backgrounds. The past 15 years have marked a revolution for patients with molecularly driven lung cancer as novel, oral, targeted therapies have been developed that demonstrate superior activity with substantially better toxicity profiles in comparison to chemotherapy. Consideration of molecular testing for a driver mutation is imperative for all providers caring for patients with a new suspected lung cancer diagnosis, as discovery of an actionable mutation will have dramatic implications in regards to patient survival and quality of life.

Outreach to primary care patients in lung cancer screening: A randomized controlled trial.

Current guidelines recommend annual lung cancer screening (LCS), but rates are low. The current study evaluated strategies to increase LCS. This study was a randomized controlled trial designed to evaluate the effects of patient outreach and shared decision making (SDM) about LCS among patients in four primary care practices. Patients 50 to 80 years of age and at high risk for lung cancer were randomized to Outreach Contact plus Decision Counseling (OC-DC, n = 314), Outreach Contact alone (OC, n = 314), or usual care (UC, n = 1748). LCS was significantly higher in the combined OC/OC-DC group versus UC controls (5.5% vs. 1.8%; hazard ratio, HR = 3.28; 95% confidence interval, CI: 1.98 to 5.41; p = 0.001). LCS was higher in the OC-DC group than in the OC group, although not significantly so (7% vs. 4%, respectively; HR = 1.75; 95% CI: 0.86 to 3.55; p = 0.123). LCS referral/scheduling was also significantly higher in the OC/OC-DC group compared to controls (11% v. 5%; odds ratio, OR = 2.02; p = 0.001). We observed a similar trend for appointment keeping, but the effect was not statistically significant (86% v. 76%; OR = 1.93; p = 0.351). Outreach contacts significantly increased LCS among primary care patients. Research is needed to assess the additional value of SDM on screening uptake.

Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines.

The National Lung Screening Trial established the benefits of low-dose computed tomography for lung cancer screening (LCS) to identify lung cancer at earlier stages. In February 2021, the US Preventive Services Task Force (USPSTF) revised the eligibility recommendations to increase the number of high-risk individuals eligible for LCS and, in effect, expand screening eligibility for vulnerable populations. One strategy for facilitating LCS is to implement targeted screening in geographic areas with the greatest need. In Philadelphia, although neighborhood smoking rates have been defined, it is not known which neighborhoods have the greatest number of people eligible for LCS. In this study, the authors estimate eligibility for LCS within Philadelphia neighborhoods using both previous and current USPSTF guidelines. They used the Public Health Management Corporation's Household Health Survey from 2010, 2012, and 2015 to identify the number of people within ever-smoker groups (current every day, current occasional, and former smokers) by neighborhood in Philadelphia. Using the 2015 National Health Interview Survey (NHIS) Cancer Supplement, they identified the percentages within ever-smoker groups that were LCS eligible using the previous and current USPSTF guidelines. Finally, they applied the percentages eligible for the ever-smoker groups from the NHIS to the numbers in these groups within Philadelphia neighborhoods. They found that the number of Philadelphians eligible for LCS increased from 41,946 to 89,231 after the revised USPSTF guidelines. The current USPSTF guidelines increased eligibility for LCS within all Philadelphia neighborhoods, with the greatest increases in the River Wards planning district. Local providers should use these results to prioritize LCS services within neighborhoods with greatest eligibility.

Detection of lung carcinoma arising from ground glass opacities (GGO) after 5 years - A retrospective review.

Pure ground glass opacities (GGO) may indicate pre-invasive subtypes of lung carcinoma. These neoplasms typically demonstrate indolent patterns of growth; Fleischner Society guidelines recommend up to five years of serial imaging. Our aim was to determine the frequency of diagnosed carcinoma arising from GGO detected beyond 5 years of surveillance. We reviewed pathologic diagnoses of lung carcinoma (n = 442) between 2016 and 2018 of a tertiary academic hospital and National Cancer Institute-designated cancer center to identify all cancers that arose from ground glass opacities detected on CT scan. Of the 442 cases of lung carcinoma, 32 (7%) were found that arose from pure GGOs and were ultimately diagnosed as cancer. Among the subgroup of GGOs, 78% (n = 25) were diagnosed within five years of surveillance, but up to 22% (n = 7) required between five and twelve years of serial follow up prior to definitive diagnosis. In order to detect 95% of cancers, GGOs would need to be followed for 7.9-12.7 years based upon a Kaplan-Meier estimate (p = 0.05). No patients who had lung carcinoma arising from GGOs died (0/32) within a follow-up time of one to three years. These data suggest that a greater number of lung carcinomas would be detected upon routine follow up of GGOs that extended beyond the current recommendation of five years. The overall survival of the cohort was 100%, consistent with existing data that these cancers are indolent. It is unknown whether a higher detection rate from longer interval follow up would impact overall survival.