Five-year outcome of lung cancer detection in patients with and without airflow obstruction in a primary care outpatient practice.

INTRODUCTION: We have previously published the outcome of a community-based lung cancer screening program. We now report on the 5-year follow-up of this study and include both patients with and without airflow obstruction. MATERIALS AND METHODS: One thousand two hundred fifty-six patients completed questionnaires in the office of their primary care physicians, and 430 of this group were assessed to be at high risk for lung cancer. These patients then underwent spirometry, and 88 of 126 patients with airflow obstruction consented to lung cancer screening test. TESTING METHODS: Complete screening testing included spirometry, two-view chest radiograph, chest CT scan, and sputum cytology examinations. RESULTS: Eight lung cancers were found in the high-risk group with airflow obstruction. No more cancers were found in the tested group in the 5 years since the earlier report. Ten cancers were found in the 304 patients with normal airflow, not previously reported. In all, 18 lung cancers were found in 430 patients deemed at risk by a simple one-page questionnaire (4.2%). CONCLUSIONS: A questionnaire, self-administered in a primary care office setting, helps identify patients at high risk of lung cancer. If upcoming results of randomized controlled trials show a benefit of lung screening, this tool could be of help to select patients for screening.

Impact of customized videotape education on quality of life in patients with chronic obstructive pulmonary disease.

PURPOSE: To compare the impact of a library of pulmonary rehabilitation videotapes versus an older videotape and usual care on quality of life and ability to perform activities of daily living in persons with chronic obstructive pulmonary disease. METHODS: Two hundred fourteen patients diagnosed with chronic obstructive pulmonary disease, emphysema, or chronic bronchitis were recruited and randomized to receive customized videotapes, standard videotapes, or usual care. Outcome measures included the Fatigue Impact Scale, Seattle Obstructive Lung Disease Questionnaire, and the SF-36(R) Health Survey. RESULTS: Differences in coping skills and emotional functioning on the Seattle Obstructive Lung Disease Questionnaire were found among the 174 subjects who completed the study. The customized videotape group improved by 8.6 and 4.8 points, respectively, whereas the score of the other groups decreased by less than 1 point for the coping skills, and the scores of the standard video and the control groups decreased by 3.0 and 2.1 points, respectively, for emotional functioning (P < .05, all comparisons). The scores using the Fatigue Impact Scale also improved for the customized videotape group, whereas the scores of the others remained unchanged. Videotape users demonstrated better conversion to and retention of exercise habits, with over 80% of customized videotape subjects who reported exercise habits at baseline continuing the habits as compared with 40% in the usual care group. Sedentary subjects at baseline were more likely to begin and maintain exercise if randomized to videotapes. CONCLUSIONS: These findings demonstrate increased quality of life, lower fatigue, and better compliance with a prescribed exercise regimen among subjects using the customized videotapes. There was a significant improvement in emotional functioning and coping skills among customized videotape subjects.

Lack of association between sputum atypia and chronic obstructive pulmonary disease mortality.

HYPOTHESIS: Chronic obstructive pulmonary disease (COPD) and lung cancer are thought to share common elements in pathogenesis. The authors hypothesized that sputum atypia would reflect the processes leading to progressive airflow obstruction and might be a novel biomarker of more rapidly progressive COPD. METHODS: The authors analyzed the association between COPD death and sputum cytologic atypia in an ongoing cohort of 2013 smokers with varying degrees of airflow obstruction during the period between January 1, 1993, and July 1, 2001. RESULTS: There were 326 deaths attributed to COPD over 4495 person-years, giving a COPD death rate of 7.25 deaths per 100 person-years, which is highly elevated compared with fewer than 0.2 COPD deaths per 100 person-years for the United States population aged between 65 and 74 years. Sputum atypia was not associated with either the degree of airflow obstruction or death from COPD. COPD death was associated with age and degree of airflow obstruction, as expected. CONCLUSION: Sputum cytologic atypia is not predictive of death from COPD. As sputum cytologic grades of moderate or worse atypia are associated with a significant increase in the risk for lung cancer and do not denote a group with increased competing death rates from COPD, patients with sputum atypia are a good high risk group in whom chemoprevention and early detection studies can be conducted.

The history of COPD.

The evolution of knowledge concerning COPD and its components--emphysema, chronic bronchitis, and asthmatic bronchitis--covers 200 years. The stethoscope and spirometer became important early tools in diagnosis and assessment. Spirometry remains the most effective means of identification and assessment of the course of COPD and responses to therapy, and is grossly underused for this purpose. Knowledge of the pathogenesis, course and prognosis, and new approaches to therapy have dramatically improved our understanding of this important clinical entity. Smoking cessation improves the early course of disease. Long-term oxygen improves the length and quality of life in selected patients with hypoxemia. Surgery benefits a select few. Today, COPD is a steadily growing global healthcare problem, with increasing morbidity and mortality. Early identification and prevention, and treatment of emerging stages of disease through smoking cessation and a growing number of bronchoactive drugs promises to change the outcome.

High prevalence of occult endobronchial malignancy in high risk patients with moderate sputum atypia.

Early stage radiographically occult lung cancer has a high cure rate, but comprises a small fraction of all lung cancer. Abnormal sputum cytology is one indication for bronchoscopy in patients with chest imaging that is not suspicious for lung cancer. While there is good evidence that sputum cytologic findings of carcinoma, carcinoma in situ or severe atypia predict high rates of diagnosis of lung cancer, less is known of the frequency in which lung cancer is diagnosed in bronchoscopies carried out for the indication of moderate sputum atypia. One small series, published in abstract form only, reported an 8% rate of diagnosis of lung cancer in subjects bronchoscoped for moderate atypia. We tested the hypothesis that moderate sputum atypia is an indicator of occult central airway cancer in a retrospective analysis of a group of high risk subjects, defined as current or former smokers with >30 pack-years tobacco smoking and airflow obstruction with moderate atypia sputum cytology. Seventy-nine such subjects with no evidence of malignancy on chest radiograph at the time bronchoscopy was scheduled underwent white light and autofluorescence bronchoscopy. Lung cancer was found in five subjects; three had invasive squamous cell carcinomas and two had carcinoma in situ. Seven additional subjects had severe dysplasia found on endobronchial biopsy. Moderate sputum atypia may be an important marker of risk for occult endobronchial malignancy in high risk subjects.

Lung cancer detection in patients with airflow obstruction identified in a primary care outpatient practice.

INTRODUCTION: This prospective study describes a community-based lung cancer identification project focusing on high-risk patients who receive general care in a primary care outpatient practice. Within 1 calendar year, a simple questionnaire was completed in 1,296 patients > 50 years old to identify 430 patients at high risk of lung cancer (smoking, family history of aerodigestive tract cancer, or occupational exposures). Spirometric abnormalities were found in 126 of these patients. METHODS: Chest posteroanterior radiographs, thoracic CT scans, and sputum cytology were offered to subjects with airflow obstruction (n = 126). Eighty-eight patients underwent all tests. Thirty-eight patients refused or could not consent in a timely fashion. RESULTS: Six cancers were found in the screened group, and all were treated. Two more cancers were found in the nonscreened patients with airflow obstruction. Both were treated by surgical resection or radiation therapy. Costs per cancer found were $11,925 per patient. CONCLUSIONS: Case finding in high-risk patients in a primary care population can be accomplished at a relatively low cost.

Benefits of and barriers to the widespread use of spirometry.

PURPOSE OF REVIEW: To review the basis for spirometry, its benefits in diagnosing and managing both acute and chronic pulmonary disorders with emphasis on chronic obstructive pulmonary disease, and to critically examine the barriers to its widespread use. RECENT FINDINGS: A number of recent articles have established the scientific basis for spirometry in the early identification of chronic obstructive pulmonary disease and in improving smoking cessation in patients with chronic obstructive pulmonary disease. Economic and other considerations are reported. SUMMARY: Spirometry is an important office diagnostic device that should be used by all primary care and most specialist physicians. Spirometry is to dyspnea as the electrocardiogram is to chest pain.

The National Lung Health Education Program: roots, mission, future directions.

The National Lung Health Education Program (NLHEP), founded in 1997, is a national health care initiative to promote early diagnosis of chronic obstructive pulmonary disease and related disorders. NLHEP creates and provides lung health publications for laypeople and health professionals and develops and conducts workshops for health care professionals, to promote clinician expertise in office spirometry and spirogram interpretation, and to increase everyone's awareness of the effects of smoking and the availability of smoking-cessation programs, support systems, and treatments. The American Association for Respiratory Care (AARC) has been a NLHEP partner from the beginning, and now those 2 organizations are adding another dimension to their partnership: AARC is going to take over all NLHEP administrative functions.