Assessment of Lung Cancer Risk Among Smokers for Whom Annual Screening Is Not Recommended.

Importance: The US Preventive Services Task Force does not recommend annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years who are former smokers with 20 or more pack-years of smoking who quit 15 or more years ago or current smokers with less than 20 pack-years of smoking. Objective: To determine the risk of lung cancer in older smokers for whom LDCT screening is not recommended. Design, Settings, and Participants: This cohort study used the Cardiovascular Health Study (CHS) data sets obtained from the National Heart, Lung and Blood Institute, which also sponsored the study. The CHS enrolled 5888 community-dwelling individuals aged 65 years and older in the US from June 1989 to June 1993 and collected extensive baseline data on smoking history. The current analysis was restricted to 4279 individuals free of cancer who had baseline data on pack-year smoking history and duration of smoking cessation. The current analysis was conducted from January 7, 2022, to May 25, 2022. Exposures: Current and prior tobacco use. Main Outcomes and Measures: Incident lung cancer during a median (IQR) of 13.3 (7.9-18.8) years of follow-up (range, 0 to 22.6) through December 31, 2011. A Fine-Gray subdistribution hazard model was used to estimate incidence of lung cancer in the presence of competing risk of death. Cox cause-specific hazard regression models were used to estimate hazard ratios (HRs) and 95% CIs for incident lung cancer. Results: There were 4279 CHS participants (mean [SD] age, 72.8 [5.6] years; 2450 [57.3%] women; 663 [15.5%] African American, 3585 [83.8%] White, and 31 [0.7%] of other race or ethnicity) included in the current analysis. Among the 861 nonheavy smokers (<20 pack-years), the median (IQR) pack-year smoking history was 7.6 (3.3-13.5) pack-years for the 615 former smokers with 15 or more years of smoking cessation, 10.0 (5.3-14.9) pack-years for the 146 former smokers with less than 15 years of smoking cessation, and 11.4 (7.3-14.4) pack-years for the 100 current smokers. Among the 1445 heavy smokers (20 or more pack-years), the median (IQR) pack-year smoking history was 34.8 (26.3-48.0) pack-years for the 516 former smokers with 15 or more years of smoking cessation, 48.0 (35.0-70.0) pack-years for the 497 former smokers with less than 15 years of smoking cessation, and 48.8 (31.6-57.0) pack-years for the 432 current smokers. Incident lung cancer occurred in 10 of 1973 never smokers (0.5%), 5 of 100 current smokers with less than 20 pack-years of smoking (5.0%), and 26 of 516 former smokers with 20 or more pack-years of smoking with 15 or more years of smoking cessation (5.0%). Compared with never smokers, cause-specific HRs for incident lung cancer in the 2 groups for whom LDCT is not recommended were 10.54 (95% CI, 3.60-30.83) for the current nonheavy smokers and 11.19 (95% CI, 5.40-23.21) for the former smokers with 15 or more years of smoking cessation; age, sex, and race-adjusted HRs were 10.06 (95% CI, 3.41-29.70) for the current nonheavy smokers and 10.22 (4.86-21.50) for the former smokers with 15 or more years of smoking cessation compared with never smokers. Conclusions and Relevance: The findings of this cohort study suggest that there is a high risk of lung cancer among smokers for whom LDCT screening is not recommended, suggesting that prediction models are needed to identify high-risk subsets of these smokers for screening.

Patient Perspectives on the Risk-Based NLST Outcomes Tool for Lung Cancer Screening.

Researchers at the NCI have developed the Risk-Based NLST Outcomes Tool (RNOT), an online tool that calculates risk of lung cancer diagnosis and death with and without lung cancer screening, and false-positive risk estimates. This tool has the potential to facilitate shared decision making for screening. The objective of this study was to examine how current heavy and former smokers understand and respond to personalized risk estimates from the RNOT. Individuals who were eligible for lung cancer screening and were visiting Walter Reed National Military Medical Center were invited to participate in a semi-structured interview to assess their experiences with and perceptions of the RNOT. Results were analyzed using template analysis. Participants found their risk of lung cancer death to be lower than anticipated and were confused by changes in risk for lung cancer diagnosis with and without screening. Most participants indicated that the RNOT would be helpful in making screening decisions, despite reporting that there was no maximum risk for a false positive that would lead them to forgo lung cancer screening. Participants provided actionable needs and recommendations to optimize this tool. Risk-based screening tools may enhance shared decision making. The RNOT is being updated to incorporate these findings.

Comparative study of survival among small cell lung cancer patients in the U.S. military health system and those in the surveillance, epidemiology, and end results (SEER) program.

PURPOSE: The U.S. military health system provides universal health care access to beneficiaries. However, whether the universal access has translated into improved patient outcome is unknown. We compared survival of small-cell lung cancer patients in the military health system with that in the U.S. general population. Stage and receipt of cancer treatment were also compared to see if they could contribute to survival difference. METHODS: The data were obtained from The Department of Defense's Automated Central Tumor Registry (ACTUR) and the national Surveillance, Epidemiology, and End Results (SEER) program, respectively. ACTUR (N = 3040) and SEER patients (N = 12,160) were matched on age, sex, race and diagnosis year. Multivariable Cox regression model was used to compare all-cause mortality between ACTUR and SEER. Multivariable logistic regression was performed to compare cancer stage and treatment. RESULTS: ACTUR patients exhibited significantly better survival than SEER counterparts (HR = 0.77, 95% CI= 0.71-0.83). ACTUR and SEER patients had similar stage, but ACTUR patients were more likely to receive radiation treatment (OR = 1.26, 95% CI = 1.12-1.42). The survival advantage of ACTUR patients remained across all tumor stages and radiation groups. CONCLUSIONS: Survival of small-cell lung cancer patients with universal health care access had better survival than similar patients in the U.S. general population. Future studies are warranted to identify factors that may contribute to the improved survival.

Optimizing routine screening for cardiac sarcoidosis through use of commonly available studies.

BACKGROUND: Sarcoidosis is a multisystem granulomatous disorder with unclear etiology. Morbidity and mortality vary based on organ involvement, with cardiac sarcoidosis (CS) associated with higher mortality; despite this, CS remains underdiagnosed. The Heart Rhythm Society (HRS) expert consensus statement recommends screening sarcoidosis patients for CS utilizing a symptom screen, EKG, and echocardiogram (TTE), while the American Thoracic Society (ATS) guideline recommends only EKG and symptom screening. These recommendations, however, are based on limited data with recommendations for further studies. RESEARCH QUESTION: The purpose is to evaluate the prevalence of abnormal screening tests in patients with sarcoidosis and the correlation of these tests with the subsequent diagnosis of CS. A specific emphasis was placed on evaluating the sensitivity of the recommendations versus the sensitivity of a modified criteria. STUDY DESIGN: and Methods: This study retrospectively evaluated a database of prospectively enrolled patients from a tertiary military academic center. All patients who underwent imaging with cardiac MRI and/or FDG-PET were identified. These results were correlated with screening studies (symptom screen, EKG, TTE, and ambulatory rhythm monitoring (ARM)) and used to calculate sensitivity, specificity, and positive and negative predictive values for each test. Using a clinical diagnosis of CS as the reference standard, the sensitivity and specificity of the HRS criteria were calculated and compared to a modified screening rubric developed a priori, consisting of minor changes to the criteria and the addition of ARM. RESULTS: This study evaluated 114 patients with sarcoidosis with 132 advanced imaging events, leading to a diagnosis of CS in 36 patients. Utilizing HRS screening recommendations, the sensitivity for CS was 63.9%, while the modified criteria increased sensitivity to 94.4%. INTERPRETATION: This study suggests that the HRS guidelines lack sensitivity to effectively screen for CS and that a modified screening model which includes ARM may be more effective.

Comparative Trends in the Distribution of Lung Cancer Stage at Diagnosis in the Department of Defense Cancer Registry and the Surveillance, Epidemiology, and End Results data, 1989-2012.

INTRODUCTION: We compared the stage at diagnosis for non-small cell lung cancer (NSCLC) patients in the military healthcare system (MHS) and the general public to assess differences between these two groups as well as to assess the trends in stage at diagnosis in the recent past. METHOD: This study was based on the non-identifiable data from the U.S. Department of Defense Automated Central Tumor Registry (ACTUR) and the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. Patients diagnosed with NSCLC between 1989 and 2012 were included. The distributions of tumor stage at diagnosis and trends in tumor stage were compared between the two populations. RESULTS: The cohorts were predominately male in both ACTUR (65.3%) and SEER (55.1%) and white patients accounted for greater than 80% of patients in both ACTUR and SEER. Among 21,031 patients in ACTUR and 773,356 patients in SEER, stage IV lung cancers predominated (ACTUR 33.6%, SEER 40.5%) followed by stage III (ACTUR 26.1%, SEER 26.4%) and stage I (ACTUR 24.7%, SEER 20.6%). Notable differences between the two populations were the higher percentage of stage I and lower percentage of stage IV, along with a lower rate of unknown stage patients after 2004, in ACTUR than SEER. Between 1989 and 2012, the percentage of stage IV disease increased in ACTUR and SEER coincident with a decrease in unknown stage disease. CONCLUSIONS: The majority of NSCLC patients in the MHS and general population are diagnosed with stage IV NSCLC and the percentage is increasing. Compared to the general population, NSCLC patients in the MHS have a higher percentage of stage I, a lower percentage of stage IV, and of unknown stage cancer. Universal care along with more rigorous staging across the MHS may play a role in these findings.

Comorbidity and stage at diagnosis among lung cancer patients in the US military health system.

PURPOSE: We investigated the association between comorbidities and stage at diagnosis among NSCLC patients in the US Military Health System (MHS), which provides universal health care to its beneficiaries. METHODS: The linked data from the Department of Defense's Central Cancer Registry (CCR) and the MHS Data Repository (MDR) were used. The study included 4768 patients with histologically confirmed primary NSCLC. Comorbid conditions were extracted from the MDR data. Comorbid conditions were those included in the Charlson Comorbidity Index (CCI) and were defined as a diagnosis during a 3-year time frame prior to the NSCLC diagnosis. Multivariable logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) of late stage (stages III and IV) versus early stage (stages I and II) in relation to pre-existing comorbidities. RESULTS: Compared to patients with no comorbidities, those with prior comorbidities tended to be less likely to have lung cancer diagnosed at late stage. When specific comorbidities were analyzed, decreased odds of being diagnosed at late stage were observed among those with chronic obstructive pulmonary disease (COPD) (adjusted OR 0.78, 95% CI 0.68 to 0.90). In contrast, patients with a congestive heart failure or a liver cirrhosis/chronic hepatitis had an increased likelihood of being diagnosed at late stage (adjusted OR 1.30, 95% CI 1.00 to 1.69 and adjusted OR 1.87, 95% CI 1.24 to 2.82, respectively). CONCLUSIONS: Among NSCLC patients in an equal access health system, the likelihood of late stage at diagnosis differed by specific comorbid diseases.

Survival among Lung Cancer Patients in the U.S. Military Health System: A Comparison with the SEER Population.

Background: The U.S. military health system (MHS) provides universal health care access to its beneficiaries. However, whether the universal access has translated into improved patient outcome is unknown. This study compared survival of non-small cell lung cancer (NSCLC) patients in the MHS with that in the U.S. general population.Methods: The MHS data were obtained from The Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR), and the U.S. population data were drawn from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. The study subjects were NSCLC patients diagnosed between January 1, 1987, and December 31, 2012, in ACTUR and a sample of SEER patients who were matched to the ACTUR patients on age group, sex, race, and year of diagnosis group with a matching ratio of 1:4. Patients were followed through December 31, 2013.Results: A total of 16,257 NSCLC patients were identified from ACTUR and 65,028 matched patients from SEER. Compared with SEER patients, ACTUR patients had significantly better overall survival (log-rank P < 0.001). The better overall survival among the ACTUR patients remained after adjustment for potential confounders (HR = 0.78, 95% confidence interval, 0.76-0.81). The survival advantage of the ACTUR patients was present regardless of cancer stage, grade, age group, sex, or race.Conclusions: The MHS's universal care and lung cancer care programs may have translated into improved survival among NSCLC patients.Impact: This study supports improved survival outcome among NSCLC patients with universal care access. Cancer Epidemiol Biomarkers Prev; 27(6); 673-9. ©2018 AACR.

Metformin use and survival after non-small cell lung cancer: A cohort study in the US Military health system.

Research suggests that metformin may be associated with improved survival in cancer patients with type II diabetes. This study assessed whether metformin use after non-small cell lung cancer (NSCLC) diagnosis is associated with overall survival among type II diabetic patients with NSCLC in the U.S. military health system (MHS). The study included 636 diabetic patients with histologically confirmed NSCLC diagnosed between 2002 and 2007, identified from the linked database from the Department of Defense's Central Cancer Registry (CCR) and the Military Health System Data Repository (MDR). Time-dependent multivariate Cox proportional hazards models were used to assess the association between metformin use and overall survival during follow-up. Among the 636 patients, 411 died during the follow-up. The median follow-up time was 14.6 months. Increased post-diagnosis cumulative use (per 1 year of use) conferred a significant reduction in mortality (adjusted hazard ratio (HR) = 0.76; 95% CI = 0.65-0.88). Further analysis by duration of use revealed that compared to non-users, the lowest risk reduction occurred among patients with the longest duration of use (i.e. use for more than 2 years) (HR = 0.19; 95% CI = 0.09-0.40). Finally, the reduced mortality was particularly observed only among patients who also used metformin before lung cancer diagnosis and among patients at early stage of diagnosis. Prolonged duration of metformin use in the study population was associated with improved survival, especially among early stage patients. Future research with a larger number of patients is warranted.

The Impact of Preexisting Mental Health Disorders on the Diagnosis, Treatment, and Survival among Lung Cancer Patients in the U.S. Military Health System.

BACKGROUND: Higher cancer-related mortality has been observed among people with mental health disorders than in the general population. Both delay in diagnosis and inadequate treatment due to health care access have been found to explain the higher mortality. The U.S. Military Health System (MHS), in which all beneficiaries have equal access to health care, provides an ideal system to study this disparity where there are no or minimal barriers to health care access. This study assessed preexisting mental health disorders and stage at diagnosis, receipt of cancer treatment, and overall survival among patients with non-small cell lung cancer (NSCLC) in the U.S. MHS. METHODS: The study used data from the linked database from the Department of Defense's Central Cancer Registry and the MHS Data Repository (MDR). The study subjects included 5,054 patients with histologically confirmed primary NSCLC diagnosed between 1998 and 2007. RESULTS: Patients with a preexisting mental disorder did not present with more advanced disease at diagnosis than those without. There were no significant differences in receiving cancer treatments between the two groups. However, patients with a mental health disorder had a higher mortality than those without [adjusted HR, 1.11; 95% confidence interval (CI), 1.03-1.20]. CONCLUSIONS: Poor survival in NSCLC in patients with a preexisting mental health disorder is not necessarily associated with delay in diagnosis and/or inadequate cancer treatment. IMPACT: This study contributes to the current understanding that health care access may not be sufficient to explain the poor survival among patients with NSCLC with preexisting mental health disorders. Cancer Epidemiol Biomarkers Prev; 25(12); 1564-71. ©2016 AACR.

Clinical Importance of Echogenic Swirling Pleural Effusions.

Thoracic sonography is an important tool in diagnosis and assessment of pleural effusions and can provide valuable information about the characteristics of accumulated pleural fluid, in addition to improving the safety of thoracentesis. In addition to the 4 classic sonographic pleural effusion patterns (anechoic, complex nonseptate, complex septate, and homogeneously echogenic), an echogenic swirling pattern has been previously described, which was originally thought to be associated with malignant effusion. Two cases of pleural effusion with an echogenic swirling pattern are described below, illustrating that this sonographic finding can be seen in both exudative and transudative effusions.

A Prognostic Model to Predict Mortality among Non-Small-Cell Lung Cancer Patients in the U.S. Military Health System.

INTRODUCTION: Accurate prognosis assessment after non-small-cell lung cancer (NSCLC) diagnosis is an essential step for making effective clinical decisions. This study is aimed to develop a prediction model with routinely available variables to assess prognosis in patients with NSCLC in the U.S. Military Health System. METHODS: We used the linked database from the Department of Defense's Central Cancer Registry and the Military Health System Data Repository. The data set was randomly and equally split into a training set to guide model development and a testing set to validate the model prediction. Stepwise Cox regression was used to identify predictors of survival. Model performance was assessed by calculating area under the receiver operating curves and construction of calibration plots. A simple risk scoring system was developed to aid quick risk score calculation and risk estimation for NSCLC clinical management. RESULTS: The study subjects were 5054 patients diagnosed with NSCLC between 1998 and 2007. Age, sex, tobacco use, tumor stage, histology, surgery, chemotherapy, peripheral vascular disease, cerebrovascular disease, and diabetes mellitus were identified as significant predictors of survival. Calibration showed high agreement between predicted and observed event rates. The area under the receiver operating curves reached 0.841, 0.849, 0.848, and 0.838 during 1, 2, 3, and 5 years, respectively. CONCLUSIONS: This is the first NSCLC prognosis model for quick risk assessment within the Military Health System. After external validation, the model can be translated into clinical use both as a web-based tool and through mobile applications easily accessible to physicians, patients, and researchers.