Haval Balata

Progress and prospects of early detection in lung cancer

Lung cancer is the leading cause of cancer-related death in the world. It is broadly divided into small cell (SCLC, approx. 15% cases) and non-small cell lung cancer (NSCLC, approx. 85% cases). The main histological subtypes of NSCLC are adenocarcinoma and squamous cell carcinoma, with the presence of specific DNA mutations allowing further molecular stratification. If identified at an early stage, surgical resection of NSCLC offers a favourable prognosis, with published case series reporting 5-year survival rates of up to 70% for small, localized tumours (stage I). However, most patients (approx. 75%) have advanced disease at the time of diagnosis (stage III/IV) and despite significant developments in the oncological management of late stage lung cancer over recent years, survival remains poor. In 2014, the UK Office for National Statistics reported that patients diagnosed with distant metastatic disease (stage IV) had a 1-year survival rate of just 15–19% compared with 81–85% for stage I.

Implementing lung cancer screening: baseline results from a community-based ‘Lung Health Check’ pilot in deprived areas of Manchester

We report baseline results of a community-based, targeted, low-dose CT (LDCT) lung cancer screening pilot in deprived areas of Manchester. Ever smokers, aged 55–74 years, were invited to ‘lung health checks’ (LHCs) next to local shopping centres, with immediate access to LDCT for those at high risk (6-year risk ≥1.51%, PLCOM2012 calculator). 75% of attendees (n=1893/2541) were ranked in the lowest deprivation quintile; 56% were high risk and of 1384 individuals screened, 3% (95% CI 2.3% to 4.1%) had lung cancer (80% early stage) of whom 65% had surgical resection. Taking lung cancer screening into communities, with an LHC approach, is effective and engages populations in deprived areas.

Prevalence of nodal metastases in lymph node stations 8 & 9 in a large UK lung cancer surgical centre without routine pre-operative EUS nodal staging

INTRODUCTION Endoscopic ultrasound (EUS) allows access to the inferior mediastinal lymph node stations (8 and 9) which are beyond the reach of endobronchial ultrasound (EBUS). The addition of EUS to EBUS procedures requires cost and resource investment. This study sought to describe the prevalence of station 8/9 nodal metastases from intra-operative lymph node sampling in a UK region where routine pre-operative EUS is not available. METHODS A retrospective review of all lung cancer resections at the University Hospital South Manchester from 2011 to 2014. Surgical variables, pre-operative PET variables and survival outcomes were collected and analysed. RESULTS 1421 surgical resections were performed in the study period. Lymph node stations 8 and/or 9 were sampled in 52% (736/1421) of patients. Overall, there were 34 patients with lymph node metastases at station 8/9. This represents 2.4% of the study populations and 4.6% of patients in whom stations 8/9 were sampled intra-operatively. Of those patients with station 8/9 metastases, 65% (22/34) had multi-station N2 disease and the majority of the additional N2 disease was present in EBUS-accessible areas (lymph node stations 2, 4 and 7). Two percent (16/736) of patients in whom station 8/9 lymph nodes were sampled intra-operatively had N2 disease that was only accessible endoscopically with EUS. There was no significant difference in overall survival in patients with pathological N2 disease stratified according to whether stations 8/9 were involved or not. CONCLUSIONS The prevalence of lymph node metastases in stations 8/9 in this UK surgical centre where routine pre-operative EUS is not performed is low at approximately 5%. Given the identification of N2 disease in two-thirds of these patients can potentially be achieved through EBUS alone, this questions whether the resource implications of EUS are justified by the impact on patient management.

Targeted lung cancer screening selects individuals at high risk of cardiovascular disease

BACKGROUND Cardiovascular disease (CVD) is a major cause of morbidity and mortality in populations eligible for lung cancer screening. The aim of this study was to determine whether a brief CV risk assessment, delivered as part of a targeted community-based lung cancer screening programme, was effective in identifying individuals at high risk who might benefit from primary prevention. METHODS The Manchester Lung Screening Pilot consisted of annual low dose CT (LDCT) over 2 screening rounds, targeted at individuals in deprived areas at high risk of lung cancer (age 55-74 and 6-year risk ≥1.51%, using PLCOM2012 risk model). All participants of the second screening round were eligible to take part in the study. Ten-year CV risk was estimated using QRISK2 in participants without CVD and compared to age (±5 years) and sex matched Health Survey for England (HSE) controls; high risk was defined as QRISK2 score ≥10%. Coronary artery calcification (CAC) was assessed on LDCT scans and compared to QRISK2 score. RESULTS Seventy-seven percent (n=920/1,194) of screening attendees were included in the analysis; mean age 65.6 ± 5.4 and 50.4% female. QRISK2 and lung cancer risk (PLCOM2012) scores were correlated (r = 0.26, p < 0.001). Median QRISK2 score was 21.1% (IQR 14.9-29.6) in those without established CVD (77.6%, n = 714/920), double that of HSE controls (10.3%, IQR 6.6-16.2; n = 714) (p < 0.001). QRISK2 score was significantly higher in those with CAC (p < 0.001). Screening attendees were 10-fold more likely to be classified high risk (OR 10.2 [95% CI 7.3-14.0]). One third (33.7%, n = 310/920) of all study participants were high risk but not receiving statin therapy for primary CVD prevention. DISCUSSION Opportunistic CVD risk assessment within a targeted lung cancer screening programme is feasible and is likely to identify a very large number of individuals suitable for primary prevention.

S13 Manchester lung screening, targeting high-risk individuals in deprived areas of the community

Background Lung cancer (LC) is the commonest cause of cancer-related death in the world. Screening with low-dose computer tomography (LDCT) had been shown to reduce LC specific and all-cause mortality. Benefit is greatest in those at highest risk, such as current smokers from areas of high socio-economic deprivation, yet participation in these ‘hard-to-reach’ populations remains a challenge. The aim of this NHS implementation project was to assess LC screening within the community in deprived areas. Abstract S13 Figure 1 Comparison of median Index of Multiple Deprivation (IMD) of Manchester and United Kingdom Lung Cancer Screening (UKLS) populations. Methods Ever smokers, aged 55–74, registered at 14 participating general practitioner (GP) practices in deprived areas of Manchester were invited to attend and have a free ‘Lung Health Check’ (LHC) in a mobile unit located at their local shopping centres. Lung cancer risk score (PLCOM2012), respiratory symptoms and spirometry were assessed as part of the LHC. Those at high risk of LC, i.e., 6 year lung cancer risk ≥1.51%, were offered immediate LDCT in a co-located mobile CT scanner. All active smokers were provided with smoking cessation advice. Results The maximum available capacity of the service was filled within days of going live. A total of 2541 individuals attended for a LHC and consented to data analysis. The mean age was 64.1±5.5 and 51.0% (n=1,296) were female. 74.5% (n=1,893) of participants were ranked in the lowest quintile of deprivation in England. The majority of individuals had left school by the age of 16 (n=2,078; 81.8%), most without gaining any ‘O’ levels (n=1,567; 61.7%). A significant number of participants reported a history of previous respiratory disease (n=566; 22.3%), pervious cancer (n=291; 11.5%), family history of LC (n=553; 21.8%) or asbestos exposure (n=612; 24.1%). 56.2% (n=1,429) qualified for LDCT screening of which 52.8% were active smokers. 46 lung cancers were detected in 42 individuals, a prevalence of 3.0%, of which 80.4% were early stage (I+II). A treatment with curative intent was offered to 89.1% of screen detected cancers. Conclusion Taking lung cancer screening into the community can identify and affect those at most risk, the so-called ‘hard-to-reach’ populations. This Results in a significant stage shift in screen detected lung cancers in deprived populations.

S62 Adequacy of intra-operative lymph node sampling during surgical resection of nsclc: influencing factors and its relationship to survival

Background Adequate intra-operative lymph node sampling is a fundamental part of lung cancer surgery but adherence to standards, particularly in the United Kingdom is not well known. The International Association for the Study of Lung Cancer (IASLC) has defined adequate lymph node sampling as: at least 3 mediastinal lymph node stations, station 7 in all cases, station 5/6 with left upper lobe tumours and station 9 with lower lobe tumours; the sampling of at least 3 hilar lymph node stations is also recommended This study sought to measure the adequacy of intra-operative lymph node sampling at a regional Lung Cancer Centre, the factors which may influence this and impact on survival. Methods A retrospective review of the pathological reports for all patients who underwent surgical resection for NSCLC at the University Hospital of South Manchester between 2011 and 2014 (n = 1407) was performed. Lung cancer resection specimens are reported in line with the minimum dataset defined by the Royal College of Pathology and contain a record of all lymph node stations sampled intra-operatively and the histological findings from these lymph nodes. The influence of clinical variables on adequacy of lymph node sampling was investigated and survival data was obtained from national death registries. Results Adequate intra-operative lymph node sampling increased significantly from 13% (23/173) in 2011 to 51% (224/437) in 2014 coinciding with a dramatic increase in the volume of lung cancer surgery (Table 1). Secondary analysis also revealed that patients with a low or high T-stage, undergoing sublobar resections and undergoing left sided resections have significantly higher rates of inadequate lymph node sampling. Overall, there was no statistically significant difference in survival between patients with adequate and inadequate intra-operative lymph node sampling. Conclusion This study provides a much-needed benchmark of current thoracic surgical practice in lung cancer in the UK and provides important granularity to facilitate changes to improve adequacy of staging. Further improvement is needed to meet the standards as defined by the IASLC, however, what constitutes an “acceptable” level of adequacy is yet to be defined and this impact on survival is not clear. Abstract S62 Table 1 Intra-operative nodal sampling during resection of NSCLC at UHSM (2011–14) Measure Year of surgery 2011/12 vs 2013/14 2011 2012 2013 2014 p-value Total number of NSCLC resections n 173 333 464 437 Overall proportion of adequate nodal sampling % (n) 13%(23) 22%(73) 38%(174) 51%(224) <0.0001 ≥3 mediastinal LN stations sampled % (n) 17%(30) 31%(103) 47%(220) 60%(262) <0.0001 Station 7 sampled % (n) 36%(63) 46%(154) 63%(290) 56%(244) <0.0001 Station 5/6 in LUL tumours % (n) 72%(42) 73%(72) 76%(104) 84%(95) <0.15 Station 9 in lower lobe tumours % (n) 49%(37) 52%(66) 60%(124) 65%(114) 0.008 Proportion of multi-station N2 % (n) 5%(8) 4%(12) 5%(25) 4%(17)