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N. Bilir
Moderator of
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MA03 - Epidemiology, Risk Factors and Screening (ID 374)
- Event: WCLC 2016
- Type: Mini Oral Session
- Track: Epidemiology/Tobacco Control and Cessation/Prevention
- Presentations: 11
- Moderators:N. Bilir, H. Olschewski
- Coordinates: 12/05/2016, 14:20 - 15:50, Lehar 3-4
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MA03.01 - Gender Disparities in Non-Small Cell Lung Cancer: A Systematic Review (ID 5803)
14:20 - 14:26 | Author(s): N.A. Alsaadoun, K. Kopciuk, D..D. Hao, K. Riabowol, M.H. Hollenbrg, G. Bebb
- Abstract
- Presentation
Background:
Although lung cancer is the second most-often diagnosed malignancy in both men and women, and the biggest cancer killer of both genders, evidence suggests that the lung cancer experience differs in women compared to men. Lung cancer incidence in men has steadily decreased since the mid-1980s, while in women it has increased. Partly, these patterns reflect sex differences in smoking behavior over the previous two decades. Additional epidemiological evidence suggests that gender impacts most facets of the lung cancer experience, including the incidence, susceptibility, severity, and molecular basis of the disease. However, there is a lack of consensus on both the magnitude and etiology of these gender-based differences. The aim of this currently ongoing systematic literature review is to more precisely define this gender disparity among non-small cell lung cancer (NSCLC) patients worldwide and summarize current opinions about the molecular basis for these observations.
Methods:
A preliminary rapid review was launched to outline gender disparity among NSCLC patients in North America, Europe and South Asia. Independent studies were utilized from Medline; Embase; Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for the period between 1996 and 2016. Based on these results, a systematic literature review was carried out for the period between 1996 and 2016 using Medline and Embase databases worldwide. The main outcome measures are incidence and factors influencing NSCLC between the genders. A validated scoring system was used to appraise eligible studies for methodological quality and level of evidence.
Results:
The preliminary rapid search identified 17 eligible articles for review. Analysis suggests that females are more susceptible to tobacco related carcinogens, have a younger age at diagnosis and higher survival rates. We also observed an increase in the inclusion of female patients in the clinical studies over this period. Based on pre-specified selection criteria, the systematic review generated a total of 367 studies which have been retrieved and considered for further analysis. We will determine gender differences in NSCLC incidence and its molecular aberration utilizing data from independent studies based on rapid analysis of observational studies published globally.
Conclusion:
Our systematic literature review will help validate our preliminary findings that gender disparities in lung cancer do exist. Our findings will provide a platform for policy makers, researchers and clinicians to design clinical trials and interventions that account for these disparities.
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MA03.02 - Lung Cancer in Women 1929 to 2016: Cold-Blooded Origins of an Epidemic (ID 4561)
14:26 - 14:32 | Author(s): F. Grannis
- Abstract
- Presentation
Background:
The epidemiologic profile of lung cancer mortality in the U.S. is highly unusual. Mortality in males began to rise rapidly early in the 1920s and continued to increase through the 1990s before leveling off. Mortality in women did not begin to rise until decades later and did not approximate mortality in men until the early years of the twenty first century. This unusual pattern of disease can be explained by review of tobacco industry documents and court records.
Methods:
A search was conducted in the Legacy Tobacco Documents library at the University of California, San Francisco, as well as review of testimony and legal reports from state and federal court decisions.
Results:
The beginning of the epidemic of lung cancer in women in the U.S. can be reliably traced back to Easter Sunday in 1929. On that date, a publicity stunt crafted by Edward Bernays was reported in the New York Times as the "parade of torches" supposedly representing an expression of freedom by American women who would henceforward not be constrained from smoking in public. The public relations effort was supplemented by an advertising campaign orchestrated by Chicago marketing expert Albert Lasker. Female smoking rates began to rise after this date, culminating over the succeeding decades in a sharp increase in lung cancer cases and deaths among women. A second phase of marketing of cigarettes to women and girls in the U.S. began in the 1970s as Philip Morris executive Joseph Cullman collaborated with tennis star Billie Jean King to market a new "slim" cigarette to young women via the Virginia Slims tennis tournament under the slogan "You've come a long way baby." A further contribution to the lung cancer mortality arose out of the efforts of the Council for Tobacco Research (CTR) and the Council for Indoor Air Research (CIAR) to manufacture controversy regarding the danger of smoking as well as involuntary second hand smoking to provide cover for legislators voting against tobacco control legislation. As a direct result, many thousands of non-smoking women have had major involuntary exposure to tobacco carcinogens in the workplace causing lung cancer.
Conclusion:
Lung cancer cases presenting today originated in deliberate campaigns by tobacco executives, marketers and public relations experts to convince women and girls to smoke, despite their clear understanding that the products they were aggressively marketing would inevitably result in hundreds of thousands of deaths.
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- Abstract
- Presentation
Background:
Female lung and breast cancers are two distinct disease entities in East Asia. Although studies on second primary cancers following the first breast cancer event have been carried out, no in-depth survey on double primary breast and lung cancers has been done. This study analyzed the association between these two distinct cancer types.
Methods:
In the exploratory cohort study, the data were obtained from the Taiwan National Health Insurance Research Database, which contained information on approximately 24.7 million insured individuals. The Taiwan Population Census and National Cancer Registry Databases were used to identify patients with breast and lung cancers. The cohort included individuals with newly diagnosed primary breast cancer between 2000 and 2011. An age- and sex-matched systematic random-sampling method was used for subject selection in the reference non-breast cancer cohort. Multivariate Cox proportional hazard regression analysis was used to determine the effects of breast cancer on the risk of lung cancer, as shown by hazard ratios (HRs) with 95% CIs. Detailed medical record and pathological reviews were done on the National Taiwan University Hospital (NTUH) patient cohort to validate the national cohort study results. The national lung cancer incidence rate was used as reference incidence rate in the validation cohort.
Results:
A total of 88,439 patients were diagnosed with female breast cancer between 2000-2011 in the national cohort. The HR for subsequent lung cancer was 1.27 (95% CI, 1.09-1.48). When stratified by age, the HR was 5.29 (95% CI, 2.26-12.4) in the patients aged less than 40 years, 1.67 (95% CI, 1.18-2.30) in the group aged 40-49, 1.27 (95% CI, 0.97-1.67) in the group aged 50-59, 1.09 (95% CI, 0.81-1.49) in the group aged 60-69, and 0.70 (95% CI, 0.48-1.02) in the group older than 70 years. A total of 13,517 primary female breast cancer patients were identified in the NTUH electronic medical record system between 2006-2015. The incidence rate ratio for second primary lung cancer was 16.08 in the patients whose primary breast cancer was diagnosed at age younger than 50 years and 1.43 for those diagnosed at age older than 50 years. These results supported the national cohort study findings that early-onset female breast cancer patients bear a relative high risk for second primary lung cancer.
Conclusion:
Our findings suggest a relative high risk for second primary lung cancer among patients whose primary female breast cancer is diagnosed at age less than 50 years.
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MA03.04 - Discussant for MA03.01, MA03.02, MA03.03 (ID 7072)
14:38 - 14:50 | Author(s): A. Jovicevic
- Abstract
- Presentation
Abstract not provided
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MA03.05 - Cost Effectiveness Analysis of CT vs Chest X-Ray (CXR) vs No Screening for Lung Cancer (LC) in the PLCO and NLST Randomized Population Trials (RPTs) (ID 5516)
14:50 - 14:56 | Author(s): J.P.E. Flores, A. Moreno-Koehler, M. Finkelman, J. Caro, G.M. Strauss
- Abstract
- Presentation
Background:
NLST was the first RPT to demonstrate a significant LC mortality reduction, when comparing CT to CXR-screening. Consequently, CT-screening is now being incorporated into clinical practice. Nonetheless, questions about the value of CT-screening remain given costs of CT and workup of false-positives. A prior cost-effectiveness analysis of CT-screening using NLST data concluded that CT was generally cost-effective (NEJM:371,1793,2014). That analysis was performed under the assumption that CXR-screening only added costs without benefit. In an independent analysis of PLCO comparing CXR to no screening, we found that CXR-screening is associated with a highly significant LC survival advantage. This benefit was unrelated to conventional screening biases, including overdiagnosis. As CXR is less expensive than CT with a lower false-positive rate, its cost-effectiveness relative to CT should be assessed. Data from PLCO and NLST allows comparison of no screening, CXR, and CT.
Methods:
Costs of screening, diagnostic studies, and LC treatment were calculated based on original PLCO and NLST trial data obtained from NCI. These were estimated in 2015 US dollars from the Medicare perspective. Outpatient costs were calculated using the Medicare-2015B fee schedule. Inpatient costs were calculated using a national payment average by assigning a DRG based on procedures performed. Survival data was generated using the Kaplan-Meier method for each study and mean survival was calculated using available data. These estimates were used to calculate incremental cost per life-year gained The NLST-eligible subset of PLCO was also used to facilitate comparison of no screening, CXR, and CT.
Results:
Analysis of PLCO data demonstrate that CXR compared to no screening was associated with a gain of 0.0152 life-years per person at an additional cost of $244 per-person for a cost per-life-year gained of $19,175. In the NLST-eligible subset of PLCO, CXR cost an additional $350 with a gain of 0.0262 life-years per-person for a cost-per-life-year gained of $13,377. In NLST, CT compared to CXR cost an additional $1,181 per-person and with a gain of 0.0157 life-years per-person, or $75,180 per-life-year gained. Using the NLST-eligible subset of PLCO for comparison, the ratio for CT compared to no screening was $36,552.
Conclusion:
CT-screening is both effective and cost-effective and represents the optimal method of screening for LC. However, the survival advantage associated with CXR-screening in comparison to no screening and relatively low cost make CXR a reasonable alternative to CT-screening, particularly in regions of the world where cost and availability limit access to CT-screening.
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MA03.06 - Cost Effectiveness of Chest Scan Screeing for Lung Cancer in Abestos Occupational Exposure Subjects: A Model Based Study (ID 5037)
14:56 - 15:02 | Author(s): J. Vella-Boucaud, J.C. Pairon, A. Duburcq, P. Brochard, S. Chamming'S, A. Luc, B. Detournay, C. Paris, P. Andujar, C. Chouaid
- Abstract
- Presentation
Background:
The National Lung Screening trial (NLST) showed that screening with low-dose computed tomography (CT) compared with chest radiography reduced lung-cancer mortality. There is very few data's on subjects with occupational abestos exposure. We examined the cost-effectiveness of CT lung cancer screening in a french cohort of abestos post professional exposure subjets (APEXS cohort).
Methods:
We estimated mean lif-years, costs and incremental cost-effectiveness ration (ICER) for screening with low-dose CT compare to no screening in this population of abestose exposed subjects. Estimations of life-years gained were based on the efficacy of NLST trial aplpied to APEXS cohort, adjusted to sex and age. Costs were limited to directs costs, from the payer perspective. We also performed sensitiviy analysis based on several assumptions of screening program efficacy.
Results:
Compared with no screening, screening with low-dose CT, over a period of 2 years, will cost, for 1000 subjects of APEXS cohort 312 645 €, will provide 9.4 additional life-years. The corresponding ICER was 33 102 € per life-gained. Sensitiviyt analysis showed that this result is sensitive to screening program efficacy (number, stage, and survival diagnosed by the program).
Conclusion:
ICER of low-dose CT lung cancer program in a cohort of abestos post occupational exposure population appears as acceptable from the French health system.
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MA03.07 - Discussant for MA03.05, MA03.06, MA03.07 (ID 7073)
15:02 - 15:14 | Author(s): T. Berghmans
- Abstract
- Presentation
Abstract not provided
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MA03.08 - Quantifying Survival in Early-Stage NSCLC: Implications of Relative Survival vs Cause-Specific Survival (ID 6290)
15:14 - 15:20 | Author(s): K.S. Tan, T. Eguchi, P.S. Adusumilli
- Abstract
- Presentation
Background:
Cancer-related mortality can be measured by two disparate methods: relative survival (RSR, observed survival of cancer patients versus expected survival of a matched population), and cause-specific survival (CSS, based on lung-cancer-specific mortality among cancer patients). Both are vulnerable to biases: RSR depends on a comparable reference population, while CSS relies on accurate cause-of-death coding. Regardless, RSR is more common in population-based studies as the cause of death is uninvolved. We apply both methods to the same dataset to assess their implications among early-stage NSCLC.
Methods:
Outcomes of patients diagnosed with stage I/II NSCLC (2000-2013) were obtained from the SEER registry. Five-year cumulative incidence of death (CID) is estimated by competing risk approach. Population-level mortality was extracted from the National Center for Health Statistics. The actuarial survival were summarized as RSR (Ederer II) and CSS, stratified by age at diagnosis and stage. In addition, the sensitivity of the methods is assessed by including patients with unknown cause of death in CSS (CSS-2).
Results:
Analyses included 15792 age <60 and 70789 age 60+ patients, with stage I (81%) or II NSCLC. Death with unknown cause was 5% of all deaths; 5-year CID for lung-cancer, other-known and other-unknown deaths were 43%, 14% and 2%. Lung-cancer 5-year CID increased with age, from 22% (age <44) to 47% (age 75+) among stage I, and 44% to 68% among stage II. CSS were greater than RSR in all cases. Although the bias was negligible for 1-year follow-up, the deviation increases with increasing age and years of follow-up. The estimated CSS-2s were always between RSR and CSS, suggesting that RSR underestimates the true lung-cancer-survival.
Conclusion:
In practice, RSR is appropriate for short follow-up and aggregate summaries, while caution is advised when reporting RSR by age groups for longer follow-up. Accurate assessment of the causes of death may alleviate such biases.Figure 1
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MA03.09 - Retrospective Predictive Performance of a Lung Cancer Screening Risk Prediction Model in a Clinical Lung Cancer Screening Program (ID 5371)
15:20 - 15:26 | Author(s): A.K. Borondy Kitts, S. Regis, A. McKee, J. Sands, B. McKee
- Abstract
- Presentation
Background:
United States Preventive Services Task Force (USPSTF) and Centers for Medicare & Medicaid Services (CMS) recommendations for annual screening for lung cancer with low dose CT (LDCT) scans rely on age and smoking history to identify those at high risk for lung cancer. The Tammemagi et al. six year lung cancer risk prediction model, PLCOm2012, developed and validated in large lung cancer screening clinical trials, demonstrated good predictive performance in study participants. A 1.51% PLCOm2012 risk threshold has been reported to outperform CMS/USPSTF entry criteria. This is the first time the model predictive performance has been evaluated in clinical practice.
Methods:
Predictive performance of a reparameterized (no education predictor variable) six year lung cancer risk prediction model, PLCOm2012noEd, was retrospectively assessed in 2297 consecutive individuals that underwent clinical CT lung screening between January 1, 2012 and November 30, 2015. All patients met the National Comprehensive Cancer Network (NCCN) Lung Cancer Screening Guidelines Group 1 or Group 2 high-risk criteria.
Results:
79 cancers were detected in the 2297 screened individuals with a mean follow-up of 2.12 years (75.9% (60/79) – NCCN Group 1). The model six year mean risk for lung cancer was higher for participants with lung cancer, 4.71%, as compared to those without lung cancer, 3.54% (p=0.008). Area under the curve (AUC) of the receiver operator characteristics (ROC) was 0.635 (95% CI 0.577 – 0.693). At the 1.51% predicted risk recommended screening threshold overall sensitivity = 86.1%, specificity = 29.8%, and PPV = 4.2%. For NCCN Group 1 (similar to CMS/USPSTF entry criteria), sensitivity = 91.7%, specificity = 20.7% and PPV = 4.04%. For NCCN Group 2 (younger, lighter smoking history, no limit on time quit with one additional risk factor) mean predicted risk for participants with lung cancer was 2.35% as compared to 1.83% for those without lung cancer but the difference was not statistically significant; p=0.2374. As the incidence of lung cancer was the same in NCCN Group 2 and NCCN Group 1 (3.24% vs 3.51%; p=0.8566) the sensitivity of the model for NCCN Group 2 at the recommended 1.51% screening threshold was reduced to 68.4% with a specificity of 56.3%.
Conclusion:
Lung cancer risk prediction model, PLCOm2012noEd demonstrated reduced sensitivity in individuals meeting NCCN Group 2 high-risk criteria undergoing clinical CT lung screening and may not be appropriate to adequately assess risk of lung cancer in this population.
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MA03.10 - Educational Level and the Management and Outcome in Non-Small Cell Lung Cancer: A Nationwide Study (Sweden) (ID 4427)
15:26 - 15:32 | Author(s): M. Lambe, A. Berglund, S. Bergström, A. Öjdahl Boden, G. Wagenius
- Abstract
- Presentation
Background:
Evidence from a variety of settings indicates the presence of socioeconomic differences not only in the risk of developing cancer, but also in management and outcomes. We examined the influence of educational level on stage at presentation, management and mortality in patients with non-small cell lung cancer (NSCLC) in Sweden, a country with a National Health System aiming to provide medical care on equal terms to all residents.
Methods:
We identified 24,385 patients with a NSCLC diagnosis 2002-2011 in Lung Cancer Data Base Sweden, a research database generated by record linkage between the Swedish National Lung Cancer Register and several other population-based registers. In analyses adjusted for comorbidity and other prognostic factors, ORs and HRs were estimated to examine associations between patients´ educational level and aspects of management and mortality.
Results:
Diagnostic intensity CT Thorax, CT upper abdomen and transthoracal biopsy were more commonly performed in patients with high education. In multivariable analysis, the likelihood to undergo PET scan and EGFR testing was significantly higher in patients with high compared to low education OR 1.39 (95% CI 1.23-1.57) and 1.28 (95% CI 1.05-1.55), respectively. No social gradients in EGFR testing was observed in an analysis restricted to non-smoking patients with adenocarcinoma. Stage and histopathology Stage at diagnosis did not differ between educational groups. Adenocarcinomas were proportionally more common in patients with high compared to low education, both in all patients (61.9% vs 53.9%) and among non-smokers (50.7% vs 46.7%). Waiting times There were no differences in waiting times between dates of referral and diagnosis, or between dates of diagnosis and start of treatment. Multidisciplinary conference and treatment intensity The odds for treatment decisions being made in a multidisciplinary setting was higher for patients with high compared to low education (OR 1.26; 95% CI 1.04-1.51). In stage IA-IIB disease, the likelihood to undergo surgery was non-significantly elevated in patients with high education (OR 1.26; 95% CI 0.98-1.63). Mortality In early stage disease, high education was associated with lower all-cause (HR 0.79; 95% CI 0.70-0.89) and cause-specific mortality (HR 0.76; 95% CI 0.66-0.88) after adjustment for treatment, sex, age, region, year, comorbidity, smoking, stage, histology and performance status.
Conclusion:
We found evidence of social gradients in diagnostic and treatment intensity in patients with NSCLC. While there were no difference in stage at diagnosis between educational groups, a lower mortality in early stage NSCLC was observed in patients with high education.
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MA03.11 - Discussant for MA03.08, MA03.09, MA03.10 (ID 6960)
15:32 - 15:44 | Author(s): O. Pikin
- Abstract
- Presentation
Abstract not provided
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Author of
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ED12 - Regional Tobacco Control Policies: Advances & Challenges (ID 281)
- Event: WCLC 2016
- Type: Education Session
- Track: Epidemiology/Tobacco Control and Cessation/Prevention
- Presentations: 1
- Moderators:Z. Zain, F. Mihaltan
- Coordinates: 12/07/2016, 11:00 - 12:30, Hall C7
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ED12.02 - Tobacco Control: The Turkish Experience (ID 6490)
11:15 - 11:30 | Author(s): N. Bilir
- Abstract
- Presentation
Abstract:
Tobacco Control: The Turkish Experience Turkey has been a tobacco producing country since Ottoman time. At that time tobacco production mostly was in the hands of foreign companies. Following the establishment of Turkish Republic in 1923, the State Monopoly on tobacco was established and tobacco production and sales was nationalized by the government, therefore production and sales of tobacco was planned and implemented by the State Monopoly (TEKEL). Only domestic tobacco products were on sale in the country, and importation and sales of foreign tobacco products was not allowed. TEKEL provided tobacco products for the smokers, but did not make any effort to increase its use; i.e. did not make any advertisement of tobacco. The tobacco monopoly has been the only responsible body on tobacco production and sales, until 1980’s. In 1984 the law passed at the Parliament allowing importation of foreign cigarettes into the country, and then tobacco advertisements started. In 1987 Minister of Health invited some interested scientists to discuss the way to control tobacco use in the country. The first tobacco control law was drafted by the Ministry and adopted at the Parliament in 1991; but vetoed by the President. Same year another law passed from the Parliament to allow multinational tobacco companies to establish tobacco production factories in the country. As the result of these changes, tobacco use started to increase, more than the population increase (Table 1) [(][1][)]. The first large-scale survey in 1988 [(2][)] on tobacco use revealed that 63% of males and 24% of females smoke. Table 1. Cigarette sales, Turkey, 1925 - 2011 As reaction to these developments, a civil society organization was established in 1993; “National Coalition on Tobacco or Health, SSUK”. By this way an organized fight against the multinational tobacco companies started. In 1995 a large scale survey on tobacco use among role model groups revealed that 43% of physicians, almost 50% of teachers, 27% of members of the Parliament and 24% of religious leaders were smoking [(3][)]. At the same time, draft tobacco control law was in the agenda of the Parliament. SSUK worked closely with some of the “sensitive” MP’s, participated in the Parliamentary Commissions to discuss the draft tobacco control law, and visited Head of the Parliament, Parliamentary Groups of the political parties. At the end of these efforts, Tobacco Control Law was adopted by the Parliament in November 1996. The Law banned smoking at some of the indoor public places, i.e. heath and education facilities and public transport, banned all kinds of advertisement and promotion of tobacco products, banned selling of tobacco products to children, etc. After more than 10 years of implementation, the Law was amended in 2008, to cover all indoor public places, including restaurants, cafes and tea houses etc. as smoke-free. In the meantime, the WHO, FCTC was adopted and MPOWER policies were announced. At that time National Tobacco control Program and Action Plan was prepared; and several studies were performed to demonstrate the results of smoke-free implementation. Three kinds of studies were done [(4)]: · Indoor air quality measurements: PM2.5 levels at various indoor public places were measured before and after the implementation of smoke-free law, (in offices, shops, restaurants, etc.) and considerable decrease were observed (Figure 1). · Complaints of the workers at hospitality workplaces: Some symptoms (watering in eyes, stuffy nose, cough, etc) of the same workers at the restaurants and cafes were inquired before and after the implementation of the smoke-free law at the same places, and good reductions in the presence of symptoms were observed. · Health consequences of passive exposure to tobacco smoke: Admissions due to acute cardiovascular and/or respiratory conditions to the emergency medical services were evaluated before and after the implementation of smoke-free policies, and some reductions were observed, particularly among males. Figure 1. Indoor air quality of some indoor public places before and after the implementation of smoke-free policies In conclusion, implementation of comprehensive tobacco control measures help to improve indoor air quality; reduces the health complaints of the workers at hospitality workplaces and reduces the emergency admissions due to acute cardiovascular and respiratory conditions. Also smoking prevalence was reduced during the 20 years period between 1993 (before the introduction of first tobacco control law) and 2012 (5 years after the comprehensive tobacco control law). In addition to smoke-free policy, Turkey is implementing more than 80% of tax to tobacco products, bans all kinds of advertisement and promotion of tobacco products and sponsorship by tobacco industry, monitors tobacco use prevalence at 4 years intervals (Global Adult Tobacco Surveys in 2008 and 2012, and was planned in 2016) [(5][)], prohibits selling of tobacco products to children less than 18 years of age and provides free treatment for tobacco dependency. As a result, Turkey was declared as the single country in the world implementing all six MPOWER measures with great success, and was awarded by WHO. Political commitment of the government and active participation of civil society and the academia were the major keys to success [(6)]. References 1. Tobacco and Alcohol Market Regulatory Authority. 2. PIAR. Public Research on Smoking Habits and Campaign against Smoking in Turkey, Ministry of Health, 1988. 3. Bilir N, Güçiz B, Yıldız AN. Smoking Behaviors and Attitudes, Ankara, Hacettepe Public Health Foundation, International Development Research Centre, Ankara, 1997. 4. Expansion of Smoke-free Public Places and Workplaces, Evaluation of Impact of Tobacco Control Policies, Turkey; Project conducted by Society of Public Health Specialists, in collaboration of Ministry of Health, H. Özcebe, N. Bilir and D. Aslan, Ankara 2011. 5. Global Adult Tobacco Survey, Turkey Report, Ministry of Health, 2012. 6. Bilir, N, Özcebe H, Ergüder T and Mauer-Stender K., Tobacco Control in Turkey; Story of Commitment and Leadership, WHO Euro, 2012.
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