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Daniel P Steinfort
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MA 14 - Diagnostic Radiology, Staging and Screening for Lung Cancer I (ID 672)
- Event: WCLC 2017
- Type: Mini Oral
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:H. Kondo, Hong Kwan Kim
- Coordinates: 10/17/2017, 15:45 - 17:30, F205 + F206 (Annex Hall)
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MA 14.09 - Impact of Lung Cancer Perceived Risk, Screening Eligibility and Worry on LDCT Screening Preference - Challenges for Engaging Patients at High Risk (ID 9669)
16:35 - 16:40 | Author(s): Daniel P Steinfort
- Abstract
- Presentation
Background:
Lung cancer screening is only effective at reducing lung cancer deaths when the highest risk individuals are screened and followed. An individual’s risk of lung cancer, and therefore their screening eligibility, has not been shown to correlate with their perceived risk or intention to participate in screening. While previous studies have suggested many at-risk individuals are supportive of screening, no validated risk perception questionnaire has been used to compare perceived risk and worry with screening preference between eligible and ineligible individuals.
Method:
Participants were current or former smokers aged 55 to 80 years old who presented for medical outpatient specialist appointments at three Australian hospitals. The survey included 1) demographics and previous cancer screening participation 2) objective lung cancer risk measured by PLCOm2012 lung cancer risk prediction model 3) perceived lung cancer risk and worry about lung cancer measured by the questionnaire developed by Park et al and validated in sub-set of National Lung Screening Trial (NLST) participants and 4) preference for screening measured by a five point Likert scale. Eligibility for screening was PLCOm2012 risk >1.5%. Ordinal logistic regression identified factors associated with screening preference.
Result:
760 people 55-80 years old participated, of which 306 were ever-smokers. The participation rate was 26.9%. 23 did not complete either sufficient smoking details for PLCOm2012 risk or screening preference leaving 283 responses. Mean±SD age was 66.3±6.5, 60.4% (171/283) were male, median (IQR) PLCOm2012 risk was 1.28% (0.44-3.11) and 45.6% (129/283) were eligible for screening. Overall screening preference was high; 72.1% (204/283) either agreed or strongly agreed to having screening if offered. Objective lung cancer risk (PLCOm2012) was weakly correlated with both perceived lung cancer risk (r=0.28, p<0.0001) and worry (r=0.21, p<0.001). In univariate analysis, worry (OR 1.37, 95% CI [1.18-1.60], p<0.001), perceived risk (OR 1.10, 95% CI[1.04-1.16], p=0.002) and PLCOm2012 risk (OR 1.06, 95% CI[1.01-1.12], p=0.02) were associated with higher screening preference, but not associated with higher screening eligibility (OR 1.50, 95%CI[0.97-2.30], p=0.06). Age, gender, smoking status, family history of lung cancer and previous screening practice were not associated with screening preference. Only worry remained significantly associated with screening preference (adj-OR 1.33, [95%CI 1.10-1.60], p=0.003) with multivariate analysis.
Conclusion:
Worry about lung cancer appears to be a more important driver for screening preference than eligibility status. This presents a unique challenge when trying to engage with eligible individuals while minimizing screening demand from the ineligible majority.
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MA 20 - Recent Advances in Pulmonology/Endoscopy (ID 685)
- Event: WCLC 2017
- Type: Mini Oral
- Track: Pulmonology/Endoscopy
- Presentations: 1
- Moderators:C. Lee, S. Sasada
- Coordinates: 10/18/2017, 14:30 - 16:15, F205 + F206 (Annex Hall)
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MA 20.09 - Accuracy & Utility of Systematic Mediastinal LN Staging via EBUS-TBNA in cN0/N1 NSCLC: Systematic Review & Meta-Analysis (ID 9154)
15:20 - 15:25 | Presenting Author(s): Daniel P Steinfort
- Abstract
- Presentation
Background:
Accurate mediastinal staging is crucial in potentially operable lung cancer to avoid non-therapeutic resection. Performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging of the radiologically normal mediastinum has been reported with inconsistent findings. We assessed the value of pre-operative systematic staging using EBUS-TBNA in cN0/N1 lung cancer.
Method:
For this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, Cochrane databases from inception to October 2016. We included studies evaluating EBUS-TBNA for systematic mediastinal staging in cN0/N1 lung cancer. For each study, we extracted data on participant age and sex, radiological stage, EBUS-TBNA protocol, number and size of lymph nodes sampled, EBUS-TBNA stage, reference standard stage, and 2x2 tables. We evaluated the diagnostic accuracy of EBUS-TBNA for detection of occult mediastinal metastases. PROSPERO registration number CRD42017057020
Result:
We identified 1,173 articles, of which nine (1,146 patients) were included in meta-analysis. Mean prevalence of N2/N3 disease was 15% (6-24%). EBUS-TBNA had a pooled sensitivity 49% (95%CI 41-57%) (see figure 1), pooled specificity 100% (95%CI 99-100%), and mean negative predictive value 91% (82-100%) for detection of unsuspected N2/N3 disease. Number Needed to Test to detect occult N2/N3 disease was 14 (95%CI 10.8-16.3), NNT was reduced to 7 for studies which added endoscopic ultrasound to EBUS-TBNA. Moderate inter-study heterogeneitywas observed (I[2] 40.6%). Figure 1
Conclusion:
Pre-operative systematic staging by EBUS-TBNA of early lung cancer can reduce rates of non-therapeutic resection and decrease incidence of post-operative upstaging. Sensitivity for detection of radiologically occult mediastinal metastases appears lower than for targeted sampling of pathologic lymph nodes. Verification of negative results by mediastinoscopy in selected cases remains of value.
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P1.14 - Radiotherapy (ID 700)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Radiotherapy
- Presentations: 1
- Moderators:
- Coordinates: 10/16/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P1.14-017 - Impact of Systematic EBUS-TBNA Mediastinal Staging on Radical Radiotherapy Planning in NSCLC (ID 8497)
09:30 - 09:30 | Author(s): Daniel P Steinfort
- Abstract
Background:
Radical radiotherapy often relies solely on radiological imaging to determine treatment volumes. Systematic mediastinal staging with endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) may identify PET-occult sites of mediastinal disease, or demonstrate benign causes for PET-positive LN. This study evaluated 1) Involved nodal coverage 2) Doses to organs-at-risk when planned based on PET-CT and EBUS-TBNA and 3) Incident dose to mediastinal nodes between 3D-CRT and Intensity-Modulated-Radiotherapy (IMRT).
Method:
Radical radiotherapy plans (60Gy/30 fractions) were created for patients with stage change following EBUS-TBNA from a prospective clinical trial. We compared lung Normal-Tissue-Complication-Probability (NTCP, pneumonitis), oesophageal and heart dose for planning to targets based on PET-CT versus PET-CT+EBUS-TBNA. The incidental dose to PET-negative/EBUS-TBNA-positive nodes from 3DCRT and IMRT was evaluated using volume receiving 35Gy as a surrogate for control of sub-clinical disease (Kepka, IJROBP, 73(5) 2009).
Result:
Of 30 patients enrolled, four were upstaged by EBUS-TBNA; these patients had a significant geographic miss of nodal GTV when planned to PET-positive nodes only (Figure 1). When planned based on PET-CT alone, the incidental dose to PET-negative/EBUS-TBNA-positive nodes was higher with IMRT for two patients (v35Gy increased by 17% & 6%; Figure 1a&b) and lower with IMRT (v35Gy reduced by 16% and 6%; Figure 1c&d) for two, dependent on nodal position relative to the primary. Six patients had negative pathology for PET avid nodal stations; Inclusion of EBUS-negative, PET-positive nodes resulted in an average increased lung NTCP of 5% (range 1%-13%), mean oesophagus dose of 13Gy (range 4-23Gy) and mean heart dose of 4Gy (range -0.1-11Gy) over plans based on EBUS-positive nodes alone. Figure 1
Conclusion:
Systematic EBUS-TBNA has the potential to improve loco-regional control and limit the probability of lung and heart toxicity. The incidental dose to adjacent tissue is inherently related to involved node/tumour position and not solely dictated by the radiation delivery technique.
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P2.13 - Radiology/Staging/Screening (ID 714)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:
- Coordinates: 10/17/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P2.13-023 - Lung Cancer Risk and Eligibility for Lung Cancer Screening in Patients Undergoing Computed Tomography Coronary Angiography (ID 10465)
09:30 - 09:30 | Presenting Author(s): Daniel P Steinfort
- Abstract
Background:
Computed Tomography Coronary Angiography (CTCA) is frequently performed for non-invasive coronary artery assessment. Extracardiac findings are frequent, with indeterminate pulmonary nodules the commonest incidental finding. Given the established efficacy of lung cancer screening with low dose CT (LDCT), CTCA has been suggested to be an opportunity for “opportunistic” lung cancer screening. This rationale has been used to justify full field of view imaging, despite limited field of view significantly reducing prevalence of nodules detected and therefore reduce downstream healthcare costs. Distribution of lung cancer risk of patients undergoing Cardiac CT has not previously been reported. We performed a cross-sectional survey to determine the proportion of patients undergoing CTCA who would be eligible for lung cancer screening, and to determine the lung cancer risk profile of eligible patients.
Method:
Patients attending two tertiary hospitals in Melbourne, Australia, for clinically indicated out-patient CT coronary angiography were screened for inclusion in the study. Patients eligible for Lung Cancer screening according to the US Preventive Services Task Force (USPSTF) recommendations were invited to complete a questionnaire including smoking history and demographic details, to determine 6-year lung cancer risk, according to the PLCO~m2012~ risk prediction model. A threshold PLCOm2012 risk at least 1.5% was used to identify a sub-group in whom LDCT screening is most likely to be cost-effective and reduce lung cancer mortality.
Result:
In a four month period, 216 patients (60% male) were screened prior to CTCA across both sites. Only 57 patients (26%) were potentially eligible for lung cancer screening according to USPSTF guidelines: 126 (58.3%) were never-smokers, with a further 33 patients (15.3%) outside the reccomended 55-80 years age range. Of 57 eligible patients, 48 (84%) consented to the questionnaire. Thirty-four were male (71%), with mean age 65.6+/-6.0 years. Median (IQR) PLCOm2012 risk was 1.30% (0.45–2.19%). Only 22 patients (45.8% of patients completing the questionnaire, estimated 12% of total cohort)had a PLCO~m2012~ risk score >1.5%, and just 18 of 48 (37.5% of patients completing the questionnaire) had a PLCOm2012 risk > 2.0%
Conclusion:
A majority of patients undergoing CTCA were never-smokers. Only 26% would be eligible for screening according to USPSTF criteria. Therefore routine use of Cardiac CT for “opportunistic” lung cancer screening is likely to result in net harm and is not appropriate A small proportion of patients undergoing CTCA have high risk for lung cancer and may benefit from full thoracic imaging at the time of CTCA
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P2.14 - Radiotherapy (ID 715)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Radiotherapy
- Presentations: 1
- Moderators:
- Coordinates: 10/17/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P2.14-001 - Mid-Treatment Perfusion PET/CT Is More Effective Than Ventilation PET/CT in Functionally-Adapted Radiotherapy for NSCLC (ID 8508)
09:30 - 09:30 | Author(s): Daniel P Steinfort
- Abstract
Background:
To assess the utility of four-dimensional (4D) ventilation/perfusion (V/Q) PET/CT lung imaging to facilitate mid-radiotherapy treatment adaption with volumetric modulated arc radiotherapy (VMAT).
Method:
In a prospective clinical trial, patients with non-small cell lung cancer (NSCLC) underwent [68]Ga-4D-V/Q PET/CT scanning before and during a six-week (60Gy) course of definitive chemoradiation. Functional lung volumes were delineated on both datasets as ‘highly perfused’ (HPLung) and ‘highly ventilated’ (HVLung), using a 70[th] centile SUV threshold. Three VMAT plans were created on the mid-treatment datatsets: optimised to anatomical lung, HPLung, and HVLung volumes, respectively. Functional dose volumetrics were assessed using the parameters of mean lung dose (MLD), and lung volume receiving 5, 20 or 30Gy, (V5, V20, and V30). Plan quality was assessed for consistency with respect to conformity indices, and doses to critical structures.
Result:
The study cohort consisted of 10 patients resulting in a total of 30 VMAT plans. PTV volumes reduced by a mean of 5.5% between scans. HVLung volume increased between scans by a median value of 39.2%. Subsequent volumetric and spatial changes were reflected in varying DICE similarity coefficients, or DSC (ranging from 0.336-0.923). HPLung decreased by a median value of 4.5% with spatial discrepancy represented by DSC of 0.568-0.805. Increase in ventilated function was most prevalent adjacent to the target, limiting the benefit of adaptive planning (Fig 1). Plan quality was consistent with the median PTV D95 ranging from 60.6-61.3Gy, and mean conformity index ranging from 1.23-1.25. Functional MLD of HPLung decreased by a mean of 7.3%, p=0.02. Plans optimised to HPLung resulted in a reduction of perfused lung V5 by a mean of 13.2%, p<0.01, with HVlung plans yielding a decrease in ventilated lung V5 of 9.6%, p=0.02. Fig 1 Figure 1
Conclusion:
To achieve reduced irradiation of functional lung, radiotherapy adaptation is more effectively facilitated by perfusion rather than ventilation imaging.
