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Clinical Tool Able to Distinguish Benign and Malignant Lesions on Lung Scans of Smokers

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Clinical Tool Able to Distinguish Benign and Malignant Lesions on Lung Scans of Smoker

A new study instigated and led by Terry Fox Research Institute(TFRI) has developed a new clinical risk calculator software that precisely  identifies (nine times out of ten), which lesions or spots are benign and which are malignant on an initial lung computed tomography (CT) scan among patients who are at great risk for lung cancer.

The study’s discoveries and results are expected to have an instant impact worldwide on healthcare professionals who diagnose and treat patients at risk for lung cancer, or who are already diagnosed with the disease. The study is also expected to provide new information on developing and enhancing lung cancer screening procedures.

The results, which have been published in the September issue of the New England Journal of Medicine (NEJM), will have ‘an immediate impact on clinical practice,’ said co-principal investigator, chair of BC's Provincial Lung Tumour Group at the BC Cancer Agency and a professor of medicine at the University of British Columbia, Dr. Stephen Lam.

"We already know that CT screening saves lives. Now, we have evidence that our model and risk calculator can accurately predict which abnormalities that show up on a first CT require further follow up, such as a repeat CT scan, a biopsy, or surgery, and which ones do not. This is extremely good news for everyone; from the people who are high risk for developing lung cancer to the radiologists, respirologists and thoracic surgeons who detect and treat it. Currently, there are no Canadian guidelines for us to use in clinical practice,” he said.

However, in countries where guidelines are in place, they are mostly based on lesion size. The pan-Canadian team's calculative model, developed by Brock University epidemiologist Dr. Martin Tammemägi, includes a risk calculator that takes several factors into account, along with size, namely: older age, female sex, family history of lung cancer, emphysema, location of the lesion in the upper lobe, part-solid nodule type, lower nodule count and spiculation (presence of sharp or needle-like points).

"Reducing the number of needless tests and increasing rapid, intensive diagnostic workups in individuals with high-risk nodules are major goals of the model," said Tammemägi.

The TFRI research team used current and former smokers (aged 50 to 70) as part of the study; coming to a total of 12,029 lung cancer lesions examined on CTs of 2,961 patients. One setting involved subjects in the TFRI Pan-Canadian Early Detection of Lung Cancer Study from 2008 to 2010, where 1,871 participants with a total of 7,008 lesions (102 which were classified as malignant) were screened and followed.

While another sitting involved 1,090 subjects with 5,021 lesions (42 which were classified as malignant) who participated in several lung cancer prevention trials carried out by the BC Cancer Agency during 2000-2010 and were funded through the U.S. National Cancer Institute (NCI). In the first study, subjects were followed on a median of three years; in the second, a median of eight-and-a-half years.

Lam mentions that the prediction model holds it own in circumstances and cases where physicians are posited by difficult challenges/decisions; for instance deciding what action to take when lesions are one centimeter (the approximate width of an adult thumbnail) or smaller. 

Moreover, while the size of the lesion can be one determinant of lung cancer, the biggest lesion that appeared on the CT was not necessarily cancerous in nature.

The team discovered that lesions located in the upper lobes of the lung were associated with a higher probability of cancer. In both studies, researchers discovered that where cancer exsited, fewer lesions were found. Therefore this model will abridge the work involved, particularly for radiologists, in evaluating and assessing lesions on scans, as well as respirologists and thoracic surgeons who must make decisions about tests and treatment for their patients.

"An accurate and practical model that can predict the probability that a lung nodule is malignant and that can be used to guide clinical decision making will reduce costs and the risk of morbidity and mortality in screening programs," wrote Lam and the study team in the article, titled: “Probability of Cancer in Pulmonary Nodules Detected on First Screening Computed Tomography."

"The findings in this study bolster the potential for the successful implementation of a lung cancer screening program using low-dose computed tomography (CT) within a high-risk population. This tool, combined with CT-screening, will increase our success in earlier detection, diagnosis and treatment of the disease. Further, this model combined with new guidelines for best clinical practice, will provide our health care system with both effective and affordable tools to implement such a program," said Nova Scotia thoracic surgeon and member of the study team, Dr. Michael Johnston.

"Many jurisdictions throughout the world are now considering whether or how to best implement lung cancer screening. Studies like this one are key to answering important questions so decisions are most likely to result in good practice and planning, and ultimately benefit patients," said vice-president, cancer control at the Canadian Partnership Against Cancer, Dr. Heather Bryant.

Such major discoveries come at a time when the U.S. National Lung Screening Trial (2011) that found a 20% reduction in lung cancer mortality with the use of low-dose thoracic computed tomography.

"This important work of Dr. Lam and colleagues is a major advance for clinicians performing lung cancer screening. They provide a tool to grapple with the problem of the high rate of positive low-dose computed tomography scans. Fewer follow-up scans with their attendant cost and fewer biopsies with their complications will need to be performed while continuing to diagnosis lung cancer at an early stage to lower mortality. Coupled with continued public health efforts to lower cigarette smoking, this work will have international impact on the leading cause of cancer death worldwide,” said co-principal investigator of the National Lung Screening Trial and former chief, Early Detection Research Group, division of cancer prevention, for the National Cancer Institute in the United States, Dr. Christine Berg.


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