May
20
2023

Lung Cancer Screening Program

In 2013 the US Preventive Services Task Force recommended a yearly lung cancer screening program. The target population was age 55 to 80. Specifically, this program was to screen people who currently smoke, or had quit within the last 15 years and had a smoking history of 30 or more pack-years. Screening occurs with a special CT scan using low-dose radiation for lung screening. In the US Medicare and Medicaid reimburse residents for the cost of this procedure. The BCMA Journal describes the introduction of a similar lung cancer screening program in BC since May 2022. In the US the lung cancer mortality experienced a 20% drop since the introduction of the lung cancer screening program. This is because physicians now find lung cancer at stage 1 where treatment with surgery, radiotherapy or chemotherapy is much more effective.

Feasibility of a lung cancer screening program

Typically, with the conventional plain X-ray screening of symptomatic patients 40% of them, which radiologists diagnosed had lung cancer at a late stage, namely stage 4. At that stage the 5-year survival is less than 10%. However, now they diagnose patients with early lung cancer at stage 1 using a low-dose CT scanner with the lung cancer screening program. At this stage the 5-year survival rate is 73% to 90%. We know that the main lung cancer cause is cigarette smoking, the second cause is the aging process.

Lung cancer screening program free for patients

Similarly to the US the government sponsors the BC Lung Cancer Screening Program with no cost to the patient. With yearly checks the low-dose CT scanner detects early lung lesions that are highly suspicious of lung cancer. The screening program includes the higher age group and the ones who were heavier smokers. This is the highest lung cancer risk group, which benefits most from the lung cancer screening program.

What happens when the lung cancer screening program identifies early lung cancer?

With all the nodules that the CT scan screening finds, some have the features of suspicious nodules that require biopsy to check histologically whether or not there is lung cancer present.

Various methods to do lung biopsies

The simplest way for the physician to do this is by way of a bronchoscopy, where he inserts a needle into the nodule and retrieves a tissue sample. The pathologist analyzes this biopsy under the microscope. Not all suspicious nodules are within easy reach by bronchoscopy. If a lesion is located close to the lung surface the physician can do a needle biopsy through the skin (transcutaneous biopsy or transthoracic biopsy). Some patients require a biopsy using video-assisted thoracic surgery, which is performed under general anesthesia. Other patients require an open biopsy, which the chest surgeon performs under general anesthesia. In this case the chest surgeon opens the chest cavity and removes a piece of lung tissue, which the pathologist later analyzes for cancer.

Test to determine the extent of the lung cancer

The lung cancer stages are: stage I, II, IIIA, IIIB and IV. Following the initial X-ray, the physician will order an MRI or CT scan in order to determine whether the lung lesion was the only finding or whether there were metastases nearby. The MRI/CT scan can show whether or not there is involvement of the lymph glands in the chest or not. If there are lymph glands in the chest, a thoracic surgeon may be called in to do a mediastinoscopy, where the surgeon can look into the space between the lungs and the rib cage and assess the extent of the metastases in this otherwise difficult to assess space.

Distant metastases

The oncologist will want to continue to do the staging tests by doing CT scans of the liver, the adrenal glands and the brain to determine whether distant metastases are present. Blood tests and bone scans will rule out bone metastases. Finally, when all this information is gathered, the oncologist can do what is called an” extent of disease evaluation”. The following could be found for the various stages.

Extent of disease evaluation: Staging of lung cancer

Stage: 

I :  solitary lung tumor of less than 3 cm (=1 1/4″) in diameter

II :  tumor more than 3cm(= 1 1/4″) in diameter, local lymph gland metastases on the same side as the tumor

IIIA :  peripheral lung tumor: invaded the chest wall; central lung tumor: invaded distal mediastinal nodes on the same side

IIIB :  same as stage IIIA, but more extensive lymph gland invasion involving mediastinal organs and pleural cavity

IV :  Any of the above stages, but in addition distal metastases

Is it wasted time to do the staging procedure?

Why are oncologists “wasting time” to do the staging procedures? Studies over several decades have taught us that treatment of cancer without staging often gives everyone a false sense of security, where they learn later that the real extent of the cancer was much worse than originally thought. While everyone was thinking no further therapy was necessary, the cancer quietly multiplied and spread until it was too late to do anything about it. With the progress in the treatment of childhood leukemia oncologists learnt that long-term survival and cure rates could show significant improvement with adequate staging in the beginning and by following appropriate treatment protocols. In the last few years this has paid off for lung cancer as well.

Treatment of lung cancer

When the oncologist does an “extent of disease evaluation” he can discuss with the patient and the family what stage the lung cancer is in and what the chances of survival for the lung cancer are based on a vast amount of knowledge. There is a discussion of treatment options in detail and the oncologist can tailor the therapy to the needs of the patient. In principle, the approach to treat stage I and II is mainly by surgery to remove all cancer within the healthy surrounding tissue.

Surgical risk and treatment of stage III and IV

With an oncological or thoracic surgeon this kind of surgery has only a mortality of 1% to 8%. In younger patients this risk is lower, in patients above 75 years of age the risk is higher. With surgery higher survival rates are achievable (up to 80 % in stage I, up to 50% in stage II). Stage IIIA can be managed surgically, but stage IIIB needs another approach. Usually with this stage as well as with stage IV radiotherapy and combination chemotherapy is needed.

Lung Cancer Screening Program

Lung Cancer Screening Program

Conclusion

In the US a lung cancer screening program is in place since 2014. Since then, lung cancer mortality has dropped 20%. Also, in 80% of cases lung cancer is in stage I, the earliest form of lung cancer. In the past the majority of diagnosed lung cancer was in stage IV with a 5-year survival of only 5-10%. Now with the CT scan lung cancer screening program the 5-year survival is 73% to 90%. Treatment is mostly surgical for earlier-stage lung cancer (stage I, II and IIIA). For stage IIIB and stage IV a combination of surgery, radiation therapy and possibly chemotherapy is in use. The emphasis is on smoking cessation and yearly screening with a low-dose CT scanner.

Dec
14
2013

Pollution And Soaring Lung Cancer Rates

In early 1900 lung cancer was unheard of. This was before the cigarette industry started to mass-produce and market cigarettes.

However, ever since the arrival of the industrial revolution air quality has suffered. In China poor air quality has now reached such enormous values that the specialized cancer agency of the World Health Organization, the International Agency for Research on Cancer (IARC) has labeled poor air quality as one of the causes of lung cancer.

When you rank countries by average air pollution measurements, one sees that Europe, the US and South America overall have good ratings, whereas the Middle Eastern countries, China and India have poorer ratings.

However, when the pollution index of cities where the population is much denser than in the countries at large, are tabulated a much different picture emerges: Cities in Iran, India and Pakistan stand out as particularly bad followed by cities in China, Eastern Europe, Paris, London, Berlin, cities in California (the populous State), Chicago and New York.

Pollution does not stay local, but travels through the stratosphere around the globe. The result is that now 10 to 15% of lung cancer in the US occurs in patients who never smoked. This translates into 16,000 to 24,000 deaths annually of never-smokers in the US.

In certain cities such as Beijing the lung cancer rates have doubled in 9 years between 2002 and 2011. As this article shows lung cancer in never smokers can be caused from exposure to radon, to second-hand tobacco smoke, and other indoor air pollutants can also cause such cancers. But the outdoor air quality has been a problem ever since the industrial revolution, which started around Europe in the 1800’s and first part of the1900’s. In the latter half of the 1900’s much of the industrial wave has migrated to the Middle East, to India and China. But the air quality of the whole world has suffered as the jet stream and other air currents carry pollution in the stratosphere all around the globe.

Pollution And Soaring Lung Cancer Rates

Pollution And Soaring Lung Cancer Rates

History of pollution in various regions

1. In Germany’s  Ruhr district (“Ruhrgebiet”) in North Rhine-Westphalia, a highly populated industrial area, pollution reached a peak in the late 1950’s. From 1963 onward many of the coal mines, iron ore mines and other mineral mines closed down. 50 years ago the German Chancellor, Willy Brand was concerned about the environment and promised that blue skies would return to the Ruhr district again.  A special task force was initiated and maximally allowable limits were established for industries’ pollution emissions and enforced by the German government. Government and industry were co-operating in developing anti-pollution measures, which have cleared up a lot of the pollution since. With regard to car emissions lead free gasoline was introduced and carburetors ensured more complete burning of exhaust gases. This is now common and accepted anywhere except for diesel fume exhaust, which nobody wants to address despite proven carcinogenicity.

Now Germany is one of the leaders in green technology, which is also important for tourism.

2. England has its own legacy of pollution in soil and air from the industrial revolution. The soil of moorland, which soaked up acid rain for decades, is more acidy than lemon juice and it will take a long time despite industrial complexes having closed long time ago, before the soil quality will be returned to normal.

3. Hamilton in Ontario/Canada has had a longstanding pollution problem, which I witnessed from 1976 until my departure in 1978. It is well known that Stelco, the local steel plant downtown Hamilton is sending polluting emissions into the air. In 1976 a vising professor from Australia gave an interesting talk about a study that was done at that time regarding the risk of developing bronchogenic carcinoma (a synonym for lung cancer) in the immediate surroundings of the Stelco plant. He said that this was one of the first studies to show that the distance of people’s houses from the source of pollution mattered as that determined how concentrated the air pollution was (the closer the more polluted the air). This  affected cancer rates: they were much higher in the immediate surrounding of Stelco when compared to the average rate in the rest of Hamilton. This difference was very significant within a radius of 1 kilometer (= 0.62 miles) from the Stelco plant.

Just in May of 2013 the local cancer agency of Hamilton announced that the lung cancer rate in Hamilton was higher than elsewhere in Ontario because of a combination of poor air quality and of a higher percentage of people smoking. Then in August 2013 the city of Hamilton announced a new air pollution bylaw for stricter pollution measures to improve the air quality in the downtown area. It is just a pity that Hamiltonians had to wait until 2013 before the city approved an anti-pollution bylaw that could have been passed 50 years earlier like in Germany’s Ruhr district!

4. In 2008 Pittsburg, a former steel manufacturer town like Hamilton, Ont. outdid Los Angeles with regard to small particle air pollution.

Lung cancer prevention by the authorities

As mentioned before up o15% of lung cancer is caused by environmental exposure. So, we ourselves can only prevent 85% of lung cancer by not smoking and not exposing ourselves to industrial emissions or to smoke from incense. However, in many cities around the world you will get exposed to air pollutants that are well above the safe limits, so the risk of getting lung cancer from just breathing the air there can be much higher than in rural areas where there is no industry.

Technologies to control air pollution are widely available. We need to exert pressure on politicians to show leadership around the world. Government regulations to lower emission rates need to be put into place and inspectors need to ensure the rules and regulations are adhered to. Without reducing emissions of cancer producing gases and chemicals right at the source (open burning of cuttings in orchards or burning cut trees), cutting emissions of cars, planes, ships, diesel cars, locomotives, electric generator plants etc. the air quality will not improve. Despite some costs involved industry, governments and individuals have to work together to make clean air happen.

The residents of those countries that have low pollution values will not benefit, if pollution continues to occur in other parts of the world as it just travels in the stratosphere around the globe until it arrives right here at home! We need an international pollution police. Satellites can be used to monitor where pollution occurs and this can be followed up through the local regulatory bodies with penalties and remedial actions.

What can I do personally to prevent lung cancer?

1.The most obvious step is to quit smoking and ask smokers who come to your place to smoke outside (not in your home).

2.Consider moving away from the city, if the air quality is unacceptable to a place where there is low air pollution.

3.Vitamin D3 has been shown to prevent colorectal cancer, but as there are vitamin D receptors found on the surface of various cells in tissue around the body including the lungs, many researchers feel that this vitamin in higher doses (2000 IU to 5000 IU) has probably a wider applicability in preventing cancers, even lung cancer.

4.Cutting out sugar and adopting a Mediterranean type diet is a prudent thing to do; also cutting down your calories to the maintenance you need (mildly ketogenic diet). If you bought body composition scales, it would display what your daily calorie consumption is and you should not exceed this, or else you’ll gain weight. An aging man who is overweight will experience hormone changes as fat is being metabolized and the enzyme aromatase contained in fatty tissue will turn male hormones (testosterone, DHT, androstenedione) into estrogen. Estrogen (particularly estradiol) is a known carcinogen that has been proven to cause breast cancer in women and prostate cancer in men. However lung cancer is also being promoted in women by estrogen as discussed in this link. In men one needs to remember that lung cells have estrogen receptors and there is concern in aging men with higher estradiol levels that this can promote cell divisions in existing lung cancer. So, it is important to maintain a normal body mass index between 21 and 24 (well below 25.0 and well above 18.5, which are the official accepted limits). This way there is no problem with insulin resistance (too high an insulin level), and other metabolic substances (cytokines, growth hormone like factors and tumor necrosis factor-alpha from body fat) that are cancer promoting.

5. If testosterone deficiency is present, which is common in older men, testosterone will have to be replaced with bioidentical hormones. It is a myth that testosterone would cause prostate cancer. Testosterone in males is necessary to maintain a normal metabolism including the immune system, which then can fight lung cancer and any other cancers.

6. Exercise and reducing beef consumption are also often mentioned in terms of preventing lung cancer.

7. Here are several recommendations from the LifeExtension Foundation that I found very useful in terms of lung cancer prevention. This link shows that antioxidant vitamins such as vitamin C, alpha tocopherol, the minerals selenium and zinc are also helping to reduce the lung cancer rate. Drinking green tea has also been shown to be effective in a dose-response curve manner (more tea protecting more from lung cancer). Vitamin B12 and folate have been shown to reduce abnormal bronchial cell growth in smokers as shown by repeat bronchoscopy studies.

8. Those who have been smokers in the past and those who have been around heavy smokers for more than 10 years in the past should consider having a preventative bronchoscopy done by a lung specialist (also called respirologist or pulmonologists). This way any suspicious areas with precancerous lesions can be biopsied during the procedure and attended to.

Hopeful research for new lung cancer treatments

Lung cancer is a disease that is best prevented. Once a person gets lung cancer, the prognosis is still very poor. However, cancer researchers are getting close to newer treatments involving genetically modified T-cells (killer cells) as was recently achieved for leukemia. Similar research is going on regarding ovarian cancer, melanoma, lung cancer and pancreatic cancer.

More information about lung cancer: http://nethealthbook.com/cancer-overview/lung-cancer/

Conclusion

It is not acceptable to let pollution take its course , the way politicians around the globe have handled this in the past 6 decades with a few notable exceptions mentioned. We all suffer a higher risk of getting lung cancer, even if we have been life-long non-smokers. Right now up to 15% of lung cancer in most populations are of this type. However, in Beijing this number is already much higher. The technology is available; Germany has led the way in the Ruhr district in the 1960’s and beyond. In my opinion the G8 meetings should have this high on their agendas and send technological aid to all the regions that have higher than the average world pollution index under the mandate of a special UN commission. This should be supported by the major industrial players with the knowledge that they will prevent the death of millions of potential consumers down the road, which will on the long-term pay off the relatively minor investment of installing pollution controls, before lung cancer levels rise even more.

Last edited Nov. 7, 2014