Cancer Screening 101: CME for Providers

May 05, 2022

Hosted by Xavier Llor, MD, PhD

Presentations:

Maryam Lustberg, MD, MPH

Breast Cancer Screening

Gulden Menderes, MD

Cervical Cancer Screening and Prevention

Lynn Tanoue, MD

Lung Cancer Screening

Information

ID: 7803
To Cite: DCA Citation Guide

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00:00OK, we're going to get started that evening.
00:03Everyone and welcome to
00:05the cancer screening 101.
00:07It is an update on cancer screening.
00:09My name is Javier.
00:10You're an associate director for cancer
00:12screening and prevention at Yale
00:14Cancer Center and Medical Director
00:15of colorectal cancer screening.
00:17And tonight we'll discuss updates on breast,
00:20cervical, lung and colorectal
00:21cancer with an extraordinary group
00:23of panelists that we have with us
00:26tonight and we're lucky to have them.
00:28We have doctor Golden Menderes,
00:30director of minimally invasive.
00:32Technological surgery program who
00:34is going to give us the update
00:36on cervical cancer screening.
00:38Dr Lin Tenui,
00:39director of the lung Cancer screening
00:42program Doctor Miriam Glasper,
00:43director of the Center for Breast
00:45Cancer and Chief of Breast Medical
00:47Oncology and who will talk to us about
00:50the updates and the rest cancer screening.
00:52You can post your questions anytime
00:54on the Q&amp;A and we will try to address
00:57that them either directly in the chat
01:00or in the Q&amp;A or at the end of the session.
01:03So without further ado,
01:04here is Doctor Goldeman.
01:06There is to talk to us about an
01:08update on cervical cancer screening.
01:10Thank you very much.
01:12Hello everyone and thanks
01:13for having me tonight.
01:14It's my pleasure to present the
01:17update on cervical cancer screening.
01:19I can everyone see my first slide.
01:24Not yet. OK.
01:39It's time to try this again.
01:46Yes, can we see it now? Yeah, we are.
01:49Yeah, we're a little good, perfect,
01:51OK, so the talk tonight is going
01:55to be essentially about the
01:57epidemiology of cervical cancer,
01:59followed by risk factors and the
02:02significant role of HPV or human papilloma
02:06virus in causing cervical cancer,
02:08as well as the significant impact of.
02:12Screening guidelines and the guidelines
02:14based on agent risk Group stratification.
02:18So in 2020, cervical cancer accounted
02:22for an estimated over 600,000 new
02:26cases and over 300,000 that's worth
02:29worldwide and not not surprisingly,
02:31over 85% of cervical cancer cases.
02:36They were from resource limited countries.
02:39Cervical cancer was the second
02:41most common type of cancer.
02:42And the third most common causal
02:45cancer mortality when we look at the
02:47continents of Africa and Central America.
02:50Here we can see the cervical cancer
02:52was the leading cause of cancer
02:54related mortality among women.
02:56Here we can see in the US we have
02:58over 13,000 new cases with over
03:014000 deaths that we see every year.
03:04And this is what we do not want
03:06to see as providers.
03:08This is a huge mass air rising
03:11from the cervix year.
03:12As well as right here,
03:15we don't want to see these cases
03:17in the in the next couple decades.
03:20Hopefully as far as the risk factors that
03:23lead to cervical cancer is concerned,
03:27we have behavioral and sexual factors,
03:29including large number of sexual partners.
03:32One might have an early age
03:34at first intercourse.
03:36Also,
03:36smoking has been linked to increase
03:38the risk of specifically the
03:40squamous kind of cervical cancer.
03:43Not necessarily the second most
03:45common kind adenocarcinoma.
03:47We have history of sexually transmitted
03:50diseases and in communities with diet
03:52low in folate carotene and vitamin C.
03:55We tend to see more numbers.
03:59Among other risk factors,
04:01again comes multiparity and early age.
04:03At first intercourse.
04:05These all increase the likelihood
04:07of HPV exposure and lack of
04:09routine screening is the one that
04:11we're going to emphasize tonight.
04:14Immunosuppression is another risk factor
04:17for developing cervical cancer and.
04:20Infection and exposure to HPV is widal HPV.
04:28All also known as human papilloma
04:30virus is central to the development
04:32of cervical neoplasia or precancer,
04:34and it can be detected in over
04:3799% of cervical cancers.
04:4180% of the population are exposed to this
04:44virus by age 50 and among more than 40
04:48different genital HPV types identified.
04:51We have about 15 known to be oncogenic.
04:54It's a double stranded DNA virus and it it
04:57infects the epithelial cells in the skin and
05:00mucous membranes of vagina and and cervix.
05:06The oncogenic HPV infection
05:08of this transformation zone.
05:11Here we can see the columnar
05:13epithelium of the cervix bordering
05:14on the squamous epithelium.
05:16This is known as transformation
05:18zone is where the HPV virus
05:21starts the infection and then
05:23that would lead to precancerous
05:26changes and eventually to cancer.
05:29If there is no screening and no treatments.
05:33Here we can see at a more cellular
05:35level the changes that HPV causes,
05:38including the coil acidic cells.
05:40Here the Halo around the nuclei of the
05:43cells as well as the by nucleation.
05:47Our objectives with screening is,
05:49uh, essentially,
05:50to prevent morbidity and mortality
05:52from cervical cancer as well as
05:55preventing overzealous management of
05:57the precursor precursor lesions that
05:59will likely request or disappear when a
06:02patient has a competent immune system.
06:06The United States adopted Pap smear
06:09screening in about 1950s and by mid 1980s,
06:14cervical cancer incidence
06:15decreased by about 70%.
06:17Multiple observational studies continue
06:19to show the reduction in cervical
06:23cancer mortality after systematic
06:25follow up and and screening guidelines.
06:28What do we screen in day to
06:30day life when we see a patient,
06:32we place a speculum in the vagina
06:34and our goal is to inspect the
06:37entire regional mucosa as well as
06:40the ectocervix and endocervix.
06:42Here we can see a close up image of the
06:47upper vagina Cervicovaginal junction,
06:49which is important for cervical
06:51cancer screening purposes.
06:53The Ectocervix and the Endocervix,
06:56which is the glandular epithelium.
06:58So both the endocervix and the ectocervix
07:01is important for practical reasons.
07:04In terms of screening.
07:08In the United States,
07:10approximately 5050 million women undergo
07:12a pop smear or HPV testing each year,
07:16and all these women about 8%
07:18will have an abnormal result.
07:20And here this pyramid shows us the breakdown
07:23of pop test abnormalities by frequency.
07:27Screening can detect the precursor as well
07:29as the early stage for cervical cancer.
07:33That way we can prevent the development
07:36of invasive cervical cancer.
07:38When a patient is exposed to HPV,
07:41the healthy young women would like likely
07:44get rid of HPV in about 6 to 12 months.
07:49Sometimes when we cannot eliminate
07:51the HPV exposure and it persists,
07:55we have low grade cervical precancer changes
07:57known as Siri and one in about 24 months.
08:01Again a healthy immune
08:03system will clear the HPV.
08:06If the patient has risk factors as
08:08well as not a competent immune system,
08:12the low grade lesions might
08:14turn into CIN two or three,
08:16which is known as high
08:18grade precancer changes.
08:20And if there is no intervention
08:21in about 10 to 13 years,
08:23the high grade pre cancer cells will
08:25turn into invasive cervical cancer,
08:27so it is not a change from HPV exposure
08:29to cancer that occurs overnight,
08:32which gives us the opportunity
08:34as providers to intervene and
08:37eliminate cervical cancers.
08:39What happens when a patient
08:41has an abnormal screening test?
08:42One of many things can happen.
08:44The patient might need further
08:45testing with HPV.
08:46It the patient might need a repeat
08:49cytology called post scopy or even
08:52endometrial biopsy if the psychological
08:54normality arises from the endocervix
08:56which is the glandular epithelium,
08:58which is very much like the endometrium
09:01and that would require evaluation as well.
09:04Or some patients would be referred
09:05to Java and oncologists when there
09:07is high grade precancer changes
09:09the way that we perform.
09:10Oscopy is in the clinic.
09:12There is a microscope that is essentially
09:16helping the provider to magnify the
09:18image in the vagina and the upper cervix and,
09:21if need be,
09:23colposcopy directed biopsies can
09:25be taken for for biopsy purposes.
09:31If the patient has any high
09:33grade precancer changes,
09:34oftentimes we recommend patient
09:36to undergo colonization,
09:38which is simply a cone shaped
09:40biopsy of the cervix to eliminate
09:43underlying invasive cancers.
09:45The way that we performed conversation
09:47is usually with a cold knife.
09:48This kind of illustrates how
09:50those procedures are done.
09:52Another way of getting a larger
09:54biopsy than just a small cervical
09:57biopsy to eliminate underlying
10:00cervical cancer is leap,
10:01which stands for loop electrosurgical
10:04excision procedure.
10:05This is mostly used by primary obgyns,
10:09and it can easily be performed
10:10in the office setting.
10:16So how do we get patients
10:18have cervical cancer?
10:19In 2022 it has to be one of
10:22many failures that lead to it.
10:25Either the patient does
10:26not show up for screening,
10:27or as healthcare providers.
10:29We do not offer screening to women
10:32when they present for annual exams.
10:34The patient might not follow up
10:36on abnormal results when there
10:38is a colposcopy and a biopsy
10:40that shows pre cancer cells.
10:42Or the patient might not get
10:44appropriate treatment to eliminate
10:46the precancer cells and eventually,
10:48unfortunately,
10:48the patients get cervical cancer,
10:51which is our ultimate goal
10:52with screening to prevent this.
10:56So tonight we're gonna mainly
10:58focus on these updated guidelines,
11:00which originate from American Cancer Society
11:032020 update and USPSTF which stands for
11:07United States Preventive Services Task
11:10Force which was most recently updated
11:13in 2018 for purposes of screening,
11:17we should define what an average versus
11:19a high risk patient is for developing
11:22cervical cancer and our age patient
11:25for us would be who is asymptomatic.
11:27With a competent immune system and who
11:30has always had normal screening results
11:32in the past and most of the guidelines
11:35focus on average risk patients.
11:37Since this is what we most commonly
11:39handle high risk patients would be
11:42the ones who have immunosuppression
11:44for any reason who has HIV or who has
11:48been exposed to deaths in eurodesk
11:50used to be a anti emetic that that
11:53was used in pregnancy until 1970s.
11:57So most of these.
11:58Women are now in their 50s sixties and
12:00it's not it's not used anymore thankfully.
12:03So there is one less risk factor these days.
12:06As far as cervical cancer screening
12:08risk risk stratification is concerned.
12:10So the 2018 USPS TF essentially recommends
12:15that cervical cancer screening should
12:17begin at age 21 and no earlier than
12:2121 regardless of the age of sexual
12:25onset and the main reason for this is.
12:28The main concern that will be associated
12:32with adverse outcomes with follow-up of
12:34young reproductive age women when they
12:37have minor cytologic abnormalities.
12:40The risk in less than 21 years
12:42of age is about zero point,
12:451% for cervical cancer.
12:46For that reason, most guidelines,
12:49including USPSTF,
12:50do not recommend starting cervical
12:53cancer screening prior to age 21.
12:58As far as ages 21 to 29 group is concerned.
13:02We have one of two ways of screening these,
13:06uh, these young women.
13:08USPSTF recommends are cytology
13:10alone every three years.
13:12On the other hand,
13:14the most recent 2020 guidelines from
13:17American Cancer Society prefers HPV testing
13:21alone starting age 2125 as opposed to 21,
13:25and doing this screening every five years.
13:28But the important thing
13:30about HPV testing is 1.
13:31It's not available in all institutions
13:33in the US or in many parts of the world,
13:36and it only it can only be
13:39performed with the two FDA approved
13:42primary HPV testing methods,
13:44including the one from COBAS and on clarity.
13:47So it uses a bit limited at
13:49the time at the time.
13:50Being in the US there are countries like
13:53Australia and Netherlands and UK which
13:56which has these tests readily available.
13:59And they have been employing HPV
14:01testing as their preferred strategy.
14:05The rationale for uh,
14:07USPSTF recommending age 21 to initiate
14:11cervical screening is again the very
14:15low incidence of cervical cancer being
14:18zero point 1% and they favor cytology
14:21or Pap smear over HPV testing because of
14:25the higher rates of transient HPV infection,
14:28this thought process is that if
14:31we do HPV testing in young women,
14:34they are more likely to test.
14:35Positive when we are going to put
14:37them through unnecessary colposcopies.
14:39Cervical biopsies and colonization
14:41biopsies that would then impair
14:43their obstetric outcomes.
14:44And these guidelines from USPSTF.
14:47They don't account for HPV
14:50vaccination rate rate,
14:51so that's one of the shortcomings
14:54of these guidelines.
14:55When we look at American Cancer Society
14:59recommending age of onset for screening,
15:0225 is.
15:04They cite 0.8% cervical cancer
15:08rate prior to age 25 and.
15:12It it was deemed not to be cost effective to
15:15screen women prior to age 25 for that reason.
15:18However,
15:19they do prefer primary HPV testing
15:21due to higher specificity and the
15:24one plus from these guidelines
15:27over USPSTF is that they account
15:29for HPV vaccination rates.
15:31When we look at the age group 30 to 6465,
15:36this is going to be a big pool of
15:38patients and we have three options here.
15:40We can either do Co testing which
15:43is known as combination of cytology
15:45or pap smear plus HPV test and this
15:48can be done every five years and
15:50not any more frequent than that.
15:53The second option would be primary
15:55HPV testing every five years
15:57or cytology alone pop,
15:59smear alone every three years.
16:01So one of these three would be.
16:03Reasonable as far as both of
16:06these guidelines are concerned.
16:08The USPSTF does not prefer one
16:10or the one over the other.
16:12However,
16:13American Cancer Society favors
16:15primary HPV testing every five
16:18years for women aged 30 to 64.
16:22How about, uh, women over age 65?
16:27Eventually this age group we will decide
16:30to discontinue or continue screening
16:32based on the patient's prior results,
16:35life expectancy,
16:36and shared decision making.
16:39If the patients never have had any
16:42CI and two or high grade cervical
16:45precancer lesions and they have
16:47adequate negative screening,
16:49which is defined as three consecutive
16:52negative pups or two consecutive
16:55negative primary HPV testing or
16:57two consecutive negative call
16:59tests within the last 10 years.
17:01This is defined as adequate
17:03negative prior screening.
17:05These women can preferably
17:07discontinue cervical cancer.
17:09Screening in many European countries.
17:12UM, they do continue until late 75.
17:15Considering the improved life
17:17expectancy in the last couple decades.
17:20And most guidelines do not
17:23study this particular question,
17:25so I I do a shared decision making
17:28with the patients when it comes to
17:31stopping cervical cancer screening.
17:3265 is not a hard stop.
17:36If the patients had a total hysterectomy,
17:39meaning they are cervix and uterus had
17:41been removed and they never have had
17:44any high grade cervical precancer cells,
17:46we can stop screening even though
17:48the patient might be younger than 65.
17:50Most women who needs hysterectomies,
17:52they do need it for abnormal
17:54uterine bleeding, which is.
17:55Something they struggle with prior to age 50.
17:59So if we have a patient age 45 who is
18:02done with childbearing and underwent a
18:05hysterectomy with removal of their cervix
18:07and uterus and they never have had any
18:10CIN 2 or high grade pre cancers in the past,
18:15that patient can be.
18:17Can stop screening for cervical cancer
18:21when is not appropriate to stop at age 65.
18:25If a patient has had these
18:27high grade precancer cells,
18:28namely CIN 2-3 or adenocarcinoma in situ,
18:312 then routine screening should continue
18:34for an additional 20 years from the
18:36last high grade precancer lesion and
18:38that might well extend beyond age 65.
18:41These all everything we talked so far
18:44essentially relates to average risk
18:47patients when it comes to high risk patients,
18:50we talk about patients with HIV patients
18:53who have been exposed to death in utero,
18:56or have immunosuppression for any reason.
18:59For those patients,
19:00the guidelines are a little bit more
19:03strict and the recommendations are
19:06to do cytology or pop smear every
19:08three years annually.
19:09Three years in a row and if
19:11the results are normal.
19:13And we can space the screening out to every
19:16three years if we decide to do Co testing.
19:19Meaning we do a pop smear along with.
19:22HPV testing at as the baseline
19:25and both side topology and HPV
19:27result came back as negative.
19:29Then we can go ahead and screen
19:30these women every three years.
19:31Moving forward we do not stop at
19:33age 65 given the higher risk of HPV
19:36persistent and higher risk of high
19:38grade precancer lesions in these
19:40women we continue throughout lifetime
19:43and we do have a lower threshold
19:45to do colposcopies and biopsies
19:48when we look at future directions.
19:52One thing to consider is going to be the.
19:54Impact of HPV vaccination is the
19:58proportional vaccinated individuals
19:59increases the prevalence of high risk
20:02HPV types is expected to decrease and
20:05that will eventually reduce the positive
20:08predictive value for both cytology,
20:10pop,
20:11smear and primary HPV testing.
20:13So we have some ongoing randomized
20:15control trials to evaluate the
20:18performance of primary HPV testing versus
20:21cytology in vaccinated HPV vaccine.
20:24Get the month.
20:25The second thing to consider
20:27moving forward in the next decade
20:29is going to be probably we will.
20:31We will see a diminishing role
20:33of cytology and uptake in primary
20:36HPV testing is the countries such
20:39as Australia and Netherlands.
20:41They that has the lowest rate of cervical
20:44cancer have been employing for over 10 years.
20:46The other possible practical
20:49solution to improving the uptake
20:51in screening is self sampling.
20:54Then Shirley patients will start sampling
20:57themselves in in in in any setting
21:00and mail these to the providers for
21:03evaluation. However, at the time being
21:05this is not an FDA approved strategy,
21:08so I'm hoping that it will be enabling
21:11providers to improve the uptake in
21:15screening once FDA approves self sampling.
21:19Summary of guidelines.
21:21Essentially, 2012 was the previous.
21:25American Cancer Society guidelines.
21:27Before the 2020 and the
21:28age of onset for screening,
21:30then was 21 and age two stop,
21:33screening was 65 with pop
21:35tests every three years.
21:37As we look at the most recent
21:40guidelines we talked about 2018,
21:42USPSTF and 2020 American Cancer Society.
21:46There is not much changes to USPSTF
21:49guidelines which says we should
21:51start at age 21 and stop screening
21:54for cervical cancer at age 65 and
21:56for women less than 30 years of age,
21:59pop smear is preferred over HPV testing
22:02since there is such high prevalence
22:05of HPV exposure in the younger.
22:08Nations and that is most likely
22:09to resolve them,
22:10persist and over age 30 we
22:12can use one of three methods,
22:15namely pop test every three years,
22:17primary HPV testing every five years
22:20or Co testing that combines the
22:22pop with the HPV every five years.
22:25When we look at American Cancer Society,
22:29it's a little easier to remember,
22:30and I think this is going to be.
22:32Kind of more prevalent moving forward.
22:34Once we continue to understand the
22:37importance of HPV in causing all
22:39these precancerous and cancerous
22:41changes and the age to start screening
22:44for American Cancer Society is 25.
22:46They recommend stopping at age
22:4965 and primary HPV testing every
22:51five years is what is preferred.
22:54So cervical cancer is one kind of women
22:57cancer that we can definitely prevent
22:59now that we know that over 99.7% of
23:02these cases are caused by the HPV virus.
23:06So as we increase the awareness and
23:08increase the uptake of screening and
23:11HPV vaccination S GYN oncologists,
23:13we hope to eliminate this cancer
23:15in the next decade or two.
23:17And this is all I have.
23:19I'll see if I have any time for questions.
23:23Thank you very much.
23:24Document there is please the audience.
23:27If you can post any questions at
23:29the Q&amp;A tab for documentaries that
23:31be great and now we're going to
23:34move on to breast cancer screening
23:36with Doctor Lasberg Dr Jasper.
23:38Thank you very much for coming
23:39to talk to us about this tonight.
23:43Thank you so much. Can you hear me?
23:46Great thank you everyone for joining
23:48the I will talk today about practical
23:52applications of breast cancer screening with
23:56an overview of breast cancer risk factors,
24:00how to screen your average risk patients
24:02patients which will be the majority of
24:04your population as well as screening
24:06high risk patients and then wrapping
24:08up quickly with some discussion of
24:11modifiable lifestyle risk factors
24:13that applies to all risk patients.
24:17So female stocks remains the most the
24:22highest risk factor for breast cancer,
24:24as all of you know as well as advancing age,
24:27family history and prolonged estrogen
24:30exposure, which can be further
24:33subdivided into early age of manner.
24:35Arch, late age of menopause,
24:37late pregnancy and hormone
24:39replacement therapy.
24:40There are additional risk factors,
24:42including exposure to radiation.
24:45Abnormal breast.
24:46Biopsy, postmenopausal obesity,
24:48and excess alcohol use.
24:51We will also talk about breast
24:53density as a risk factor for breast
24:56cancer in in the subsequent slide.
25:00So that there are multiple models
25:03for assessing your patients
25:04risk of breast cancer,
25:06and it can sometimes be
25:08confusing which one to go with.
25:10The Gale model is the most common one
25:13and it's easily searchable and it's
25:16relatively easy to do where the risk
25:19factors that are included include age,
25:21age of first period,
25:23age of first live birth,
25:25number of first degree,
25:27relatives with breast cancer.
25:29And history of breast biopsy,
25:31as well as history of pre malignant changes
25:34such as atypical ductal hyperplasia,
25:37does not consider family history
25:39beyond first degree of relatives,
25:41and this is one of the
25:43limitations of this tool,
25:44and it does not take into account other
25:47cancers or any paternal relatives
25:50with cancer in the risk assessment.
25:53For this reason,
25:54it may not be the most useful in making
25:57recommendations for risk reduction.
25:59Particularly in individuals with
26:01hereditary genetic syndromes,
26:03but as I said,
26:05it's relatively easy to
26:07use and very accessible.
26:09And more comprehensive tool is
26:11the Tyra Kuzyk or the Ibis model
26:15and this is more extensive,
26:17still very easily accessible by
26:20quick search online and it includes
26:23some additional non genetic risk
26:26factors including height and weight.
26:29For BMI it includes amounts
26:33of family history.
26:36Cast of the RC one and two mutation has the
26:40risk of invasive breast cancer DCIS overtime.
26:44I'm here,
26:44rest and a lifetime rest and it tends to
26:48perform best in a high risk population,
26:50but tends to overestimate risks,
26:52particularly in those with HPR.
26:55The newer the newest version,
26:57version eight,
26:58also takes into account breast density,
27:01which I will highlight again why that is
27:04important in the in a few slides coming up.
27:06Another older model class.
27:10Include as many factors as the Tier 2
27:13SEC and it tends to underestimate risk
27:17and for this reason not as recommended,
27:20and it tends to be an older data
27:22set and whether it's applicable
27:24to current population.
27:26This is this is one of the
27:28concerns about this tool.
27:29So if you compare the three
27:31models that I've listed
27:33here, you can see that the the Klaus
27:35model is the most limited and the
27:37tire acoustic or the Ibis model
27:40takes into account the most factors.
27:42So if you're particularly worried
27:44about your patients risk,
27:46that is the model that we would recommend.
27:49So quick take home points on risk
27:51assessment in your busy practice.
27:53Pick one calculator that
27:55you feel comfortable using.
27:57Know which patients are average risk
27:59versus those who are high risk and those
28:02are over 20% lifetime risk of breast cancer.
28:04I will talk more about the high
28:07risk population coming up and
28:08if there's a question on risk.
28:10Whether you're worried that
28:11your patient is higher risk,
28:12you can absolutely refer them
28:14to a high risk genetics program,
28:16and for any patient with any type of.
28:19These factors it's also important to
28:22address modifiable risk factors such
28:24as obesity, exercise and alcohol.
28:27So moving on to screening average
28:30risk breast patients.
28:31Obviously the point of screening
28:33is to identify breast cancers at a
28:36much earlier stage so that there
28:38is a lower chance of metastasis.
28:42And to have a curable disease.
28:44So the guidelines don't always
28:46agree on the age.
28:48To start screening,
28:49you can see all the different
28:51ages that are listed here,
28:53with the USPSTF being the most
28:55conservative with a start age of 50.
28:58Although most recently they have added
29:00the clause that patients in their
29:0340s could be screened after informed
29:05discussion with their providers.
29:07American Cancer Society were
29:08recommend starting at 45 and the
29:11American College of Radiology.
29:13As one of the few other societies,
29:15including NCCN,
29:16recommends starting annually at age 40.
29:19I have the NCCN guidelines here for you.
29:23As you can see again,
29:24if your patient is under the
29:27age 40 with average risk.
29:29The recommendation is for breast awareness,
29:32not necessarily breast self exams and
29:35clinical encounters or clinical exams.
29:37Every one to three years.
29:39And an annual screening
29:41mammogram starting at age 40,
29:43with a preference for tomosynthesis
29:46or or 3D mammography,
29:48is available to the patient
29:49and in your practice.
29:51Patients with increased risk are listed here,
29:54and these.
29:54These include those who have a
29:57lifetime risk of greater than or
29:59equal to 20% thoracic radiation.
30:02Those with pre invasive lesions
30:06such as LCIADAH and a strong
30:10family history of genetic factors.
30:13Even though you may not be able to
30:16clearly identify their genetic risk.
30:18So for these average risk patients,
30:21it's important to.
30:22Our recommendation is to begin
30:24mammography at 8 between the
30:26ages of 40 to 45 annually.
30:28Which mammograms should you choose?
30:30I think the trend is moving
30:33towards offering tomosynthesis or
30:353D mammography to most patients.
30:37It has improved resolution,
30:40reduced recall rate,
30:42and it takes a little longer to interpret.
30:45But the radiologist really has a
30:47much clearer view of what it is.
30:49Going on in the breast issue a
30:51question that often comes up is is
30:53this much higher radiation dose when
30:55we use 3D mammography and the answer is,
30:58it's only a very slight increase
31:00in whole body radiation with 13D
31:04mammogram rate increased radiation dose
31:07corresponding to about two months of
31:11natural annual background radiation.
31:13What about increased breast density?
31:15So, so if your patient is noted in
31:18the report to have kids or geniously
31:21dense or extremely dense grass,
31:23then in this particular case
31:25absolutely using 3D mammography
31:27or tomosynthesis is important.
31:30It both increases cancer detection
31:33rate and reduces recall.
31:35As as many of you know,
31:37dense breast tissue can can be very
31:40hard to interpret on mammography,
31:42and it's also an independent risk
31:45factor for breast cancer with with
31:48extremely dense breast tissue.
31:50Increasing the the the the future
31:52risk of breast cancer 5 fold.
31:55There is a law in place that in 27 states,
31:58including Connecticut,
31:59that patients need to be notified of
32:02their breast density on their mammography,
32:04and as you can see in the pie
32:06graph on the bottom,
32:07approximately half of your patients
32:09will have either heterogeneously dense
32:12breast or extremely dense breast.
32:14And these are the categories
32:16and more clear detail for you.
32:18The two categories you need to be
32:20most concerned about is Level 3 M 4.
32:22Which will be written in the
32:24in the report as hydrogenous.
32:26They danced or extremely dance.
32:28And So what is the action plan for
32:30your patients with high breast density?
32:32I think absolutely incorporating
32:34tomosynthesis or 3D mammogram in
32:37their annual imaging for sure,
32:39and then discussing the pros and
32:42cons of supplemental imaging with an
32:44automated whole breast ultrasound.
32:46This supplemental imaging increases
32:49cancer detection rate to about three to
32:53four additional cases per 1000 cases screen,
32:56so it's a modest increase,
32:58and it's important for patients to to
33:00be aware that it's not a huge increase.
33:03However,
33:03it has some additional drawbacks in
33:06addition to some additional costs.
33:08Depending on insurance,
33:09it can be associated with
33:11increased recall rates and false
33:14positives and increased biopsies,
33:16particularly in less.
33:17Experience centers therefore what
33:18what we're not recommending is that
33:20every one of your dance breast tissue
33:23patients have a whole breast ultrasound,
33:25but it should be a dialogue
33:27and shared decision making.
33:29So take home points for average risk,
33:32offer breast imaging starting
33:33at age 40 to 45.
33:35It has you have less recall rates with 3D
33:38mammograms regardless of your breast density,
33:40but surely for those with
33:42high breast density,
33:43definitely do tomosynthesis and then
33:45discuss the pros and cons of supplemental
33:47imaging with automated full breast
33:49ultrasound to those with impressed breasts.
33:52Density moving on to
33:54screening high risk patients.
33:56These are patients with
33:57a strong family history,
33:58greater than or equal to 20%.
34:00Lifetime risk of breast cancer and
34:04the strongest recommendation is to
34:06incorporate breast MRI with contrast.
34:09It's not as useful without contrast
34:12as an adjunct to 3D mammography.
34:15So typically what we recommend is
34:19alternating the breast mammography with MRI.
34:22So some type of breast imaging
34:24is done every six months.
34:26And obviously the purpose is
34:28to identify internal cancers at
34:30a much earlier stage.
34:31As you can see in the pictures depicted,
34:33the MRI clearly has a much higher
34:36resolution and is able to detect things
34:39much more clearly than in mammogram.
34:41However, it does need expert breast
34:44radiology opinion, it can be.
34:46And said it can be uncomfortable for
34:48patients and it can lead to false positives,
34:51leading to sometimes unnecessary biopsies.
34:55You might ask, well,
34:56what if my patient is very high risk?
34:59Should I also add a third breast
35:02imaging modalities such as an ultrasound
35:04to the mammogram and the MRI?
35:06And the answer is clearly no
35:09based on the Eva trial,
35:11the MRI plus mammogram gave the best
35:14cancer yield and the addition of an
35:17ultrasound to these two modalities
35:19as a third imaging procedure
35:21did not add anything additional.
35:23If for whatever reason.
35:25The patient cannot tolerate an MRI.
35:27You can see that an MRI plus ultrasound
35:31can also give relatively good yield.
35:34So back to the NCCN guidelines
35:36for your patients with high risk.
35:38It's really important to to
35:40know first who's at risk.
35:42So this comes back to good family history.
35:45Doing using the risk calculators and
35:48then the age of screening is very
35:52much dependent on who the youngest
35:55family member with the positive
35:57family history was and we we recommend
36:00starting ten years prior to that
36:03initial youngest family member diagnosis.
36:06And this should.
36:07This should not start prior to age
36:1134 for MRI to similar start 10 years
36:14prior to the youngest family members,
36:18but not prior to age 25.
36:20And consider risk reducing strategies,
36:23including medications which I'll
36:25briefly touch on,
36:26as well as continuing to emphasize
36:29breast awareness so your patients report
36:31to you if you're if they're noticing changes.
36:34There are multiple reasons that a patient
36:36can be high risk apart from family history,
36:39and that includes thoracic radiation
36:42between the ages of 10 and 30 years old,
36:45and as you can see,
36:46same idea here,
36:48where imaging typically starts eight years
36:52after radiation but not prior to age 30,
36:55and that also applies to breast MRI imaging.
36:59These are the genetic alterations
37:02that are recognizable to most of you,
37:04and it's the high penetrance and
37:07moderate penetrance genes that are
37:10that have very firm guidelines about
37:12earlier and more extensive breast imaging.
37:16Whereas the genes listed on
37:18the right hand column,
37:19which have insufficient evidence,
37:21we don't have as clear and evidence in
37:24terms of making screening recommendations
37:27and for for for for those category.
37:30Patient really,
37:31the screening is a lot by family
37:33history and if this can be confusing,
37:36certainly a high risk breast
37:37clinic can help you with those
37:40decision making juncture so.
37:41But as you can see here,
37:43the highest risk genes are listed in
37:46the red box and just reemphasizing
37:48the need for alternating mammogram
37:51and MRI starting at an early age and
37:55certainly at risk reducing mastectomy
37:57can be discussed with this very high risk.
38:00Population with,
38:01with the caveat that none of these risk
38:05reducing surgeries have
38:07impacted overall survival,
38:09and so it's really about shared
38:11decision making about many patients
38:13can choose to follow the screening
38:15guidelines and do not necessarily have
38:17to have these risk reducing surgery.
38:19If that's not their wish.
38:22This table here summarizes who
38:25should undergo genetic testing,
38:26both those with a history of breast
38:29cancer as well as those who do not have
38:32a personal history of breast cancer
38:34but have a strong family history.
38:36I think if you search under NCCN
38:39genetics training guidelines,
38:40this would be the best way to to
38:43kind of decide who should be tested.
38:45So what do you do when you do find
38:47out that your patient is high risk?
38:49Certainly it does change their screening.
38:51Recommendation as we talked about
38:54there is an option of risk reducing
38:57chemoprevention with a number of drugs,
39:00with tamoxifen being available for
39:03premenopausal and postmenopausal women.
39:06Relaxed offen and exemestane and actually
39:08also have data in post menopausal women.
39:12Depending on the genetic risk
39:14factor and family history risk,
39:16reducing surgeries can also be considered
39:19and we always want to continue to
39:22target modifiable risk factors.
39:24So when should you refer a patient
39:27to to to high risk genetics clinic?
39:30Really,
39:30if you're not sure if they have
39:33very high risk of history such as
39:36prior chest wall radiation and
39:38known hereditary alteration,
39:40a strong family history,
39:42that's very confusing or finding
39:44of LCIS atypical ductal hyperplasia
39:47or other pre invasive risk lesions.
39:50If if if the risk model is estimating
39:52risk as greater than 20%.
39:54We are happy to help.
39:56So in your busy practices I know this
39:58can be a lot to take on sometimes
40:01and depending on your comfort level,
40:03we're happy to assist.
40:05So take home points for high risk patients.
40:08Annual mammogram alternating with
40:10an annual breast MRI,
40:12and there is some evidence that by
40:14staggering these two tests you're
40:17essentially offering your patient
40:19close observation through imaging
40:21every six months.
40:22Do not screen women with life
40:25expectancy less than 10 years,
40:27and generally all our screening
40:29data pretty much stops at age 75.
40:32However, I think beyond age 75.
40:35Depending on patient preference
40:37and life expectancy,
40:38I think individual decisions can be made.
40:41A wrap up in the next few minutes
40:43on the lifestyle factors and
40:45breast cancer risk reduction.
40:46I think we're all aware of multiple
40:50sets of data and studies showing that
40:54that diet levels can be profoundly
40:58important for cancer risk reduction,
41:01particularly with respect to breast cancer.
41:05And the data are actually
41:08strongest for physical activity.
41:09So as you can see in this plot,
41:12our activity level even in adolescence.
41:17They can can help determine our future
41:20risk of breast cancer and so so any
41:23even patients who are who are not active,
41:27inactive,
41:27and adolescence but become
41:29active later in life,
41:31have the option of reducing
41:32their future breast cancer risk.
41:34So this is something that.
41:36I think it's easy to say
41:38it's much harder to
41:39implement in our sedentary society,
41:42but it's something that that that should
41:45definitely be discussed for patient.
41:47So in terms of next steps,
41:49obviously I think following the
41:51guidelines in terms of risk
41:54assessment and imaging for sure.
41:57And then I think we also need to focus on
42:00system level support for weight management,
42:03physical activity and diet interventions,
42:05and particularly the high risk populations
42:09and continue to promote health education
42:12within the Community with awareness
42:14of the role of obesity, obesity,
42:17activity level and higher breast cancer risk,
42:21without, of course, shaming more patients.
42:23Because this is, this is these issues are.
42:27Very endemic in our culture currently
42:30and it's not any one patient's fault.
42:34However, if we can even make
42:36some steps toward modifying,
42:38if you have these factors,
42:39it can reduce their risk.
42:41I'm happy to take questions.
42:43I have my cell phone number up on the slide
42:46and I'm happy to get curbside questions.
42:49My email is also listed and
42:51I thank you for your time.
42:53Thank you.
42:55Thank you very much that the last Berg
42:57and you can go ahead also and post your
43:00questions to Q&amp;A or as actor last word,
43:02make herself available through
43:03her email and cell phone.
43:05She's not with us tonight so she's got
43:08some technical difficulties connecting,
43:10so we deeply appreciate the fact
43:11that you you made it happen.
43:13Regardless. Thanks a lot.
43:14We'll move on then to the lung cancer
43:17screening with Doctor Lynn Tanui.
43:19Thank you very much.
43:20Doctor tanui.
43:29OK, thanks everybody for being
43:30here to listen to these talks,
43:32I've actually learned a huge amount
43:35so that that's a hard act to follow.
43:37My name is Lynn Tanoe.
43:39I'm in the Department of Medicine
43:41at Yale School of Medicine,
43:42and I direct our lung
43:45screening and natural program.
43:48I don't have any disclosures.
43:51And tonight what I'd like to get
43:55across in this talk is that you
43:57are aware of the updated USPSTF
43:59recommendations for lung cancer screening.
44:01I think it's important to understand
44:03the evidence based is demonstrating
44:05the mortality benefit because that
44:07means that screening is successful
44:10and lung cancer screening has been
44:12a long time to come to this table
44:14and I hope that at the end of the
44:17next 20 minutes that you will be
44:19motivated to implement lung cancer
44:21screening in your clinical practices.
44:24So I'm going to give you a very
44:26high level lung cancer background.
44:28We'll talk about the USPSTF
44:30recommendations for lung cancer screening,
44:32which we just updated last year and
44:34I'm just going to talk about 3 studies
44:37that form the fundamental evidence
44:39based for lung cancer screening and then,
44:42with the little bit about benefits and risks.
44:46So in the United States,
44:48cancer is the leading cause of lung cancer.
44:51Is the leading cause of cancer
44:53death in both men and women in 2022,
44:56it's estimated that about 100 eighteen
44:59118,000 men and 119,000 women will
45:03be diagnosed with lung cancer,
45:04and this is the first year that
45:07this unfortunate imbalance exists
45:09that women now get lung cancer
45:12more frequently than men.
45:13I guess it will cause an estimated 69,000
45:16deaths in men and 61,000 deaths in women.
45:21That's 130,000 people dying
45:23of lung cancer this year.
45:25These are data from the American Cancer
45:27Society going back to 1930 when the
45:29state of first started being kept
45:31lung cancer deaths and men on the top
45:33are in this red line and on women
45:36in the bottom again in the red line,
45:38and you can see that lung cancer causes
45:40more deaths than all of these other,
45:41more most common tumors.
45:43Archie causes more deaths than breast,
45:46colorectal and prostate cancer combined.
45:50It is the second most common
45:53cancer in men and women.
45:55Again,
45:56first leading cause of cancer death and
45:59really the problem we face with lung
46:01cancer is that the five year survival
46:03is so low and so in last year the
46:07five year survival for lung cancer was 22%.
46:10That's actually a lot better
46:12than it was even ten years ago,
46:15which reflects advances in
46:17research and therapies.
46:19But you can see that that.
46:21I just survival really pales into
46:23comparison with what we have
46:25achieved for colorectal breast.
46:27And prostate cancers at three.
46:29Next most common cancers where five
46:32years of Bible has improved tremendously
46:35and for many of these cancers,
46:37we're talking about 10 and 20 years survival.
46:40And that is really what we need
46:42to achieve with lung cancer.
46:43But it's a big mountain to climb,
46:46and the reason 5 year survival
46:48is so poor in lung cancer is
46:50that we diagnose cancers late,
46:52and so if we look at this
46:53pie chart for lung cancer,
46:55nearly half are diagnosed at stage 4.
46:57Or when disease is already metastatic
47:01and only 23% at stage one.
47:04The earliest stage that we can find
47:07that cancer and when cure is possible.
47:10And when you look at five year
47:13survival for the stages 1234,
47:15you can see how steeply that falls off.
47:18We certainly need to do
47:19better with stage one,
47:20but when you have a four 4% five
47:23year survival for stage four
47:24and half of the patients are
47:26being diagnosed at that stage.
47:28You can see then why our five year
47:30survival rate overall is so low and the in.
47:33In contrast, breast cancer really
47:36demonstrates the opposite,
47:37where half of patients with breast
47:39cancer are diagnosed at stage
47:42one and only 6% at stage four.
47:44And when you look then at five year
47:46survival for each stage you can see
47:48why the breast cancer survival over
47:50five years is so high because most
47:52patients are really being diagnosed
47:54here and so we really need to do
47:56early detection for lung cancer.
47:58And for the past eight or nine
48:00years we have had that ability,
48:03but we've been underusing it.
48:06So in on the very last day of 2013,
48:10USPSTF made this landmark recommendation
48:13for annual screening for lung cancer
48:16with low dose CT in adults aged age
48:1850 to 80 years of a 30 pack year
48:21smoking history and currently smoke or
48:23have quit within the past 15 years.
48:26And that was the first time that
48:29USPSTF recommended any lung cancer
48:32screening in the United States.
48:35Decades has been spent looking at
48:37chest X ray as an intervention for
48:39lung cancer screening and the bottom
48:41line was all the Childs were negative,
48:43culminating really in the publication
48:45from the prostate, lung colon,
48:47and ovarian PLO screening trial.
48:50Looking at their 155,000 participants
48:53who've been followed for multiple years,
48:57they looked at chest X ray versus
48:59no screening,
49:00which was actually standard of
49:02care and it really doesn't matter
49:04whether you had a chest X ray.
49:05Or no chest X ray,
49:07because the curves for cumulative
49:09deaths superimpose and so chest X
49:12ray is not an effective screening
49:14tool because it does not increase,
49:17it does not decrease mortality with a
49:20decrease in mortality being the gold
49:23standard for successful screening.
49:25The USPSTF change in recommendation
49:28December 31st,
49:292013 really was based predominantly
49:31on the national lung screening trial,
49:34which is the first of the three studies.
49:36I would like you to see and LST
49:39enrolled 53,000 participants
49:41and followed them for six years.
49:45High risk for lung cancer for this
49:47study was identified was identified,
49:50identified as ages 55 to 74
49:53greater than or equal to 30.
49:55Pack years of smoking and currently
49:56smoking or quit within 15 years.
49:58And if that sounds familiar
49:59because I just said it.
50:00For USPSTF, it's because it's based on this.
50:05Patients were randomized to either annual
50:07screening with low dose CT or chest X ray.
50:10There were a total of three screens done
50:13over the span of three years once a year
50:16and the study was powered so that it could
50:18identify a 20% reduction in mortality
50:21from lung cancer which was felt to be.
50:25Kind of a threshold for successful screening.
50:29This study cost $250 million to do and and
50:34really involve so many patients because
50:37that was the power that was required to
50:40achieve potentially that mortality reduction
50:43and the data are here on the right.
50:45And what you can see is that in terms of
50:49the number of lung cancers identified,
50:51low dose CT identified more than chest
50:54radiography and that was significant.
50:56But more importantly, more.
50:59People who were enrolled in the intervention
51:02model CT arm had fewer lung cancer deaths.
51:05The study was actually stopped early
51:07because it was clear that this
51:10endpoint was going to be achieved.
51:12So what the actual mortality
51:14reduction could have been.
51:16We're never going to know because
51:17it was stopped when the 20% became
51:20inevitable to be achieved.
51:23The other important piece of information
51:25is that most of the cancers diagnosed
51:27in NLST were early.
51:29Age 63% were stage one and so the screening,
51:33in this case achieved what the intent was,
51:36which which was to diagnose cancers
51:39early when they could be cured
51:41and to decrease mortality,
51:43and this study had probably the shortest
51:45conclusion I've ever seen for it.
51:47New England Journal of Medicine
51:50Paper screening with low dose CT
51:53reduces mortality from lung cancer.
51:55This study was followed by a study
51:57in Europe called the Nelson study.
51:59This was done in the Netherlands
52:01and in Belgium.
52:02It was a smaller study but also a
52:05double blind randomized control trial.
52:07They had 16,000 participants,
52:09most of whom were men.
52:11They were ages 50 to 75,
52:13so included a a slightly younger
52:15population and less cigarette exposure.
52:18Greater than 15 cigarettes per day
52:20for 25 years, or 10 cigarettes a day.
52:23For more than 30 years.
52:24They were the heavy smokers and the
52:27medium smoking history was 38 Packers.
52:29They had to have been more
52:31approximately smoking,
52:32currently smoking or quit within 10 years
52:34and the Nelson study had the advantage
52:37over NLST of measuring the positive findings,
52:40which are lung nodules by volume as
52:42opposed to linear diameter and so they
52:45could actually calculate doubling time,
52:48which is a much more sensitive measure
52:50of growth than a than linear diameter.
52:53We do have actually the capability
52:55in our city.
52:55Scanners to do this,
52:57but it is very time intensive
52:59for the radiologist.
53:00This is probably the next iteration
53:03of screening down the road in
53:05the United States to incorporate
53:07natural volume measurement,
53:08but for the time being you are have
53:11no results will be reported back to
53:13you as linear diameters of noxious.
53:15These patients were randomized
53:17to low dose CT screening or
53:20nothing, but they did not
53:21do a chest X ray arm.
53:23There were four low dose CT done
53:25over the span of six years and
53:27the patients were followed for 10
53:30years so they're duration between
53:32screens was longer than analyst.
53:34The study was also positive,
53:36not stopped early and the data are here,
53:39and although the curves
53:40look different than NLST,
53:41what you can see is that there
53:43were more cancers diagnosed.
53:45That's good that was screened
53:47with low dose CT.
53:48Then in the control group.
53:49That didn't get any screening and
53:51there were fewer cancer deaths in the
53:54screening group compared to the control.
53:57So the cumulative rate ratio for death
54:00from lung cancer was .76 and that was
54:03statistically significant significance.
54:04So they actually had a 24% reduction
54:06in lung cancer mortality and there
54:09was a signal that this was actually
54:13stronger in women with the 34.
54:15Percent,
54:16I'm sorry this is 24 percent
54:1834% reduction in mortality,
54:19but there weren't enough women
54:21in this study unfortunately.
54:23To reach significant significance.
54:25Although this was a very interesting finding.
54:30Nelson also demonstrated again
54:32that there is a shift towards
54:34earlier stage when you screen,
54:36and so the Nelson intervention group
54:38with low dose CT is shown here in the
54:41blue bars and you can see that more
54:43than 50% of patients were diagnosed
54:46with cancer at early stage stage 1A and B.
54:49This is solitary nodule
54:51less than 3 centimeters,
54:53whereas only about 11% were
54:55diagnosed with stage four.
54:57And if you remember the pie chart,
54:58this is a dramatic change.
55:00From that distribution and what's
55:02really striking is that the bars in
55:04red and green are the control arm
55:06and green and their cancer registry,
55:09which is essentially another
55:10sort of control group,
55:12and you can see that half of
55:14patients are diagnosed at stage 4,
55:16which is again with that pie chart
55:17shows so when you look at the blue
55:19bars compared the red and green bars,
55:21you really see this move with
55:24screening towards detecting
55:26cancer at much earlier stage.
55:28And the last study is the
55:31Southern Community Cohort study.
55:32There are clearly many,
55:33many studies looking at screening,
55:35but this particular one was
55:37important because it really
55:38addressed health disparities in lung
55:41cancer and lung cancer screening.
55:42So, Doctor Aldrich,
55:44who's from Vanderbilt,
55:45did a prospective study of lung
55:47cancer screening and 12 Southern
55:49states in the in 2002 to 2009.
55:53They looked at everybody in
55:56a lot of community clinics.
55:59Predominantly convenient,
56:00not academic Medical Center
56:03clinics and they looked at 48,000
56:06African American and white current
56:08and former smokers is 40 to 79.
56:11Two thirds of the population
56:13was African American and 1/3 was
56:15white and what they what they saw
56:18was that 17% of African American
56:21smokers were eligible for screening
56:23compared to 31% of white smokers.
56:27And so there's this big
56:28discrepancy in who would.
56:29To be eligible of course,
56:31screening that was associated with race.
56:34They then looked at all of
56:36the cancers that occurred
56:37in this population over that time frame,
56:40and they came up with about
56:421300 new lung cancers and when
56:44they looked at those patients,
56:46what they found was that 32% of
56:49the African American patients
56:50who had gotten lung cancer were
56:52eligible for lung cancer screening.
56:54Based on the USPSTF criteria compared
56:57to 56% of white so many more.
57:01Whites were eligible for lung
57:03cancer screening than blacks,
57:05and really the lack of eligibility
57:08was primarily associated with lesser
57:10smoking among African Americans
57:12who got lung cancer with the median
57:15pack years of 26 compared to 48 in.
57:18In the white smoking patients who
57:20had gotten lung cancer and this
57:23really again brought out this
57:26observation that African Americans
57:27and women seem to get lung cancer.
57:31That's a lower smoking intensity
57:34exposure and also at younger age.
57:38So that aldriches group.
57:40Has recommended that the smoking
57:42pack here eligibility criteria for
57:45USPS screening be decreased to 20
57:48pack years to try to address this
57:51health disparity where fewer African
57:53Americans were being screened because
57:55they weren't eligible on the basis
57:58of the smoking intensity and if
58:00that were to be implemented that
58:02it would increase the percentage
58:04of African African American smokers
58:06who would be eligible for screening
58:08and they did this very interesting.
58:11Sensitivity study and I'm not going to
58:13go through everything on this graph,
58:15but what they looked at was in
58:18the population with the existing
58:20USPSTF guidelines,
58:22what is the sensitivity of screening
58:23to pick up a lung cancer and African
58:26American sensitivity is shown here in
58:29the solid orange line and whites in
58:31the dotted orange line and you can
58:34see that the sensitivity of screening
58:36was much much lower and so the question is,
58:40well, how can you?
58:42Bring that sensitivity more equitably
58:44to so the curves look more similarly,
58:48and they modeled out what would
58:49happen if you,
58:50if we had screened at 20 pack
58:52years as the threshold,
58:54and you can see that the the solid
58:57orange line and the dotted orange
58:59line still don't quite meet,
59:00but they become much closer,
59:02and there is no decrease in sensitivity
59:05in whites by making that change.
59:08And so on.
59:09The basis of that and actually many other
59:12cancer screening studies last March.
59:15So a year ago,
59:17USPSTF updated its recommendation
59:18for lung cancer screening to include
59:21adults now ages 50 to 80 years.
59:23So younger population with a 20 pack
59:26year smoking history along the lines
59:28of the recommendation of the group
59:30from Vanderbilt who are currently
59:32smoking or quit within the past 15 years.
59:35And this expansion of the USPSTF criteria.
59:39Now makes about 14 million Americans
59:42eligible for lung cancer screening.
59:45So.
59:48Both speakers so far have mentioned
59:50shared decision making and I think
59:52we incorporate that into all
59:54of our daily practices.
59:55Lung cancer screening does differ
59:58from other screening for cancers
01:00:00because it's actually mandatory
01:00:02that you do it to be for the test
01:00:04to be reimbursed by Medicare so
01:00:07that there must be documentation
01:00:09that is shared decision making
01:00:11session with the patient was
01:00:13actually actually occurred.
01:00:15The updated guidelines.
01:00:18Now do not make it necessary for that
01:00:21shared decision making to occur with.
01:00:23Position or PRN?
01:00:25A trained individual including a
01:00:27our end or some other healthcare
01:00:31providing person can now do that
01:00:33shared decision making our visit
01:00:35and it is very important because
01:00:38like all other cancer screenings,
01:00:40there are known benefits and
01:00:43potential harms that we're very
01:00:45clear in all of these studies.
01:00:47This is a CT scan that actually
01:00:50includes imaging of every part
01:00:52of the chest and upper abdomen,
01:00:54and that makes it different.
01:00:55Than other cancer screenings where it's
01:00:58really only the organ of interest that
01:01:01appears on whatever study is being done.
01:01:04There are a lot of false positive the false
01:01:07positive rate and NLST was actually 94%,
01:01:09so most of the nodules that are identified
01:01:12by screening are not going to be cancers,
01:01:14and so it is very important that the.
01:01:18American College of Radiology Lung
01:01:20Rads algorithm for natural evaluation
01:01:22is used because the intent of that is
01:01:25to minimize unnecessary evaluation of
01:01:27nodules that are not likely to harm,
01:01:30and it does provide this opportunity
01:01:31to talk to the patient about tobacco
01:01:34cessation and many people feel this
01:01:36is the teachable moment that when a
01:01:38patient is motivated to listen to you as
01:01:41the expert about lung cancer screening,
01:01:44that that may be the time when your 3
01:01:46minutes of smoking cessation counseling.
01:01:48He's most effective.
01:01:50So there are also lung cancer risk
01:01:53assessment models for patients
01:01:55who smoked or actually didn't
01:01:57smoke lung cancer screening.
01:01:59Those only offered by Medicare to
01:02:03patients with that pretty incentive.
01:02:05Smoking history.
01:02:05This is the prostate lung colon
01:02:08ovarian model that was developed in
01:02:112012 based on the PL fuel population.
01:02:14This is the website where you can
01:02:16get it really easy by Googling.
01:02:18PLCOM 2012, Brock University.
01:02:20The primary author for this model
01:02:22is that Brock University in Canada,
01:02:25and I think what this demonstrates is
01:02:27that there are a lot of risk factors
01:02:29for lung cancer besides smoking.
01:02:31Although smoking is the causative
01:02:33agent in probably 85 to 90% of
01:02:37of all comers with lung cancer,
01:02:39or at least a contributor.
01:02:41But many other factors create
01:02:44risk body mass index.
01:02:46Whether you have other lung disease.
01:02:48If you hadn't other cancer yourself,
01:02:52or that there's a family history
01:02:54of cancer and there's definitely
01:02:56influence based on race and ethnicity
01:03:00as well as smoking intensity and the
01:03:02nice thing about this calculator is
01:03:04it does give you a probability of
01:03:06lung cancer in the next six years.
01:03:08And so for this 73 year old patient
01:03:10who has these demographics?
01:03:12That lung cancer risk is about 5%
01:03:14and that actually turns out to be
01:03:17double the risk of NLST or Nelson,
01:03:19and so this patient would be
01:03:21considered very high risk even though
01:03:23that number may not look so high.
01:03:25So it's important to ground that in.
01:03:26Who is the high risk population
01:03:28for all those studies?
01:03:29And what did that mean?
01:03:31So the benefits of lung cancer
01:03:33screening I think are pretty obvious.
01:03:35Decreased lung cancer mortality,
01:03:37detection of lung cancer,
01:03:38early stage detection of
01:03:40disease when it's treatable,
01:03:42improvement in survival and quality of life,
01:03:44and providing that teachable
01:03:46moment for tobacco cessation.
01:03:48But there are also risks,
01:03:49predominantly related to
01:03:51the high false positive.
01:03:53Likelihood of finding a nodules
01:03:55that are not destined to harm,
01:03:57and those nodules can create unnecessary
01:04:00testing and procedures and economic,
01:04:02emotional and physical costs which
01:04:04hopefully can be minimized if
01:04:06we stick to the algorithm used.
01:04:08Meeting of Longreads given to us by PCR.
01:04:12There can be false negative results.
01:04:14We used to worry a lot more about the
01:04:17detection of indolent disease that
01:04:19would really not render any benefit
01:04:21and that is known as overdiagnosis.
01:04:23There is some radiation.
01:04:24Exposure related to having a
01:04:26test with radiation every year,
01:04:28but it really takes thousands and
01:04:3010s of thousands of examinations
01:04:32to generate enough harm that one
01:04:34person would get lung cancer or
01:04:37another cancer from their screening.
01:04:39And then I've already mentioned
01:04:40that this is a CT scan of more
01:04:43than one organ and so incidental
01:04:45findings are quite frequent.
01:04:47Speaking with patients in these and
01:04:49these shared decision making visits
01:04:51makes it clear what that there are
01:04:54actually individual patient level
01:04:56barriers to lung cancer screening
01:04:58related to stigma of fear of a test,
01:05:00and in particular this is often
01:05:02confused with a closed MRI and
01:05:04you can alleviate that.
01:05:06Patients are afraid of getting
01:05:07a cancer diagnosis so may avoid
01:05:10having the screen they're afraid of
01:05:12having surgery or radiation or more.
01:05:15You know, medical therapy.
01:05:17By screening,
01:05:18APRN recently had a patient telling her
01:05:20I can't afford to have lung cancer.
01:05:23I'm not sure I want this screen
01:05:25access and cost,
01:05:25and I think we all of these are common,
01:05:28perhaps to all screening interventions,
01:05:31but particularly too long.
01:05:34And then I I just want to encourage
01:05:36everybody on this call to think
01:05:38about lung cancer screening and talk
01:05:40to their patients because it is a
01:05:42relatively new screening program.
01:05:44We should have had this long
01:05:46ago because lung cancer kills so
01:05:49many patients every year.
01:05:51These are these are statistics across
01:05:53the states in the United States in 2020,
01:05:56and this is Connecticut and you can
01:05:59see that in 2020 in Connecticut,
01:06:017% of eligible patients underwent.
01:06:03Cell cancer screening which is really low.
01:06:07We really need to increase that
01:06:08number if we want to get to that.
01:06:10We can save 20 out of 100 lives from
01:06:12cancer and what's really ironic on
01:06:14this slide is the state of Kentucky,
01:06:17which has the highest smoking
01:06:18prevalence in the country and
01:06:20the highest lung cancer incidence
01:06:22actually is screening twice as
01:06:24many patients percentage wise as
01:06:26we are doing Connecticut,
01:06:28and the reason that this is actually
01:06:30really taken off and Kentucky is because
01:06:32of Community and state based efforts.
01:06:34To really get the word out and so
01:06:37there have been laws passing the
01:06:40Legislature support lung cancer
01:06:42screening and a lot of community
01:06:44advocacy groups that have to take in
01:06:46this on and so the take home points
01:06:48for tonight from this section is that
01:06:50remember lung cancer is the leading
01:06:52cause of cancer deaths in both men and
01:06:55women in this country in the world.
01:06:57It is the leading cause of cancer death.
01:06:591.6 million deaths last year,
01:07:02detection of disease at early stage.
01:07:04Improved survival and increases
01:07:06the chance of cure.
01:07:07There's a very strong evidence
01:07:09based demonstrating that screening
01:07:11for lung cancer with low dose CT
01:07:13decreases lung cancer mortality,
01:07:15so this will save lives.
01:07:17The 2021 updated recommendations
01:07:19expands the populations of all people,
01:07:23but particularly is geared towards
01:07:26resolving the health disparities
01:07:28that we see for African Americans
01:07:30and women who are now increasingly
01:07:32eligible for screening and 14 million.
01:07:35People are eligible in this country,
01:07:37but right now we're screening only
01:07:395 to 10% and so just to remind you,
01:07:42please screen your patient to
01:07:44meet the eligibility criteria.
01:07:4650 to 80 years old who have a 20 pack
01:07:48year smoking history and currently smoke
01:07:51or have quit within the past 15 years.
01:07:54Thanks very much for listening.
01:07:58Thank you very much, Doctor.
01:07:59Thank you for this wonderful review
01:08:01and hopefully hopefully we'll start
01:08:03getting more and more patients
01:08:05referred for lung cancer screening.
01:08:07As important as you've shown.
01:08:09Very good and we're gonna move
01:08:11on now to the last presentation.
01:08:13And that's on a colorectal cancer screening.
01:08:20And I have no conflicts
01:08:22of interest to disclose,
01:08:23so we're gonna reveal colorectal
01:08:26cancer incidence trends to The Tonight.
01:08:29We are going to be looking at screening
01:08:31with ALITIES and also we'll review
01:08:33the newest guidelines and starting
01:08:35screening at an earlier age that most
01:08:37of you are familiar with already.
01:08:40So colorectal cancer,
01:08:41still the third leading cancer,
01:08:44and both men and women and
01:08:46also the third leading.
01:08:48Cancer related deaths both in men and women,
01:08:51but the good news really,
01:08:52on colorectal cancer is
01:08:54what I'm showing here,
01:08:55which is these very nice steady
01:08:58decrease in both incidence and
01:09:01mortality since the mid 1980s,
01:09:03beginning 1990s of colorectal cancer.
01:09:06Again incidence and mortality,
01:09:08and a lot of it has to do with
01:09:11exactly what I'm showing here,
01:09:13which is this steady increase also in
01:09:16the utilization of colonoscopy as we.
01:09:18Been doing more colonoscopies,
01:09:20uh, we've seen that decrease
01:09:22in the incidence rate.
01:09:23Other factors have played also a role
01:09:26in that decrease in colorectal cancer,
01:09:28but certainly screening has played a very,
01:09:31very important role over the last few years.
01:09:34We've been hearing more and more
01:09:35about not starting with colonoscopy
01:09:39screening as the first screening option,
01:09:42but also other types of screening
01:09:47tests that recent.
01:09:49Studies have shown their their usefulness
01:09:52for colorectal cancer screening,
01:09:54so those include city colonography,
01:09:56but it also includes stool based studies
01:10:01that basically test for alterations,
01:10:03either blood or cold blood in the
01:10:06stool or some a cold blood plus DNA
01:10:10abnormalities related to malignant
01:10:12cells that at the end of the day would
01:10:16result in a positive test that would require.
01:10:19The follow up colonoscopy but the
01:10:22issue about this test is that really
01:10:25and that was very recognized in
01:10:28nineteen 2016 by USPSTF is that we
01:10:31really don't have a lot of data
01:10:35that compares head-to-head.
01:10:36Those different screening methods.
01:10:38We have very good studies showing
01:10:40efficacy of all the methods that
01:10:42I showed to you and the legitimacy
01:10:45of using these methods,
01:10:46but not much comparison between
01:10:48the the two different.
01:10:49Fans in in the also stated that
01:10:51all those single test performance
01:10:53is an important issue.
01:10:55The detection of colorectal
01:10:56cancer sensitivity of the test
01:10:58of our time is more important.
01:11:00How the test perform over time.
01:11:03So with that in mind,
01:11:05they try USPSTF.
01:11:07What they did is they commissioned what
01:11:10they called the cancer intervention and
01:11:13Surveillance Modeling network sysnet
01:11:15and that included three different.
01:11:18Analytical models have performed
01:11:20in different institutions to
01:11:22inform really recommendations for
01:11:25colorectal cancer screening.
01:11:26These are the three different
01:11:28groups and what they did is they
01:11:30use the they based the modeling on
01:11:32historical colorectal cancer incidence
01:11:34data from the pre screening area.
01:11:36So from 1975 to 1979 were really we
01:11:39could not see the effects of screening
01:11:41because colorectal cancer screening
01:11:43cannot be implemented at that time.
01:11:46So and the analysis would have to.
01:11:50Include benefits,
01:11:51harms and burden of colorectal
01:11:54cancer screening.
01:11:55That's what they really looked at,
01:11:57so this is some of the data that came
01:12:00out of that modeling commissioned
01:12:02by USPSTF here on the left side.
01:12:07You see all the different modalities
01:12:09of colorectal cancer screening.
01:12:10There's an added one which is the
01:12:13multi target stool DNA every year,
01:12:15which is not the recommended one.
01:12:17Recommended one is every three years.
01:12:18The other ones are.
01:12:20Standard of care recommendations,
01:12:22but they look that went to in that
01:12:24specific time frame and there were several
01:12:26things that we assessed in this one.
01:12:28I'm showing life years gained per
01:12:31thousand individual screen and what
01:12:33they saw is I'm showing here the the
01:12:36middle of the different of the different
01:12:40brackets when it comes to the estimates.
01:12:43According to the three models,
01:12:44so they life years gained per thousand
01:12:48colonoscopies actually using colonoscopies.
01:12:50Primary methods would be 270 will end
01:12:54the one with the lowest performance will
01:12:57be flexible sigmoidoscopy every five
01:12:59years with 221 at the end of the day.
01:13:02Though all the all the different screening
01:13:06modalities were within were yielding
01:13:09within the 18% range of the highest
01:13:12performer which would be colonoscopy here.
01:13:15So pretty good performance and
01:13:18as assessed per life years game.
01:13:21For 1000 screen individuals,
01:13:23and this is another one
01:13:25that's colorectal cancer.
01:13:26Deaths averted per thousand screen
01:13:29and they got 24 and the modeling for
01:13:32colonoscopy every 10 years versus the
01:13:34lowest performers which were flexible
01:13:36sigmoidoscopy every five years,
01:13:38and the multi target stool
01:13:40DNA every three years.
01:13:41But at the end of the day again,
01:13:43a difference of one to four,
01:13:45depending on which modeling you would use.
01:13:48One to four deaths of difference
01:13:50among the different screening.
01:13:51Questions per thousand screened individuals
01:13:53and they look also for complications.
01:13:57And here obviously the more aggressive test
01:14:00for screening is obviously colonoscopy,
01:14:03and that had the highest number of predicted
01:14:08complications with the lowest number
01:14:12being 9 for the multi targets to DNA test,
01:14:17so a difference overall from four
01:14:20to six complication difference.
01:14:21Among the different screening options per
01:14:24hundred per thousand screen individuals,
01:14:27finally they look at the burden of
01:14:29these and the burden here in this case,
01:14:31looking at how many colonoscopies it does
01:14:34require per thousand individual screen.
01:14:37So when they looked at colonoscopies
01:14:39needed when you are using colonoscopy
01:14:41every five every 10 years as
01:14:44your screening method of choice.
01:14:46That would be about four colonoscopies
01:14:48in a lifetime per individual.
01:14:51But, uh,
01:14:52if we look at the lowest,
01:14:54the one that required less colonoscopy,
01:14:56that will be when screening for
01:14:59with a feed test every year that
01:15:02will be close to 2000 colonoscopies
01:15:04per thousand individual screens.
01:15:06So that would mean that basically
01:15:08that would cut in half the number of
01:15:11colonoscopies needed per patient from
01:15:134 colonoscopies to two colonoscopies
01:15:15to that still a significant burden.
01:15:18Even using the these other pre screening.
01:15:21Test if if we choose to do so,
01:15:24but certainly it would definitely decrease
01:15:27the overall burden of for colonoscopy.
01:15:30So non colonoscopy strategies pretty
01:15:32much resulted in about half of the
01:15:36total colonoscopies performed.
01:15:37So based on all that,
01:15:39the USPSTF really departed from the
01:15:42prior iterations where really there was.
01:15:46There were sets of preferred tests
01:15:47and in this case it was colonoscopy.
01:15:49The preferred test to are
01:15:51no longer emphasizing that,
01:15:53and really emphasizing that the
01:15:55clinical decision should involve all
01:15:57the considerations that we're talking
01:15:59about in not only evidence alone
01:16:01and more options than that's there
01:16:04a good number of studies that show.
01:16:07And more options can result in
01:16:09better screening uptake.
01:16:11Some individuals may be more amenable
01:16:12to some of the options and others,
01:16:15and in some other cases availability of
01:16:18some tests, particularly colonoscopy,
01:16:20may not be as available,
01:16:23and therefore the stool based test,
01:16:26for instance,
01:16:27or city colonography could be
01:16:30more attractive.
01:16:31Choices,
01:16:32so individualized decision making to
01:16:34the specific patient or situation
01:16:36as well as local availability of
01:16:39testing options was really emphasized,
01:16:41so I think that goes also to doctor
01:16:44Tannous comment about the shared
01:16:46decision making where more and more
01:16:49with all the options that we have and
01:16:51none of them really being right and wrong,
01:16:53but really making sure that
01:16:58everything or every we.
01:17:01Look at all the different
01:17:04possibilities that can actually
01:17:06fit our individual patient.
01:17:08That's probably the what's going
01:17:09to give us the best chance for
01:17:11a high uptake of screening,
01:17:13and this is an important message that
01:17:15came out from those guidelines in 2016.
01:17:18They they stated the screening is
01:17:20a cascade of activities that must
01:17:23occur in concert cohesively and
01:17:25in an organized way for benefits
01:17:28to be realized from the point of
01:17:30the initial screening examination,
01:17:32including related interventions
01:17:33or services that are required
01:17:35for successful administration of
01:17:37the screening tests.
01:17:38Such as a bowel preparation for instance.
01:17:39Or sedation with endoscopy to the timely
01:17:42receipt of any necessary diagnostic.
01:17:44Follow up and treatment.
01:17:46So really we have to put
01:17:48it in this larger context.
01:17:49We can screen with colonoscopies,
01:17:52but beef patients are not well prepped.
01:17:54We are going to fail in in really
01:17:58detecting lesion so there's just
01:18:00anywhere using a stool based test
01:18:02if we don't have a proper way to
01:18:04really follow up and make sure
01:18:06that they happen in the either.
01:18:08Yearly or every three years for
01:18:10the multitarget stool DNA test.
01:18:12We are not going to be able to succeed.
01:18:14So whatever we do,
01:18:15it should be in an organized fashion to
01:18:18really maximize the benefit from it.
01:18:22So with all these where we stand
01:18:24with oral cancer screening in the
01:18:26US after all these years,
01:18:28screening rates have increases have
01:18:31slowed over the last few years and
01:18:33we still close to 1/3 of eligible
01:18:36individuals who are not up to date
01:18:39with screening and individual groups
01:18:42that are less than 50% up to date
01:18:46with screening would be individuals
01:18:47in the 50 to 54 years of age range.
01:18:50Hispanics,
01:18:50people with less than high school.
01:18:52Diploma or individuals
01:18:54with Medicaid or uninsured.
01:18:56So there's these groups of individuals
01:18:59were really screening is a dismal
01:19:01still has dismal numbers among all
01:19:04the non up-to-date group over a
01:19:06third are individuals age 50 to 54.
01:19:09So even though for many years we've been
01:19:12recommending to start screening at age 50,
01:19:14we still underperformed dramatically in
01:19:17that age, and there are a lot of reasons.
01:19:19Some of them is that lack time.
01:19:21That I'm stating here where.
01:19:23Need for screening to really finally happen.
01:19:27We do need to talk to patients for a
01:19:29while before they become convinced,
01:19:31but also they are.
01:19:33The other reason is that more
01:19:35as as the population is younger,
01:19:37they have less medical illnesses.
01:19:39They have less contact with
01:19:41the medical system.
01:19:42There are less opportunities for
01:19:44us to really talk to them about
01:19:46colorectal cancer screening,
01:19:48but also have of the,
01:19:49even though we said that Medicaid and
01:19:51uninsured have the lowest screening rates.
01:19:54Half of the.
01:19:56Individuals,
01:19:56private insurance,
01:19:58and a quarter of medical patients do
01:20:00are not up to date with screenings.
01:20:02Or certainly there's a lot of room.
01:20:04But anyways,
01:20:05we are much more effective screening
01:20:07the captive audience as we were
01:20:08talking about individuals we have.
01:20:13Context and then regular basis
01:20:15with our healthcare system,
01:20:16we really need to figure out a way
01:20:18to really reach out those those
01:20:20individuals who are not regularly
01:20:22seen by medical providers and who
01:20:23happen to be in this younger age.
01:20:25And I'll show you in a minute
01:20:27why that is so important.
01:20:29So without this.
01:20:32In in, in one of the facts that we
01:20:35really recognize over the last few years
01:20:38is that in spite of these wonderful.
01:20:42Data over the last 30 years or so
01:20:45on the steady decrease in incidence.
01:20:48Colorectal cancer in older than 50.
01:20:50We have seen this very steady increase
01:20:53in the incidence of the younger
01:20:56individuals in between 20 and 49 that's
01:20:59translated in an increase in annual
01:21:01increase of 1.8% from 2006 to 2015.
01:21:05Individuals that are younger than 55 really
01:21:09pretty significant increase particularly.
01:21:12So when comparing with the
01:21:14overall numbers in that,
01:21:16so I'm adults younger than 55,
01:21:19there's been a 51% increase in
01:21:22incidence of colorectal cancer from
01:21:2494 to 2014 and an 11% increase
01:21:28in mortality from 2005 to 2015.
01:21:30And if you look at here in
01:21:32this graph here we have years,
01:21:35year of birth, and if you look closely,
01:21:39basically almost all individuals.
01:21:42Uh, were born after eight after uh, 1960.
01:21:47In all age groups,
01:21:49we see an uptick in colorectal
01:21:52cancer incidence.
01:21:53So anyone basically who has
01:21:55been born after that after 1960,
01:21:58we've seen that increase in colorectal
01:22:00cancer incidence and the increase in
01:22:03the annual percentage change in the
01:22:05incidence rate for adults aged 40 to 49,
01:22:08which is a which has been on average 1.3%
01:22:10has been more than twice that of the adults.
01:22:13Age 50 to 54.
01:22:15So really dramatic increase in the
01:22:18younger side of the of these patients.
01:22:21This suggests that the risk for
01:22:23the younger cohort will continue
01:22:25to carry forward into the group age
01:22:2750 to 54 over the next few years.
01:22:29Therefore,
01:22:30the the effect will be really
01:22:32important and and what I'm really
01:22:34showing here is that truly what
01:22:37we call the age 45 is the new 50
01:22:40and and that clearly is been shown
01:22:43here where basically.
01:22:44Uh,
01:22:45what we've seen is that the incidence
01:22:48of a of the colorectal cancer at
01:22:51age 45 in 2015 has reached the same
01:22:55incidence that we had at age 15,
01:22:58nineteen, 93,
01:22:59which is about 30 per 100,000 individuals.
01:23:02And that's where we say 45 is the
01:23:05new 50 in colorectal cancer,
01:23:07because that's where we.
01:23:08That's where we are right now.
01:23:10And that's how backing away we've
01:23:13moved from that standpoint.
01:23:14Unfortunately,
01:23:15so adults born around 1990 have twice
01:23:18the risk of colorectal cancer and
01:23:20four times the risk of rectal cancer
01:23:23compared to adults born around 1950,
01:23:26so and so we can see that while in
01:23:311996.4% of colorectal cancers were
01:23:33among individuals younger than 50
01:23:35that in 2015 had doubled to 12.4%,
01:23:38so really significant increase,
01:23:40and I think that really,
01:23:42this like really shows a lot which is.
01:23:45Even though the numbers are much
01:23:47lower in this younger population,
01:23:49when you look at life years,
01:23:51life years lost due to this
01:23:55disease in the group of 45 to 49,
01:23:57that's about 10% of all life
01:23:58years lost due to this disease.
01:24:00And that compares to 13% for the 50 to 54.
01:24:03And this is really a strong.
01:24:07Argument to make a about
01:24:10decreasing screening at age to 45.
01:24:13So the with all these data,
01:24:15the ACS in 2018 that decided to
01:24:17reevaluate the optimal age to start
01:24:19screening for average risk population
01:24:21and basically what they did.
01:24:23Is that OK?
01:24:24Well, they look at the Commission.
01:24:27One of these modeling groups that
01:24:30actually USPSTF has been using and what
01:24:34they did is they analyzed outcomes.
01:24:37Not only under that assumption that
01:24:40that the of the prescreening years,
01:24:43but also the what they did is
01:24:45they incorporated the the recent
01:24:47cleared data incidence data,
01:24:49showing that increase in the
01:24:50young set colorectal cancer.
01:24:51And in that case,
01:24:52what they showed is that here
01:24:54we have the different methods.
01:24:55Colonoscopy, CT, Colonography,
01:24:57flex,
01:24:576 feet and others to test as
01:25:00starting either at 45 versus 50.
01:25:02What they saw is that moving to 45
01:25:05starting training range we would increase.
01:25:086.2% live years again with the cost
01:25:11of about 717% more colonoscopies,
01:25:13so they did conclude that modeling
01:25:16convincingly demonstrated that due to
01:25:18the rising incidence of colorectal
01:25:19cancer in younger individuals,
01:25:21screening all average risk persons
01:25:23between the ages of 45 and 75
01:25:26reduces mortality from colorectal
01:25:27cancer with an acceptable risk as
01:25:30measured by number of colonoscopies
01:25:32per life years gained,
01:25:33so the trend of increasing colorectal
01:25:36cancer incidents in in success.
01:25:38That successfully younger birth cohort
01:25:40suggests that these recommendations
01:25:42will really continue to be appropriate
01:25:44in the future and the benefit burden
01:25:47balance strongly favors changing to 45.
01:25:49After that,
01:25:50the USPSTF and that was published
01:25:52last year commissioned the
01:25:53same modeling groups again,
01:25:55and they did the same process
01:25:56that it did before in 2016,
01:25:59comparing age 50 versus 8 starting at age 45.
01:26:04And here we they look at
01:26:06additional live years game.
01:26:08And basically what they saw is that
01:26:10starting at 45 to 75 they would.
01:26:13We would increase about from 22 to 27.
01:26:16The number of additional life years gained
01:26:19per hundred per thousand individual screen.
01:26:22Here they looked at additional
01:26:23colorectal cancers,
01:26:24averted and starting at food at 45
01:26:28would result in three more additional
01:26:31colorectal cancers averted out of 1000
01:26:34individual screen would again with 17% more.
01:26:38Colonoscopies,
01:26:38so all these data.
01:26:40USPSTF came up with the same
01:26:42recommendation with it that the
01:26:44ACS came up with in 2018 which was
01:26:47starting screening for average
01:26:49average risk individuals at 45 instead
01:26:52of age 50 as it had been so far.
01:26:55So for the USPSTF in summary screening,
01:26:58average risk,
01:26:59asymptomatic adults age 50 to
01:27:0275 is of substantial benefit,
01:27:04and modeling suggests the benefits
01:27:06will also be substantial for age 45.
01:27:09The benefits of early detection and
01:27:11intervention for colorectal cancer
01:27:12screening seem to decline after age 75
01:27:15and decision to screen individuals from
01:27:1876 to 85 should really be individual
01:27:21and the individual one considering over
01:27:23our health prior screening history and
01:27:26benefiting after age 85 seems to be a very,
01:27:29very unlikely benefit given the
01:27:31potential for adverse events.
01:27:33So, with all these,
01:27:37group of us have tried to really.
01:27:39Incorporate all that type of information
01:27:42in a way that the providers in our
01:27:45system will have all the tools to
01:27:47really work on that decision making
01:27:49process shared with the patients
01:27:51and trying to really find the
01:27:52appropriate way to screen individuals.
01:27:54And that came out came life in
01:27:56the epic system wide at Yale,
01:27:58New Haven Health just yesterday.
01:28:01And that's the correct cancer screening
01:28:03pathway where we really go through the
01:28:07different recommendations when it comes for.
01:28:10Uh, when we should?
01:28:11We should not screen,
01:28:12but then after that it gives you the takes
01:28:16you into evaluating if the individual
01:28:18is high risk versus average risk.
01:28:21Here we have some examples where
01:28:24basically as you hover in all
01:28:27these blue text you'll see,
01:28:29for instance,
01:28:30this is hovering over stool based testing
01:28:32will be a benefits and risk for instance.
01:28:35Or actually you can have here
01:28:37opening up a table of sensitivity,
01:28:39specificity of all the different.
01:28:42Screening tests for both polyps and cancer,
01:28:46and it takes you down here helps you also
01:28:49analyze who is at high risk and therefore
01:28:52we would be suggesting colonoscopy
01:28:54versus non colonoscopy approaches
01:28:56and basically at the end of the day.
01:29:00Once you make that decision,
01:29:02it also allows you to really place
01:29:05the orders directly for colonoscopy,
01:29:07for City colonography and
01:29:08for a stool based test so it.
01:29:12Within the same path we were able to
01:29:13really go through the whole process,
01:29:15so we hope that these two
01:29:17will be really helpful,
01:29:18not only to increase screening grades,
01:29:20but also to help the providers to
01:29:22have those discussions with the right
01:29:25information and and making sure that
01:29:27that every patient does have the
01:29:30benefit of really being able to.
01:29:33Make a well informed decision about
01:29:36screening approaches and that is all
01:29:39I wanted to talk to you about tonight
01:29:43and I think we'll run out of time.
01:29:46So.
01:29:48We may not have time for answers,
01:29:51but anyone can feel free to email us
01:29:54and we'll be very happy to to address
01:29:58any questions from this session.
01:30:00Unfortunately, yeah, time will run out,
01:30:02but again,
01:30:02Richard was directly be very happy and,
01:30:05again, thanking tremendously doctors.
01:30:10There is a tanui and lasberg for being here,
01:30:14sharing their knowledge,
01:30:15and in such wonderful presentations
01:30:18it's been a pleasure to to share
01:30:20that time with them.
01:30:21Thank you all for being here tonight.
01:30:23Goodnight