The High-Risk Lung Assessment Program at Columbia University Medical Center
Every year, hundreds of thousands of people are diagnosed with lung cancer, mesothelioma, emphysema, or another serious lung disease.
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A new program at Columbia University Medical Center aims to turn the tide on both genetic and acquired lung diseases by helping people who are at high risk to get the care they need in the earliest stages of disease progression. New this year, the High-Risk Lung Assessment Program is directed by Joshua Sonett, MD, Chief, General Thoracic Surgery.
Many individuals have a family history of lung disease, or have been exposed to substances such as smoke, asbestos, or even dust from the World Trade Center. It is important that they receive screening for lung diseases, and that after initial screening, that any abnormalities are followed up appropriately.
Many people do receive an initial CT scan, either from their primary care physicians or at the hospital. Up to 50% of patients will have some abnormality on these screenings. In many cases, such abnormalities are harmless, according to Dr. Sonett. But it is critical that suspicious lesions be carefully assessed and closely monitored, so that those requiring intervention can be treated earlier than later. Although many centers treat cancer, not all institutions are experienced in screening and treating patients with non-cancerous conditions. For instance, alpha-1 antitrypsin deficiency is an important cause of chronic obstructive pulmonary disease. The genetics department at Columbia University has extensive experience in identifying individuals at risk for this and for other genetic diseases.
The High-Risk Lung Assessment Program uses an algorithm-driven approach to provide comprehensive, thorough care to two groups of people. The first group, the "worried well," includes those at risk for pulmonary disease due to family history or exposures. The program helps to define the risk each patient faces, and to try to mitigate risk factors by referring them to Columbia's Smoking Cessation Program, or conducting further screening through lung function tests or additional CT scans. This group of patients includes many New York firefighters who responded to the attack on 9/11, as well as people who have been exposed to chemicals, paint, or other toxic substances.
The second group targeted by the program includes people who have begun a screening protocol, or who have been found to have an abnormality on a CT scan. For these patients, the program uses the best available evidence to manage the results of screenings and provide comprehensive follow-up care.
The program's algorithm-based approach includes a series of steps to help determine the probability that a nodule may be malignant or benign. This assessment incorporates both patient characteristics and features of the lesion itself. Patient characteristics include age, smoking history, family history of lung cancer, and the presence of other diseases such as chronic obstructive pulmonary disease. Characteristics associated with the nodule include features such as calcification, size, and shape. Using the algorithm to assess both kinds of factors, the physicians derive the probability that a lesion may be malignant or not. Results fall into three categories, with abnormalities identified as high-, intermediate-, and low-risk for cancer. An example of a high-risk lesion would be a three cm, spiculated (unevenly edged) nodule in a 65-year-old smoker, whereas a one cm, smooth, calcified lesion in a 34-year-old non-smoker would be considered low-risk for cancer.
The determination of risk is then used to guide treatment decisions. For low-risk lesions, Dr. Sonett typically recommends follow-up imaging at algorithm-specified intervals. All imaging and follow-up appointments are coordinated by the program. If a lesion is highly likely to be cancerous, the program may recommend biopsy or removal of the lesion. In most cases, the program uses minimally invasive surgical methods. For those patients with lung cancer, the program uses endobronchial ultrasound, which provides sophisticated staging of the lesions. In addition, the program includes thoracic oncology evaluation for consideration of chemotherapy when appropriate.
For intermediate lesions, the team uses other tools to try to refine the probability of malignancy. One is to follow the lesion over time, because malignant nodules tend to grow, whereas benign ones do not. Sequential CT scans at three-month intervals may be recommended to monitor for signs of change. Another strategy is to use PET/CT scanning to determine whether a nodule may be metabolically active, because malignant lesions tend to be metabolically active while benign nodules do not. It is important for patients to understand that even PET/CT, which detects metabolic activity in the body, is not 100% accurate, and it is possible to have false positives and false negatives due to several factors.
The program's systematic approach to assessing risk and to providing follow-up care helps both patients and their physicians, says Dr. Sonett. Furthermore, by marshalling NewYork-Presbyterian/ Columbia University Medical Center's extensive resources, it facilitates rapid referral to other experts when needed, including the lung failure team, the Interstitial Lung Disease Program, and others.
SCREENING FOR LUNG CANCER: WHAT THE RESEARCH SAYS
The story of screening for lung cancer is complicated. Early detection of cancers is clearly important to patients' survival. But if a nodule is detected, the course of monitoring and treatment is often not straightforward. Not all cancers grow aggressively and today's tests are not able to reliably distinguish non-invasive from aggressive lung cancers.
Many researchers are now working to develop tools to differentiate the types of nodules; at Columbia, we are working to develop molecular tests to distinguish aggressive from noninvasive cancers. With funding from the National Institutes of Health, our team performs translational research studies to identify the mechanisms and biomarkers associated with the progression of lung cancer. The research team includes experts in cancer biology research, pathology, thoracic oncology, thoracic surgery, pulmonary medicine, and radiology.
In the meantime, physicians must rely on the data that is available to guide their screening and treatment decisions. Three large trials in the 1970s concluded that intensive X-ray screening for lung cancer detected more cancers than were found in patients who were not screened intensively, but that there was no difference in mortality rates between the two groups after five years. This apparent contradiction might be explained by the theory that the screenings preferentially detected cancers that were slow-growing and less likely to cause death in patients than more aggressive forms of cancers that grow faster.
Some recent studies suggest that CT screening does improve survival outcomes, while others conclude the opposite. To determine the answer to this critical question, a large trial funded by the National Cancer Institute, currently in its fourth year, is studying over 50,000 smokers. Half will receive screenings by CT scan, and the other half by X-ray (based on the 1970s trials, X-ray screening is considered equal to no screening, or the negative control group).