Archive for the ‘Lung Cancer’ Category

Making Sense of the USPSTF Recommendations on Lung Cancer Screening

Posted on January 1st, 2014 in Lung Cancer | No Comments »

On December 30th , via a publication in the Annals of Internal Medicine found here, the United States Preventive Services Task Force (USPSTF) announced they recommend annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55-80 years who have a 30 pack-year smoking history (the number of years smoking x number of packs per day, for example 2 pack/day smoking habit for 15 years equals 30 pack-years, or 1 pack/day smoking habit for 30 years also equals 30 pack-years) and currently smoke or have quit within the past 15 years.  The USPSTF also recommended that screening should discontinue once a person has stopped smoking for 15 or more years, or has developed a medical condition that would preclude curative surgery if a lung cancer was to be found.

These ground breaking recommendations are a follow-up to the USPSTF recommendations released July 29th, 2013.  Since their July 29th announcement, the USPSTF reviewed multiple data including US and European randomized clinical trials, and employed population modeling studies commissioned from the Cancer Intervention and Surveillance Modeling Network (CISNET).  The USPSTF’s support of lung cancer screening by LDCT is a departure from their last report in 2004, where they found no evidence in support of lung cancer screening by LDCT or chest x-ray or sputum analysis.

So what is the USPSTF?  The USPSTF is an “independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.” ( Agency for Healthcare Research Quality).  The USPSTF offers graded recommendations from A (high certainty that the net benefit [of an intervention] is beneficial) to D (recommendation against [the intervention]).  There is an alternative grade called “I” or insufficient evidence.  The USPSTF provides a grade “B” recommendation for lung cancer screening with LDCT; randomized clinical trials looking at LDCT for lung cancer screening provides “moderate certainty” of the benefit to a high-risk population.

So why are the USPSTF recommendations on lung cancer screening important?  Currently very few insurance plans, including Medicare or Medicaid, cover the costs of lung cancer screening.  Most asymptomatic patients who fit the high risk group defined above must pay out of pocket expenses if they want a LDCT specifically for the purposes of lung cancer screening.  Lesser et al demonstrated (Lesser et al, Ann Fam Med. 2011) that from 2007 to 2009 the USPSTF recommended 15 preventative interventions for adults aged 65 years and older.  Medicare partially covered 93% of the recommended services.  In the same time frame, USPSTF recommended against 16 preventive services, and Medicare partially covered only 44% of those services.  So although the USPSTF recommendations, per their own disclaimer, “are independent of the US Government”, the Centers for Medicare and Medicaid Services (CMS) take their recommendations seriously when determining clinical services coverage.

What information is the USPSTF using for their recommendations?  Although the USPSTF reviewed multiple studies and randomized clinical trials, the largest study they looked at is the National Lung Screening Trial (NLST).  The NLST was a US, academic, multi-hospital randomized clinical trial comparing chest X-ray to LDCT for screening in patients considered high risk (aged 55-74, 30 pack-year smoking history, current smoker or quit within 15 years at point of eligibility).  Patients underwent three annual screening exams.  The results demonstrated that LDCT reduced death from lung cancer by 20% compared to chest X-ray, and overall death from all causes by 6.7% compared to chest X-ray.  70% of the lungs cancers found by LDCT were stage I or II, or the earliest most curable stage.

Why is lung cancer screening important?  Currently 75% of patients who are diagnosed with lung cancer are diagnosed at stage III or IV, or locally advanced or metastatic stages.  Although there have been improvements in targeted molecular therapy as illustrated here, long term survival for patients with advanced stage lung cancer is difficult.  As mentioned above, 70% of the lung cancers found by screening LDCT were early stage tumors, where 5 year survival is 75-80%.  This is an incredible “stage-shift” which will have marked benefits on society.

What else did the USPSTF say?  The USPSTF highly recommended that smoking cessation be incorporated into any screening program.  This brings up the important point; any lung cancer screening program should be a comprehensive screening program.  What does that mean?  It means that a patient should enter the appointment with a referral from a primary-care provider.  This allows for communication of results, and continuity of care.  All active smokers should undergo smoking cessation counseling.  Patients with abnormal lung findings should have the opportunity to receive counseling and guidance form a lung cancer screening program clinician.  In addition the screening program should be multidisciplinary, and have frequent continuous quality improvement meetings to oversee the efficacy and results of the program.  Our UC Davis Comprehensive Lung Cancer Screening Program fits theses criteria, and is comprehensive in its design and implementation.

Is there any controversy to the USPSTF recommendations?  Not controversy, but the USPSTF recommendations focus on a group that is defined as high risk (aged 55-80, 30 pack-year smoking history, current smoker or quit within 15 years), but what about patients that do not fit the smoking criteria but are also at risk for lung cancer?  Those patients include, but not limited to those individuals who have been exposed to asbestos, have COPD, high levels of radon exposure, history of interstitial lung disease and a family history of lung cancer.  The National Comprehensive Cancer Network recommends LDCT screening in patients who are aged 50-74, 20 pack-year smoking history and have one additional risk factor.  Risk factors include the following:  personal lung cancer history (>5 years), family history of lung cancer (first degree relative), chronic lung disease, and carcinogen exposure (excluding second hand smoke exposure).  We have also incorporated the NCCN guidelines into our UC Davis Comprehensive Lung Cancer Screening Program.

How can I learn more about lung cancer screening LDCT?  There are a number of patient-centered resources.  The National Cancer Institute has a NLST Patient and Physician Guide.  The American Lung Association offers an online patient-centered tool found here, that helps patients determine if they are candidates for LDCT lung cancer screening.  A great social media community is #LCSM, which regularly has Twitter chats that discuss lung cancer issues, and has an associated blog.  Finally our representatives from our UC Davis Comprehensive Lung Cancer Screening Program are available to answer questions at 916-734-0655.




Transparency of Value in the Care of Patients Undergoing Lung Cancer and Esophageal Cancer Surgery

Posted on October 6th, 2013 in Esophageal Cancer, General, Lung Cancer | No Comments »

Medicine is evolving where the focus expands to not just state of the art technology and procedures to care for our patients, but also what value can medicine provide to patients.  That value is defined by not just the overarching goals of therapy, i.e. cure of cancer, resolution of infection, amelioration of pain, but also by the effects on quality of life, function after surgery, and most importantly, what immediate outcomes are important to patients and their families.

For a potential patient and their family, transparency in provider outcomes is key.  The patient-centered outcomes of the UC Davis General Thoracic Surgery Program are tracked by several quality databases and evaluation organizations including the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database and the LeapFrog Group.  These bodies compare medical institutions outcomes to national benchmarks and determine how individual institutions rank.  For example, in the case of ACS NSQIP, comparisons determine if an institution’s results in eight measured outcomes are in line with its national peers (As Expected), underperform its peers (Needs Improvement) or out perform its peers (Exemplary).

Below are our UC Davis Thoracic Surgery Program Outcomes as measured by the most recent national quality assurance measures:


Mortality Exemplary
Pneumonia Exemplary
Ventilator > 48 hours Exemplary
Morbidity As Expected
Unplanned Intubation As Expected
Deep Venous Thrombosis As Expected
Urinary Tract Infection As Expected
Return to the Operating Room As Expected


Where Mortality is the rate of surviving the hospital experience after an operation; pneumonia is a lung infection acquired during the hospitalization; ventilator > 48hrs refers to the time on a breathing machine after an operation; morbidity is the accumulative complications after an operation; unplanned intubation is the need for a breathing tube to be put back in after an operation; deep venous thrombosis is a blood clot in the arms or legs that may develop after an operation; urinary tract infection is an infection often from a bladder catheter that is placed for an operation; return to the operating room is an unplanned re-operation after the intended or index operation.

STS General Thoracic Surgery Database (2010-2012)


UC Davis

National Average

All Procedures Discharge Survival



All Procedures 30-Day Survival



Where Discharge Survival is the rate of leaving the hospital alive after the operation, and 30-Day Survival is the rate of surviving 30 days after an operation, even after having gone home.

LeapFrog Group Ratings for Esophageal Resection (2013)

 4-Bar, Best Odds for Survival Ranking or Highest Quality of Care Rating: Top in the Sacramento region.

Where 4-Bars (Highest Quality of Care Rating) means the patient has the best chances of surviving an esophageal resection.  An esophageal resection or Esophagectomy is a surgery to remove the esophagus and replace it with the stomach or colon and is most commonly performed for cancer, though sometimes it needs to be performed for very extreme non-cancer disease.

The LeapFrog Group determines the Highest Quality of Care Rating by surveying participating hospitals and measuring their outcomes.  A hospital can achieve a Highest Quality of Care Rating by:

-       Participating in the Leapfrog Survey

-       Performing ≥ 13 esophagectomies during the survey year

-       All of the esophagectomies performed by high-volume surgeon (≥ 2 esophagectomies/year)

The LeapFrog Highest Quality of Care Rating determines quality or value based on the volume, or the number of procedures performed.  The thinking is that having experience with a procedure refines quality outcomes and promotes value.  This volume-outcome relationship has been demonstrated in the scientific literature (Birkmeyer et al, New Engl J of Med, 2002) for both esophageal cancer surgery (Esophagectomy) as well as lung cancer surgery otherwise called pulmonary resection, such as lobectomy and pneumonectomy.

Since 2008 our UC Davis General Thoracic Surgery Program has performed 100 esophagectomies and over 200 lobectomy and pneumonectomies.

Patient-centered value outcomes, as mentioned above, have a lot to do with the skill of the surgeon and the surgeon’s volume based experience.  However the central driver of quality outcomes is careful planning, attention to detail, and scientific evidence based best-practice treatment algorithms that are followed in consensus by the entire care team.  Care processes or pathways that are patient/family-focused, foster coordination and communication amongst all providers can promote efficiency and improve results that are important to patients (Vanhaecht et al, Health Serv Mange Res, 2007).

At UC Davis, we have developed novel evidence based post-operative care pathways for esophagectomy (Cooke et al, Society of Thoracic Surgeons 49th Annual Meeting, 2013) and lung resection as well as Respiratory Therapy pathways that are designed to prevent pneumonia, need for replacement of a breathing tube and pronged need for a breathing tube (Tanner-Corbett…Cooke et al, 14th World Conference on Lung Cancer, 2011), and in effect, “stack the deck” in the patients favor to achieve important top clinical outcomes.

With our evolving health care system, the definition of quality has matured from not only advanced technology that is available, but also the value in outcomes that the patient experiences, and maximization of the outcomes that are most important to patients and their families.  Transparency in provider outcomes helps patients make informed decisions on how their care should be directed.

Comprehensive Lung Cancer Screening at UC Davis

Posted on August 27th, 2013 in Lung Cancer | No Comments »

UC Davis Comprehensive Lung Cancer Screening Program


UC Davis CLSP is a multidisciplinary program for comprehensive lung cancer screening.  The innovative program provides low-dose chest computed tomography (LDCT) technology to detect lung cancer early in its most treatable form in those individuals at the highest risk for lung cancer.   The groundbreaking National Lung Screening Trial (NLST) clearly shows that screening with LDCT scans reduces the risk of dying from lung cancer in heavy smokers by 20% compared to screening with simple chest X-rays.  (N Engl J Med. 2011).

The UC Davis Comprehensive Lung Cancer Screening Program addresses the recent recommendations released on July 29, 2013 by the United States Preventive Services Task Force (USPSTF) for annual LDCT scans to screen individuals who are at high risk for lung cancer.  To serve our patients in the program, we use a multidisciplinary team of Radiologists, Thoracic Surgeons, Pulmonologists, Pathologists, Medical Oncologists and Radiation Oncologists to develop a best-practice, patient-centered plan.

Who Do We Screen?

      UC Davis CLSP serves a specific high-risk population for lung cancer.  This population is defined by the results of the multi-institution NLST, the USPSTF recommendations and the National Comprehensive Cancer Network (NCCN) and includes the following:

a)     High-Risk Patients: Group 1

 i.   Current or former smokers 55-80 years of age;

ii.   Smoked the equivalent of one pack of cigarettes a day for at least 30 years;

iii.   If a former smoker, he/she should have quit within the previous 15 years.

b)     High-Risk Patients:  Group 2

i.     Current or former smokers 50-80 years of age;

ii.    Smoked the equivalent of one pack of cigarettes a day for at least 20 years;

iii.   Have one additional lung cancer risk factor.  Risk factors include the following:   personal lung cancer history (>5 years), family history of lung cancer (first degree relative), chronic lung disease, and carcinogen exposure (excluding second hand smoke exposure).


How do I Schedule an Exam?


We would be happy to assist you with lung cancer screening or answer additional questions through our Radiology Department. Their phone number for scheduling is 916-734-0655. We will need a referral from your Primary Care Provider or PCP. The referral can be faxed to 916-703-2254.


Insurance does not currently pay for lung cancer screening, and an out-of-pocket price for the exam is $375.


The results will be reported back to your PCP. Should an abnormality be found which requires further evaluation; our UC Davis CLSP Practitioners, including Pulmonologists and/or Thoracic Surgeons, will assist you, if your PCP wishes to consult them.


In addition if interested, we can offer you advice and help on strategies to stop smoking.


Thank you again for choosing UC Davis CLSP!

New Point-of-Care App, PulmaCalc PPO, Predicted Post-operative Pulmonary Function Calculator

Posted on July 16th, 2013 in Blow Your Mind Technology, Cool Research, Lung Cancer | No Comments »

Brought to you by the UC Davis Section of General Thoracic Surgery: PulmaCalc PPO is a predicted post-operative pulmonary function calculator.  This unique point of care app, is ideal for health care providers, trainees and patients interested in patient centered medicine to easily calculate predicted post-operative (PPO) pulmonary function based on known pulmonary function test (PFT) values and knowledge of the extent of anatomic lung tissue removed.

The easy to use, intuitive interface allows the user to determine the PPO pulmonary function after segmentectomy, lobectomy or pneumonectomy, using known values for Forced Expiratory Volume in 1 second (FEV1) and Diffusing Capacity of the Lung for Carbon Monoxide (DLCO).

For segmentectomy and lobectomy, the user may utilize the anatomic graphic feature or the slide bar to input the number of anatomic segments removed for calculation.

For pneumonectomy a slide bar for the fraction of lung perfusion measured by quantitative radionuclide ventilation/perfusion (V/Q) scan can be used to determine PPO FEV1and DLCO.

Additional tabs describe the role for calculating PPO pulmonary function and the evidence-based medicine behind it.

This application is for informational purposes only and is not intended as a substitute for medical care, advice or professional services.

Available for the iPhone and iPad

To download PulmaCalc PPO click here:

To trouble shoot or additional questions contact:


PulmaCalc in iTunes

What is the New Lung Cancer Staging System?

Posted on January 12th, 2013 in Lung Cancer | No Comments »

In July 2009 a new lung cancer staging system was revealed: The 7th edition of the Tumor/LymphNode/Metastasis (TNM) classification. The 7th edition TNM classification is a result of the International Staging Committee (ISC) created by the International Association for the Study of Lung Cancer (IASLC), resulting in the IASLC Lung Cancer Retrospective Staging Project.1

            The ISC compiled clinical data on over 100,000 patients diagnosed with NSCLC and SCLC between 1990 and 2000, making the patient population examined 20 times the size of the 1997 analysis.  All components of the staging system were considered for upgrading, with the majority of changes occurring in the T and M components.1

            The 6th staging edition divided tumors into two size groups: T1 < 3cm in diameter, and T2 ≥ 3cm in diameter.  However, most thoracic surgeons and medical oncologists can anecdotally attest that the biologic behavior of node negative tumors that are 6-7cm, behave differently then 3cm node negative tumors, despite both being in the same broad T2 grouping.  The ISC confirmed this assumption.  Results suggested that new size groupings should be created of 2, 3, 5 and 7cm.  5 year survival rates for the pathologic groupings with negative nodes and no metastasis were 77% for T1 ≤ 2cm, 71% for T1 > 2cm and ≤ 3cm, 58% for T2 > 3cm and ≤ 5cm, 49% > 5cm and ≤ 7cm and 35% for T2 > 7cm.  Subsequently, the ISC recommended subclassifying T1 into T1a (≤ 2cm) and T1b (>2cm and ≤3cm) and subclassifying T2 into T2a (> 3cm but ≤ 5cm or tumor with any other T2 descriptors, but ≤ 5cm) and T2b (> 5cm but ≤ 7cm), and reclassify T2 tumors > 7cm to T3.2

                        No formal changes were recommended for nodal staging.  Malignant pleural effusion was reclassified to M1a.  The ISC found that extrathoracic metastasis had poorer prognosis than intrathoracic metastasis.  M1 was therefore sub-classified to M1a for additional tumors in the contralateral lung, malignant pleural and pericardial effusions, and nodular pleural dissemination, and M1b for extrathoracic metastasis.3,4

            The new stage groupings are as follows:  T2b tumors ((> 5cm but ≤ 7cm) that are N0M0 are upstaged from IB to IIA; T2a tumors (≤ 5cm) that are N1M0 are down staged from IIB to IIA, and T4 tumors that are N0/1 are down staged to IIIA.  Restaging the patient population in the study based on the proposed 7th TNM edition, found a pathologic 5 year survival rate 73% for IA, 58% for IB, 46% for IIA, 36% for IIB, 24% for IIIA, 9% for IIIB and 13% for IV.5

            The 7th edition TNM staging system for NSCLC is an exciting accomplishment, and will help the clinician to better understand the outcomes of lung cancer and offers an exciting advance to our specialty. 


1. Rami-Porta R, Crowley JJ, Goldstraw P.  The revised TNM staging system for lung cancer.  Ann Thorac Cardiovasc Surg. 2009 Feb;15(1):4-9.


2. Rami-Porta R, Ball D, Crowley J, et al.  The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol. 2007 Jul;2(7):593-602.

3. Rusch VW, Crowley J, Giroux DJ, et al.  The IASLC Lung Cancer Staging Project: proposals for the revision of the N descriptors in the forthcoming seventh edition of the TNM classification for lung cancer.  J Thorac Oncol. 2007 Jul;2(7):603-12.


3. Postmus PE, Brambilla E, Chansky K, et al.  The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer.  J Thorac Oncol. 2007 Aug;2(8):686-93.


4.  Goldstraw P, Crowley J, Chansky K, et al.  The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours.  J Thorac Oncol. 2007 Aug;2(8):706-14. Erratum in: J Thorac Oncol. 2007 Oct;2(10):985.


5. Rusch VW, Asamura H, Watanabe H, et al.  The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer.  J Thorac Oncol. 2009 May;4(5):568-77.


Introducing the UC Davis Lung Cancer Chat Room

Posted on January 10th, 2013 in Lung Cancer, Medical Education | No Comments »

The UC Davis Lung Cancer Chat Room is an interactive meeting of learning and support for patients, families, friends and caregivers affected by lung cancer.

This support group is proudly sponsored by the UC Davis Comprehensive Cancer Center.

The UC Davis Lung Cancer Chat Room provides a time for education, sharing and an opportunity to connect face-to-face with people who can relate the realities of lung cancer. Special guest speakers are invited to give presentations on topics of interest to patients. Educational and support materials are provided.

3rd Thursday of each month
UC Davis Comprehensive Cancer Center
4501 X St. Sacramento, CA
Room #1103

For more information about this group, please contact Jena Cooreman, LCSW at 916-734-5198

2013 Calendar of Group Speakers

February 21st

David Copenhaver, MD, MPH
Director of Cancer Pain, Division of Pain Medicine
Pain Management

March 21st

David Tom Cooke, MD, FCCP, FACS
Section Head of General Thoracic Surgery
Lung Cancer Surgery: When is it Necessary?

April 18th

Kathleen Newman, RD, CSO
Senior Clinical Dietician
Nutrition and Cancer Treatment

May 16th

Elizabeth A. David, MD
Minimally Invasive Lung Cancer Surgery: What Are We Doing Now, What’s on the Horizon?

June 20th

Valerie Kuderer, RN
Thoracic Surgery Nurse Coordinator
Recovery After Lung Cancer Surgery

July 18th

Karen Kelly, MD
Associate Director of Clinical Research
We Might Have a Clinical Trial for That

August 15th

Megan Daly, MD
Advances in Radiation Oncology

September 19th

Marlene von Friederichs-Fitzwater, PhD, MPH
WeCARE! Cancer Peer Navigation Program

October 17th


November 14th

Tina Li, MD
Personalizing Lung Cancer Therapy: How Tumor Molecular Testing Can Help Your Cancer Care