Overview of Lung Cancer Statistics, Causes, Symptoms, Natural Disease History, Treatment, Screening, Stigma and Tobacco Control

1. All About Lung Cancer
Andrea Borondy Kitts
@findlungcancer
November 20, 2014

2. Agenda
• Dan’s Story
• Lung Cancer Statistics
• What is Lung Cancer
• Lung Cancer Risk Factors
• Natural History and Treatment
• Lung Cancer Screening
• Tobacco Control
• Summary
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3. Lung Cancer Is Personal
© 2014 Free to Breathe
Dan’s Story

4. Lung Cancer is the 2nd Leading Cause of Death in the US
• Lung cancer is the leading cause of
cancer deaths in both men and
women in the US
– 160,000 die each year, more than
breast, colon, prostate and
pancreatic cancer combined
– 5 year survival at 16.8% essentially
unchanged since 1975
• Most common cancer worldwide
– 1.6 million deaths in 2012
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5. © 2014 Free to Breathe
Lung Cancer Facts

7. © 2014 Free to Breathe
Lung Cancer Risk

8. © 2014 Free to Breathe
• Lung Cancer Risk

11. © 2014 Free to Breathe
Lung Cancer Facts

13. Global Lung Cancer Incidence and Mortality
Most common cancer worldwide
• 1.6 million deaths in 2012
Fifty eight percent of new cases in
underdeveloped regions
Highest incidence and mortality in men
• Central and Eastern Europe
• Eastern Asia
Women have lower incidence and
mortality
• Highest in North America – cultural
differences in smoking prevalence
• Lag in when women started smoking
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http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx

14. Lung Cancer is a Non-Infectious Chronic Disease
http://www.nccn.org/patients/guidelines/nscl/index.html#8
Most are carcinomas and initiate in
the lining of the airways
• Bronchi
• Bronchiole
• Alveoli
Today’s smokers are more likely to
develop lung cancer than smokers
50 years ago.
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15. 87% Non-Small Cell Lung Cancer (NSCLC); 13%
Small Cell Lung Cancer (SCLC) Histology
Molecular Challenges in Lung Cancer
Ben Leach Published Online: December 17, 2012
http://www.targetedonc.com/publications/targeted-therapy-news/
2012/November-2012/Molecular-Challenges-in-Lung-Cancer
NSCLC further
characterized
histologically into:
• Adenocarcinoma
• Squamous Cell
• Large Cell
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16. Over 80% of Lung Cancers are caused by Tobacco
U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking – 50 Years of
Progress A Report of the Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/reports/50-
years-of-progress/50-years-of-progress-by-section.html
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17. Lung Cancer Risk
Other than smoking, what else can cause lung
cancer?
- Secondhand exposure to smoke
- Radon
- Having had smoking related cancer
- Family History
- Environmental pollutants (pollution, dust,
© 2014 Free to Breathe
asbestos)
- COPD or Pulmonary Fibrosis

18. Natural History of Lung Cancer
DNA
damage to
cells
Abnormal
cell growth
Lesion
Pathological
Evidence
Approximately 85%
of diagnoses at a
late stage
5 year survival 16.8%
Localized – 54%
Distant – 4%
Metastasis Diagnosis Treatment Death
Damage
accumulates
with age and
exposure to
agents e.g.
tobacco.
Average age
of diagnosis is
70
Few symptoms
in early stages
Screening test
(LDCT) not
generally
available until
2015
Early stage –
Surgery and
possible adjuvant
chemo/radiation
Late stage –
palliative and life
extension
CT
PET/CT
Biopsy
MRI
Staging
http://www.nccn.org/patients/guidelines/nscl/index.html
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http://seer.cancer.gov/statfacts/html/lungb.html

19. Surgical Treatment in Early Stages; Systematic
Treatment in Late Stages
Surgical Options include wedge resection,
lobectomy, bilobectomy, and
pneumonectomy via traditional,
minimally invasive (VATS) or robotic
surgery
• sometimes preceded by, or followed
with, adjuvant chemotherapy and/or
radiation
Systematic treatments include chemotherapy,
radiation, targeted molecular treatments, and
immunotherapy
• Approximately 67% of NSCLC have an
identified genetic mutation
http://www.onclive.com/publications/Oncology-live/2013/January-
2013/Targeting-Tumors-Early-Trials-Push-Novel-Agents-to-Forefront/2
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20. © 2014 Free to Breathe
• Lung Cancer Symptoms

21. 80% of Lung Cancers Diagnosed after the
Cancer has Spread When Chance of Cure Small
Stage IV NSCLC
<1% = 5 year OS
11/20/2014 Low Dose Lung Cancer Screening 21

22. Annual Low Dose CT Scan Screening Finds Lung
Cancer Early When Chance for Cure High
Stage T1AN0
92% 5-year Overall Survival
Goldstraw P, Crowley J, Chansky K, et al. (2007) 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
2:706–714.
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23. National Lung Screening Trial Design Overview
• 53,456 participants
– LDCT scan
or
– CXR
• Enrolled 2002 – 2004
• 3 Annual Screenings
National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed
tomographic screening. N Engl J Med 365(5):395–409.
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24. National Screening Trial Results
The National Lung Screening Trial Research Team . N
Engl J Med 2011;365:395-409.
More Lung Cancers found in LDCT Arm
• Total Cases
• LDCT 1060
• CXR 941
• Cases per 100k person years
• LDCT 645
• CXR 572
Difference primarily early stage disease
More Lung Cancer Deaths in CXR Arm
• Total Deaths
• LDCT 356
• CXR 443
• Deaths per 100k person years
• LDCT 247
• CXR 309
20% Reduction in mortality with LDCT
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25. Stage shift seen with LDCT screening in NLST shifts back
after screening stopped - greater than 20% mortality
improvement possible
67.1 VS 33.2
20.5 VS 52.5
The National Lung Screening Trial Research Team . N Engl J Med
2011;365:395-409

26. Annual Lung Cancer Screening
Recommended For the High Risk Population
Age
55 to 80 (age 74 for Medicare)
Smoking History
30 pack years or more
• 1 pack a day for 30 years/2 packs per day for 15 years etc.
Current or Former Smoker Quit within the last 15 years
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27. • More than 10 million Americans in the recommended population
to screen
• Estimated to save more than 20,000 lives a year
• Additional benefit for smoking cessation
– Published smoking cessation rates in lung cancer screening trials and
studies show 2 to 3 times the cessation rate as compared to the general
population (11 to 22% vs 5 to 7%)
"This has the biggest impact on lung cancer that we have ever seen
in our lifetime," he said. "This will do more to save lives than
anything else we have done to date in lung cancer, from a clinical
perspective.”
Reginald Munden, MD
MD Anderson Cancer Center in Houston
Principal site investigator in the NLST
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28. Stigma due to Strong Link with Smoking
People with lung cancer blamed and/or blame themselves for their disease
http://cancergeek.wordpress.com/2013/11/16/cancer-the-harsh-story-of-lung-cancer-vs-breast-cancer/
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29. Deadliness of disease and images of horrible death
Lack of survivors and advocates = less research $’s
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30. Tobacco Company Marketing Targets Youth – Every adult who dies
early because of smoking is replaced by two new young smokers.
• $8.4 Billion spent on
advertising annually
• $23 million every day
• 90% of regular smokers start
smoking by age of 18
• Smoking harder to quit
than heroin
Blakeslee, Sarah. (1987). Nicotine: Harder To
Kick...Than Heroin. Retrieved October 29, 2014
from The New York Times website:
http://www.nytimes.com/1987/03/29/magazine
/nicotine-harder-to-kickthan-heroin.html
Centers for Disease Control and Prevention. (2014). Economic Facts About U.S. Tobacco Production and Use,
Retrieved on October 24, 2014 from
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm
BeTobaccoFree.gov. (2014). Nicotine
Addiction and Your Health. Retrieved on
October 29, 2014 from
http://betobaccofree.hhs.gov/health-effects/
nicotine-health/index.html
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31. Smoking is The Cancer Trigger
Smoking is now known to cause
13 different types of cancer—
almost everywhere in the body.
 1 out of 3 U.S. cancer deaths
are tobacco-related.

32. Smoking is The Breath Blocker
Chronic Obstructive Pulmonary Disease (COPD)
Smoking causes most
cases of COPD.
There is NO CURE for COPD

33. Smoking is the Heart Stopper
• Smoking causes cells lining veins and arteries to swell.
• Narrower arteries mean
reduced blood flow to the
heart, brain, and organs.
• Clots can block narrowed
arteries, causing heart attack,
stroke, and even sudden
death.
• Even occasional smoking
damages blood vessels.

34. Government Policies and Social Context
Warning Labels on Tobacco Products
• Many now advocating for “plain
packaging”
Ban on Cigarette and Smokeless Tobacco
Advertising on TV and Radio
Smoking Restrictions in Public Places
Increased Cigarette Taxes
• 10% increase reduces consumption 3
to 5%
Tobacco Master Settlement Agreement
• Dollars go into general fund. Not being
used for original intent of tobacco
control
Graphic CDC Anti-smoking Campaign
Lung cancer incidence reduced from
42% in 1965 to 18% in 2012
Decline in teen smoking
incidence leveling off.
5.6 million youths will die
prematurely of tobacco related
illness
New threat E-cigarettes
Unintended consequence is
stigmatization of people with lung
cancer increasing the disease burden
Large tax revenues and strong
lobbying stymie will to make tobacco
illegal
http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-progress-
by-section.html
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http://www.cdc.gov/tobacco/data_statistics/by_topic/policy/legislation/

35. Primary Prevention: States Have Failing Grades
for Most Tobacco Control Measures
Spending
Cessation
Excise Taxes
Smoke Free Air Laws
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http://www.stateoftobaccocontrol.org/state-grades/state-rankings/

36. Summary
• Lung Cancer is a Non-Infectious Chronic Disease
– More than 80% of cases caused by tobacco use
– 90% of regular tobacco use starts by age 18
– Smoking harder to quit than heroin
– Cigarettes more addictive now than in 1960’s
• Lung cancer is the most common cancer worldwide and the leading cause
of cancer deaths in men and women in the US
– Mortality rate high due late stage at diagnosis
• USPSTF and CMS now recommend LDCT screening annually for the high
risk population
– 10 million Americans eligible
– Estimate more than 20,000 lives saved per year
– Need to raise awareness with primary care physician community and the
population at risk
• Tobacco control efforts, although resulting in some success, have failed
to eliminate smoking
– E-cigarettes threaten to erode smoking incidence reduction achieved to date
• Increased research funding needed for improved screening and
treatment modalities
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37. Back Up Slides
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38. Lung Cancer Incidence and Mortality Rates Decreasing
in the US
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http://seer.cancer.gov/statfacts/html/lungb.html

39. Public Health Policy Implications
Improve lung cancer survivability via USPSTF recommended low dose CT
(LDCT) lung cancer screening. Improved survival leads to positively reinforcing
loops of reduced stigma, increased advocacy, increased research, increased
survival
Need CMS to cover LDCT
lung cancer screening.
Continuation of tobacco
control policies should add
lung cancer screening as a
teachable moment for smoking
cessation. Also, switch focus from
negative portrayal of smokers and
focus on tobacco and e-cigarette industry
actions targeting addiction & marketing to youths
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40. Tobacco Control Policies Stigmatize Smokers
Tobacco Industry Response to 1964 Surgeon General Report:
deny addictive nature of smoking
portray smoking as lifestyle choice
Tobacco control policies de-normalized smoking and stigmatized smokers
smoking as environmental health issue (2nd hand smoke)
legislation of smoke free public areas and work places
portraying smoking as a personal choice leading to a horrible death
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Stuber J, Galea S, Link BG. Smoking and the emergence of a stigmatized social status. Social Science in Medicine. 2008;67(3):420–430.

41. Lung Cancer Stigma has Adverse Impacts on Depressive
Symptoms, Quality of Life and Physical Symptoms
• People with lung cancer experience dual burdens of
their disease and stigma
• Lung cancer stigma is an independent factor
– 2.1% impact on quality of life (QOL)
– 3% of the impact on depressive symptoms
– 1.3% increase in severity of symptoms
• Depression impacts QOL and QOL prognostic factor
for survival (ref below)
Ediebah DE, Coens C, Zikos E.,Qinten C., Ringash J., King MT., Schmucker von Kich J., Gotay C., Greimel E., Fletchner H., Weis J., Reeve BB.,
Smit EF., TaphoornMJ., Bottomley A.Does change in health-related quality of life score predict survival? Analysis of EORTC 08975
lung cancer trial.Br J Cancer. 2014 Apr 17. doi: 10.1038/bjc.2014.208. (Epub ahead of print)
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42. LUNG CANCER (LC) STIGMA CONCEPTUAL MODEL
Tobacco Control Policies
Decreased Smoking Prevalence
Reduced LC Incidence
Reduced LC Advocacy
Reduced LC Research
Low Survivability
Andrea Borondy Kitts April 2014
Increased LC Stigma
Adverse LC patient impacts
Stigmatized smokers
Tobacco control policies effective at decreasing
smoking prevalence however stigmatized smokers
and people with lung cancer. Reduction in incidence of lung
cancer offset by low survivability due to stigma resulting in negatively
reinforcing loops of increased stigma, adverse patient impacts,
less advocacy and reduced research.
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43. © 2014 Free to Breathe
Lung Cancer Facts

44. Lung cancer is the leading cause of cancer deaths for
both men and women
© 2014 Free to Breathe

45. Lung Cancer is the Leading Cause of Cancer Deaths in the US
• The leading cause of cancer deaths in both men and women
– 160,000 die each year, more than breast, colon, prostate and pancreatic
http://apps.nccd.cdc.gov/uscs/toptencancers.aspx
cancer combined
– 5 year survival at 16.8% essentially unchanged since 1975
http://www.cancer.org/acs/groups/content/@research/documents/webco
ntent/acspc-042151.pdf

46. © 2014 Free to Breathe
• Why You Should Care

47. Overall Lung Cancer Incidence in US is 60.1 cases per 100,000;
Highest in African American Men at 93.0 per 100,000
Average age at diagnosis 70
http://seer.cancer.gov/statfacts/html/lungb.html
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48. Lung Cancer Screening with LDCT now Recommended for the
Population at High Risk
“The USPSTF recommends annual screening for lung cancer with low-dose computed
tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history
and currently smoke or have quit within the past 15 years. Screening should be discontinued
once a person has not smoked for 15 years or develops a health problem that substantially
limits life expectancy or the ability or willingness to have curative lung surgery."
http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm
• More than 10 million Americans in the recommended population to screen
• Estimated to save more than 20,000 lives a year
• Additional benefit for smoking cessation
– Published smoking cessation rates in lung cancer screening trials and studies show
2 to 3 times the cessation rate as compared to the general population (11 to 22%
vs 5 to 7%)
Sifferlin, Alexandra. 2013. "Surviving Lung Cancer." Time 182, no. 7: 15. Academic Search Premier, EBSCOhost (accessed October 28, 2014).
Moyer VA, on behalf of the U.S. Preventive Services Task Force. Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation
Statement. (2014). Annals of Internal Medicine, 160:330-338. doi:10.7326/M13-2771
Townsend, C. O., Clark, M. M., Jett, J. R., Patten, C. A., Schroeder, D. R., Nirelli, L. M., Swensen, S. J. and Hurt, R. D. (2005). Relation between smoking
cessation and receiving results from three annual spiral chest computed tomography scans for lung carcinoma screening. Cancer, 103:, 2154–2162. doi:
10.1002/cncr.21045
Tammemagi, M.C., Berg, C.D., Riley, T.L., Cunningham, C.R., Taylor, K.L. (2014). Impact of Lung Screening Results on Smoking Cessation. Journal of the
National Cancer Institute, 10:6, DOI:10.1093/jnci/dju84
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