Lung Cancer: A Conference for Health Care Professionals

1
The Irish Cancer Society welcomes you
to
Lung Cancer A Conference for Health Care
Professionals
Thursday 29th March 2007 Stillorgan Park Hotel,
Co. Dublin
Kindly supported by
2
John McCormack
Chief ExecutiveIrish Cancer Society
3
Dr. John Kennedy
Consultant Medical Oncologist, St. Jamess
Hospital, Dublin Medical Committee
Chairman,Irish Cancer Society
4
Prof. Des Carney
Consultant Medical Oncologist, Mater
Misericordiae Hospital and St. Lukes Hospital,
Dublin
5
Lung Cancer Is there a Role for Screening High
Risk Patients?

• Frank Sullivan, MB MRCPI
• Consultant Radiation Oncologist, University
  College Hospital Galway
• Irish Cancer Society
• March 2007

6
Quality of life indicator

• Dublin Airport to Stillorgan
• Taxi travel time 1 hr. 45 mins
• Cost 74.40 euro
• Galway to Dublin
• Aer Arann travel time 30 mins
• Cost 44 euro

7

• Where does Lung Cancer fit on our screening
  horizon in Ireland?

8

• Established 01 January 2007
• SI 632 of 2006

9

• Rationale for Establishment of NCSS
• Successful governance model of BreastCheck.
• Clinical and Other success of BreastCheck.
• Desire to have specific governance mechanism for
  all screening programmes.
• Need to avoid duplication.
• Cost efficiency.
• Sharing of expertise.

10

• SI 632 of 2006
• A) Carry Out the Following
• Programme for the early diagnosis of breast
  cancer, and arrange primary treatment.
• Programme for the early diagnosis of cervical
  cancer, and arrange primary treatment.

11

• SI 632 of 2006
• B) Advise the Minister on the Following
• Health technologies, including vaccines, relating
  to cervical cancer.
• Carrying out Programmes concerning any cancer.

12

• SI 632 of 2006
• C) Implement special measures to promote
  participation in its Programmes by disadvantaged
  persons.

13
BreastCheck

• Historical
• Steering Group and Quality Assurance Committee
  established 1997.
• National Breast Screening Board established 1998.
• Screening commenced February 2000.
• 2005 National Breast Screening Board was
  re-established.

14

• Historical
• Blue Book 1996.
• Established as a pilot in Mid West in 2000.
• Part of Public Health Department, Mid Western
  Health Board.
• Roll out part of HEBE (2003).
• January 2005 became part of Population Health
  Directorate , HSE.
• Decision to include programme in NCSSB June 2006.

15

• Ministerial Policy Letter Received
• February 2007

16

• Human Papillomavirus (HPV) Vaccine
• I would be grateful for your Boards advice on
  the role of the HPV vaccines in the prevention
  and control of cervical cancer. Such advice
  should include a detailed assessment of the
  priority to be given to such a vaccine, the
  implications for the screening programme,
  relative clinical and cost effectiveness for the
  different age groups. The National Immunisation
  Advisory Committee is examining the public health
  benefit and appropriate use of the vaccine. My
  Department will make this advice available to the
  Board as soon as it is to hand.

17

• - Colorectal Screening
• I would also be grateful for your Boards advice
  on the development of a population based
  colorectal screening programme and a screening
  programme for high risk groups. Such advice
  should include an evaluation of options, clinical
  and cost effectiveness including an effective,
  well organised and quality assured treatment
  service. You should ensure that your advice is
  developed and insofar as is possible agreed with
  the Health Service Executive.

18

• -Prostate
• -Lung
• -Other
• so far, no plans

19
Overview of any screening program

• Objective to reduce mortality and/or morbidity?
• Need for careful evaluation (ethical, financial,
  as well as medical)
• Differing recommendations for populations vs
  individuals
• Differing burdons of responsibility

20
Criteria of Jungner Wilson 1968

• Relatively common disease
• Seriously disabling
• Identifiable preclinical phase
• Understanding of the natural history
• Recognised acceptable treatment available
• Facilities for treatment available

21
Criteria for screening test

• Simple, quick
• Inexpensive
• Acceptable to population
• Accurate
• Repeatable
• Sensitive Specific
• Available

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The mixed message

• Help us to dx your cancer earlier
• Better prognosis, higher cure rates
• Less invasive and toxic treatments
• Better outcomes
• Detection before symptoms/the earliest possible
  pick up point
• Screen for breast (yes)
• Screen for cervix (yes)
• Screen for prostate (no)
• Screen for lung(hell no!)
• or anything else for
  that matter

27
The problem

• Application of different standards to different
  diseases
• Studies non uniform, at differing stages of
  maturity
• Do we have to have a reduction in mortality
  before we recommend screening?
• Is a reduction in morbidity not a sufficient goal
  where mature mortality reduction data is not
  available?

28
Prevention and screening

• Lets not mix these up!
• Both are important
• Complimentary programs targetting healthy but
  distinct populations
• Importance of smoking cessation programs with any
  lung screening program
• Importance of vaccination with cervical screening

29
CT SCREENING FOR LUNG CANCER The International
Early Lung Cancer Action Program

30
I-ELCAP MISSION

• Diagnostic mission
• Screening for a cancer is pursuit of the cancers
  early diagnosis (before symptoms and signs).
• Prognostic mission
• Determine the proportion of early-diagnosed cases
  that are cured by prompt treatment as compared to
  those with delayed or no treatment

31
THE CRITICAL QUESTIONS Diagnostic performance

• Screening for a cancer is pursuit of the cancers
  early diagnosis (before symptoms and signs).
• How often does screening lead to a diagnosis of
  cancer?
• Among these, what proportion are Stage I?
• All that is needed to answer these questions
  are people at high risk of the disease who are
  diagnosed by the screening

Clinical Imaging 1994 18 16-20 and Chapter in
Progress in Oncology 2002 (eds. VT DeVita, S
Hellman, SA Rosenberg) Jones and Bartlett, Boston
MA. 2002 90-101
32
IDEAL DESIGN FOR DX
Diagnostic Mission
Lung Cancer Distribution (Stage/Size)
!

• Everyone
• Screened

Two years baseline and annual repeat

• When comparing 2 diagnostic tests, use both and
  compare
• Lung cancer Lancet 1999 354 99-195
• PIOPED NEJM 2006
• Digital mammography

33
THE CRITICAL QUESTIONS Prognostic performance

• Determine the proportion of early-diagnosed cases
  that are cured by prompt treatment
• Are these screen-diagnosed cancers genuine?
• Would they lead to death in the absence of
  treatment?
• How curable are these genuine cancers?

Clinical Imaging 1994 18 16-20 and Chapter in
Progress in Oncology 2002 (eds. VT DeVita, S
Hellman, SA Rosenberg) Jones and Bartlett, Boston
MA. 2002 90-101
34
IDEAL EVALUATION

• Diagnostic Mission
• Perform screening to diagnose lung cancer
• When comparing 2 diagnostic tests, use both and
  compare the two tests (see Lancet 1999 354
  99-195)
• Prognostic Mission
• This is where the control group belongs
• Randomize people who were diagnosed with early
  lung cancer into immediate or delayed treatment
  to learn about
• the natural course of lung cancer
• the curability of different subtypes

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IDEAL EVALUATIONDx of lung cancer followed by RCT
Diagnostic Mission
Prognostic Mission
!
Rx
Deaths
Lung Cancer Distribution (Stage/Size)

• Everyone
• Screened

Rx later
Deaths
Two years baseline and 1 annual
specific to stage and size
36
Randomized Stage I RCT

• Cannot be performed based on knowledge
  accumulated for the past 30 years
• (Imagine randomizing screen detected beast
  cancers to no treatment)
• Buell (1971) reported a 10-year survival rate of
  80 for lung cancers lt 20 mm in diameter
• Martini et al. (1995) reported a 10-year survival
  rate of 93 for lung cancers lt 10 mm in diameter
• SEER cases (2001) have 8-year survival rate of
  75 for cancers lt 15 mm in diameter
• But some subtypes, perhaps it can be performed
• Alternatively, other approaches for treatment
  comparisons can be used

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TRADITIONAL COMPROMISEScreening RCT NLST
(ongoing)
Early Diagnosis/ Early Intervention
Deaths
CT Screening

• Randomize

Symptom Diagnosis/ Late Intervention
Deaths
CXR screening


0 Time
(years) 10
13

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TRADITIONAL COMPROMISEScreening RCT Imagine
this was Breast Cancer
Early Diagnosis/ Early Intervention
Deaths
Mammogram

• Randomize

Symptom Diagnosis/ Late Intervention
Deaths
Nothing


0 Time
(years) 10
13

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Problems of Randomized Screening Trials

• Requires many rounds of screening before effect
  can be seen
• Typically 10 years of screening
• Very costly
• Requires many participants because only a few
  will develop the disease
• Need to follow everyone in each cohort
• Problems in the primary outcome measure
• Retrospective ascertainment of deaths
• Problems due to differential ascertainment of
  deaths
• Use of cumulative deaths without consideration of
  which deaths are affected by the screening

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Problems of Randomized Screening Trials

• Lack of protocol adherence contamination
• Requires everyone to stay in the trial in their
  respective arms over a long period of time
• Typically lacks an optimal regimen
• Nelson and ACRIN worked hard to change this
  culture, but the PLCO arm still does not
• All these problems have been documented in prior
  lung and breast cancer screening trial

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THE ELCAP APPROACHDx, then compare prompt
treatment with alternatives
Diagnostic Mission
Prognostic Mission
!
Rx
Deaths

• Everyone
• Screened

Lung Cancer Distribution (Stage/Size)
No Rx or Delay in Rx
Baseline and annual repeat 0
years 2


Deaths
specific to stage and size
Clinical Imaging 199418 16-20
42
ELCAP Diagnostic Results

• Developed a regimen for screening
• Showed that the proportion of lung cancer
  identified in Stage I was 85
• Also showed that CXR missed 83 of those in Stage
  I

Lancet 1999 354 99 - 105
43
ELCAP Prognostic Projections

• Based on the diagnostic distribution of cancers
  achieved in ELCAP and cure rates from prior
  publications
• It was estimated that the proportion of deaths
  that could be prevented is conservatively 60,
  but likely to be as high as 80

Lancet 1999 354 page 103
44
International Conferences on Screening for Lung
Cancer

• The demand resulting from the Lancet publication
  led us to start the Conferences
• 1st in October 1999 15th in October 2006
• The Conferences led to the formation of I-ELCAP
• The I-ELCAP protocol was developed, unanimously
  adopted, and then published (Lung Cancer 2002
  35 143-148)
• The protocol has been regularly updated and
  posted on the I-ELCAP website (www.IELCAP.org)

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I-ELCAP Enrollment
Second hand smoke exposure Family history
NEJM 2006 355 1763-71
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I-ELCAPRegimen of screening

• Baseline 13 have a positive result on the
  initial CT
• Repeat 5 have a positive result on the
  initial CT
• Biopsy when recommended by protocol results in
  92 of diagnoses being malignant

I-ELCAP Protocol is on www.IELCAP.org NEJM 2006
355 1763-71
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Figure 1. Lung cancer diagnoses resulting from
baseline and annual repeat CT screening
Baseline Screenings N 31,567
Annual Repeat Screenings N 27,456
Enrollment (see Table 1)
Positive result At least 1 solid or part-solid
nodule gt 5 mm in diameter or at least 1
nonsolid gt 8 mm in diameter N 4,186
No nodules or Having nodules not qualifying as a
positive result N 27,381
Positive result any newly identified
non-calcified nodule N 1,460
No newly identified non-calcified nodules N
25,996
Symptom- prompted work-up within 12 months
I-ELCAP annual repeat management algorithm
Symptom-prompted work-up within 12 months
I-ELCAP baseline management algorithm
All baseline cases of lung cancer N 405
All annual repeat cases of lung cancer N 74
All interim diagnoses of lung cancer N 5
All interim diagnoses of lung cancer N 0
All cases of lung cancer N 484
Clinical Stage I cases of lung cancer N 412
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I-ELCAP Diagnostic Performance

• Outcome performance, per diagnostic distribution
• Proportion of diagnoses in Stage I (clinical)
• in baseline, 85 (348/410)
• in repeat cycles, 86 (64/74)
• Stage I cases
• all confirmed as cancers by expert pathology
  panel 95 already invasive.
• The eight that were not treated were, without
  exception, fatal within 5 years.

NEJM 2006 355 1763-71
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I-ELCAP Diagnostic Performance
Diagnostic Mission Prognostic
Mission
!
Rx
Deaths
Stage I lung cancer in 85 of diagnoses

• Everyone
• screened

specific to stage and size
No Rx or Delay in Rx

Deaths
Baseline and annual repeat screenings
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10-year Kaplan-Meier survival
Resected clinical Stage I 92 (95 CI 88-95)
All cases 80 (95 CI 74-85)
All cases 484 431
354 279 181 90 50
28 16
9 2 Resected Stage I 300
279 241 191
119 59 34 18
12 7
1
No. at risk
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I-ELCAP Prognostic Performance
Diagnostic Mission Prognostic
Mission
!
Rx
10-year survival rate of 92
Stage I lung cancer in 85 of diagnoses

• Everyone
• screened

All died within 5 yrs
No Rx

Baseline and annual repeat screenings
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I-ELCAPProportion of Deaths Prevented
It is estimated by the overall rate of 80 or
of Stage I x cure rate in Stage I 85 x 92
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Currently in US 5 95 of people with lung
cancer die of it (164,000/173,000, ACS
statistics)
NEJM 2006 355 1763-71
53
CT Screening

• Can save more lives than PAP smear, mammography
  and colonoscopy screening combined

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Comparison with mammography Quality Determinants
of Mammography Guideline Panelfor people 40
years and older

• Baseline cancer detection rate of 0.6 - 1.0
• Annual cancer detection rate of 0.2 - 0.4
• compared to CT screening for lung cancer
• Baseline CT cancer detection rate of 1.3
• Annual CT cancer detection rate of 0.3

NEJM 2006 355 1763-71
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CT screening for lung cancer Different risk
criteria

• CT screening for lung cancer in 40 year old
  smokers, former smokers, and never smokers
• Baseline cancer detection rate of 1.3
• Annual cancer detection rate of 0.3
• CT screening for lung cancer in 60 year old
  smokers and former smokers
• Baseline CT cancer detection rate of 2.7
• Annual CT cancer detection rate of 0.6
• Twice the number of cancers as in 40 year-olds

NEJM 2006 355 1763-71
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SUMMARYCT Screening for lung cancer

• The debate about the results of the RCTs
  performed for mammography screening led to
  congressional hearing on February 28, 2002 at
  which key representatives from NCI and ACS
  testified that
• Screening mammography is justified because it
  finds the cancer earlier and
• Treatment is better for earlier cancer
• For lung cancer, we have shown
• It can be found early no one disagrees
• Treatment of early stage lung cancer is better
  no one disagrees
• NCI and ACS also testified that the Cornell Group
  had identified flaws in the studies (Miettinen et
  al. Lancet 2002 359 404-5)

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Criticisms typically raised

• Lead time bias
• Occurs when comparing the effectiveness of a
  treatment having lead time with a treatment
  without lead time.
• We did not do this.

NEJM 2007 356743-747
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Criticisms typically raised

• We do have a comparison group
• The comparison group are early screen-diagnosed
  lung cancers whose treatment is delayed until
  symptoms occur or who are untreated
• Important to determine when these deaths occurred

NEJM 2007 356743-747
59
Criticisms typically raised

• Overdiagnosis bias
• Assess growth before biopsy
• All were found to be genuine lung cances by the
  expert pulmonary pathologists
• All who received no treatment died within 5 years
  of diagnosis

NEJM 2007 356743-747
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Criticisms typically raised

• False positives
• We have shown that the workup can be kept
  reasonably low at about the same rate as
  mammography
• Following protocol recommendations, unnecessary
  biopsies are kept at a minimum (92 rate)
• Much lower than the 50 malignancy rate
  recommended for breast biopsies

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Criticisms typically raised

• Too many operations for cancers that are not
  fatal
• Expert pathologic review of the resected
  specimens found them to be genuine cancers.
• Invasion was identified in 95
• All those not treated died of their disease
• Radiation dose
• The dose of a low-dose CT is about that of a
  mammogram and both are less than the average
  background radiation of a person living in the US
• Mammogram dose equivalent to travelling 100
  miles by air or 10 miles by car, or smoking .1
  cigarette, or existing for 3 mins at age 60 yrs.

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Criticisms typically raised

• Cost to society is too high
• This screening would cost no more than other
  accepted screening such as mammography and much
  less than colonoscopy.
• Cost of early stage treatment is about ½ of late
  stage treatment and therefore finding cancers
  early will save money in addition to saving
  lives.
• Perhaps the cost of not providing the screening
  is too high

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Bach et al. JAMA 2007 297953-961

• Computed Tomography Screening
• and Lung Cancer Outcomes
• Peter B. Bach, MD, MAPP
• James R. Jett, MD
• Ugo Pastorino, MD
• Melvyn S. Tockman, MD, PhD
• Stephen J. Swensen, MD, MMM
• Colin B. Begg, PhD

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Summary

• Screening under aegis of NCSS
• Breast
• Cervix
• ? Colorectal
• No plan for Lung
• No randomized trial showing reduction in
  mortality for lung
• NLST trial ongoing (CT vs CXR)
• I-ELCAP showed that screening saves lives
• up to 80 curability rate
• 92 10 yr actuarial survival with resected screen
  detected lung cancers

66
Remember the Criteria of Jungner Wilson
1968and lung cancer

• Is Lung Cancer?
• A relatively common disease
• Seriously disabling
• Does it have an identifiable preclinical phase
• Do we have an understanding of the natural
  history
• Do we have a recognised acceptable treatment
  available
• Are facilities for treatment available

67
Criteria for screening test

• Are CT lung scans?
• Simple, quick
• Inexpensive (see mammogram)
• Acceptable to population
• Accurate
• Repeatable
• Sensitive Specific
• Available

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Summary

• Lung cancer kills more than breast prostate,
  colorectal, lymphoma, gynaecologic tumors,
  thyroidcombined!
• SEER data USA
• Can we afford not to engage in dialogue around
  screening for lung cancer?

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The Irish Cancer Society welcomes you
to
Lung Cancer A Conference for Health Care
Professionals
Thursday 29th March 2007 Stillorgan Park Hotel,
Co. Dublin
Kindly supported by
71
Lung Cancer Early Detection, Referral and
Diagnosis

• Finbarr OConnell

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Figure 1 Lung Cancer Care Pathway
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25
50
75
Age
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Figure 1 Lung Cancer Care Pathway
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Referral and Diagnosis

• Referral
• early
• high suspicion, low threshold
• open access
• Diagnosis and Staging
• efficient
• multidisciplinary team

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Referral and Diagnosis

• Referral
• early
• low threshold, high suspicion
• open access
• Diagnosis and Staging
• efficient
• multidisciplinary team

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Lung Cancer organisation of services

• early referral
• rapid access
• efficient diagnosis and staging
• multidisciplinary assessment
• thoracotomy rates 10 ? gt20
• improved survival
• Laroche et al Thorax 53, 445-9

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Figure 1 Lung Cancer Care Pathway
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Aims of the Guidelines

• to raise awareness of lung cancer among health
  care professionals, health care providers,
  patients and the general public
• to assist in the provision to all patients of
  rapid access to high quality multidisciplinary
  lung cancer care

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Indications for Urgent Chest X-ray smokers

• Symptoms
• Haemoptysis
• New onset unexplained cough or alteration in
  character/severity of chronic cough
• Unexplained chest pain or dyspnoea
• Unexplained weight loss/cachexia
• Unexplained bone pain/neurological symptoms
• Signs
• Clubbing
• Lymphadenopathy
• Focal chest signs
• Hepatomegaly

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GP Referral Guidelines

• range of cancers including lung
• guidelines for referral to cancer teams
• key information about the cancer
• contact details of cancer specialists/MDT members
• mechanisms of referral
• due for launch May 2007
• Eileen Nolan, Regional Oncology Guidelines
  Officer

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Figure 1 Lung Cancer Care Pathway
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Lung CancerManagement

• Tissue diagnosis
• Clinical stage
• Performance status, co-morbidity and weight loss
• Pulmonary function (particularly where surgery or
  aggressive chemo/RT under consideration)

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Initial Assessment at Respiratory/Medical OPD

• Full clinical evaluation including specific
  assessment of -
• performance status/general medical condition
• co-morbidity
• weight loss
• bone pain
• hoarseness
• superior mediastinal obstruction (superior vena
  cava syndrome)
• neurological symptoms, brachial neuritis,
  Horners syndrome
• lymphadenopathy, especially cervical
• skin nodules
• hepatomegaly
• paraneoplastic syndromes (Table 7)
• Review CXR film
• ECG
• Blood tests
• FBC
• Coagulation screen
• biochemistry (renal, liver and bone)
• Pulmonary function tests (if available)

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Case 7
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Advances in diagnosis and staging

• CT prior to bronchoscopy
• PET and PET/CT
• Bronchoscopy
• peripheral lesions
• fluoroscopy and TBNA
• Superdimension
• mediastinal staging
• TBNA
• EBUS
• on-the-spot cytology

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Advances in diagnosis and staging

• CT prior to bronchoscopy
• PET and PET/CT
• Bronchoscopy
• peripheral lesions
• fluoroscopy and TBNA
• Superdimension
• mediastinal staging
• TBNA
• EBUS
• on-the-spot cytology

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Case 6 PET scan
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Case 5 NSCLC

• 69 yo female smoker
• haemoptysis
• no abnormal signs
• bronchoscopy ? tumour apical RLL
• CT ? no obvious mediastinal glands
• PET/CT ? N2 disease

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Case 5 NSCLC

• T2N2M0 IIIA

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Case 5 NSCLC

• T2N2M0 IIIA
• mediastinoscopy
• surgery if N2 negative
• chemoRT if N2 positive
• PET may be false ve or false -ve

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PET negative mediastinum pStage T2N2M0 IIIA
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CT/PET ve mediastinum pStage T2N0M0 IB
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Mediastinoscopy

• to confirm N2 disease demonstrated on CT, PET,
  PET/CT
• consider in patients with N1 disease
• patients with demonstrable N1 disease on CT/PET
  often have microscopic N2 disease

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Advances in diagnosis and staging

• CT prior to bronchoscopy
• PET and PET/CT
• Bronchoscopy
• peripheral lesions
• fluoroscopy and TBNA
• Superdimension
• mediastinal staging
• TBNA
• EBUS
• on-the-spot cytology

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TBNA
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Role of Cytology on Site in Peripheral TBNA
p 0.003
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TBNA for peripheral lesions
BAL/Washings
TBBx
TBNA Positive in 42/56 (76.8) Only positive
procedure in 12/56 (21.4)
TBNA
N56
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Advances in diagnosis and staging

• PET and PET/CT
• Bronchoscopy
• peripheral lesions
• fluoroscopy and TBNA
• Superdimension
• mediastinal staging
• TBNA
• EBUS
• on-the-spot cytology

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Advances in diagnosis and staging

• PET and PET/CT
• Bronchoscopy
• peripheral lesions
• fluoroscopy and TBNA
• Superdimension
• mediastinal staging
• TBNA
• EBUS
• on-the-spot cytology

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Mediastinal staging EBUS TBNA
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Mediastinal sampling by TBNA

• blind EBUS
• sensitivity 66 90
• false ve rate 33 10

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Advances in diagnosis and staging

• PET and PET/CT
• Bronchoscopy
• peripheral lesions
• fluoroscopy and TBNA
• Superdimension
• mediastinal staging
• TBNA
• EBUS
• on-the-spot cytology
• Mediastinoscopy

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Figure 1 Lung Cancer Care Pathway
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Referral and Diagnosis

• Referral
• early
• high suspicion, low threshold
• open access
• Diagnosis and Staging
• efficient
• multidisciplinary team

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Lung CancerMDT

• respiratory physicians
• radiologists
• cytohistopathologists
• cardiothoracic surgeons
• medical oncologists
• radiation oncologists
• palliative care

• oncology nurse coordinator
• clinical nurse specialists
• data manager
• MDT coordinator
• research team

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0
25
50
75
Age
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The Irish Cancer Society welcomes you
to
Lung Cancer A Conference for Health Care
Professionals
Thursday 29th March 2007 Stillorgan Park Hotel,
Co. Dublin
Kindly supported by
123
Progress in Tobacco Control

• Irish Cancer Society Inaugural Lung Cancer
  Conference for Healthcare Professionals
• 29th March 07Norma Cronin

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Prevalence of Smoking
Yes 24.68
No 75.32

• 7 Decrease since 1998

12 month period ending Dec 06 Source Office of
Tobacco Control, March 07
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Cigarette Smoking By Social Class
12 month period ending December 2006
5.24
27.49
32.81
24.04
10.43
Based on all reported smokers Ref OTC March 07
129
The huge burdenof smoking

• Smoking is the single largest cause of
  preventable ill health and premature death
• 6,000 people die every year in Ireland due to
  smoking related diseases
• 30 of all cancers are caused by smoking
• 95 of lung cancers are caused by smoking
• 50 of all smokers will die from tobacco related
  disease

130
Health Consequences of Smoking

• Cancer - lung - mouth, larynx, throat,
  oesophagus - cervix - bladder - pancreas
• COPD
• Coronary heart disease
• Cerebrovascular disease
• Peripheral vascular disease
• Pregnancy and birth complications

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Tobacco and Cancer

• Lung Cancer
• Lung cancer is the leading cause cancer deaths in
  Ireland
• In Ireland
• Over 1500 new cases p/a
• Male 965 and Female 534 - NCRI 1994-2001
• Over 1450 deaths p/a
• Risk is associated with dose and duration
• People who start smoking before 15 have twice as
  many cell mutations as those who started after
  age 20 - (Bonn 1999)

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Women and Lung Cancer

• While breast cancer is the leading cause of
  cancer death among women around the world, in a
  growing number of developed countries, lung
  cancer is surpassing breast cancer as the leading
  cause of cancer death
• Murray, CJL Lopez, AD
• The global burden of disease, Geneva WHO,1996

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Cost-Effective Interventions in Tobacco Control
(World Bank 2003)

• Higher taxes on cigarettes and other tobacco
  products
• Bans/ Restrictions on smoking in public and
  workplaces
• Better consumer information
• Comprehensive bans on advertising and promotion
  of all tobacco products, logos and brand names
• Large, direct warning labels on cigarette packs
  and other tobacco products
• Help for smokers who wish to quit, including
  increased access to NRT and other cessation
  therapies

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The WHO Framework Convention on Tobacco Control
(FCTC)

• The FCTC is the worlds first public health
  treaty. It commits governments to action to
  protect their citizens from illness and death
  caused by tobacco
• Came into effect February 2005
• 168 countries are signatories
• 140 countries have ratified the treaty.

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Tobacco ControlScaleJoossens and Raw 2006
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Taxation of Tobacco Products

• Excise duty on cigarettes should be substantially
  increased each year above the rate of inflation
• Evidence shows that the most effective measure
  against smoking is a sharp price increase
• Ref A Strategy for Cancer Control in Ireland
  2005

137
Why do people smoke - Addiction

• It is the compulsive use of a drug that has
  psychoactivity and that may be associated with
  tolerance and physical dependence
• (i.e may be associated with withdrawal symptoms
  after the cessation of drug use)
• Tobacco addiction is similar to the addition of
  drugs such as heroin and cocaine
• Surgeon Generals 1988 Report on Nicotine
  Addiction

138
Most Smokers Want to Give Up
Research commissioned by Office of Tobacco
Control and carried out by MRBI in 2002
139
Benefits of Quitting Smoking
Time After Stopping
20 minutes
15years
BP, HR peripheral circulation improve
Risk of stroke back to normal
8 hours
10 years
Nicotine CO levels Fall by 50.
Risk of lung cancer reduced by 50. Risk of MI
back to normal
24 hours
1 year
All Nicotine eliminated Taste smell improved
Risk of MI reduced by 50
3-9 mths
48 hours
Cough wheeze improve
CO normal, mucociliary clearance, risk of MI falls
72 hours
2-12 wks
Breathing easier, bronchospasm relaxes. Energy
improves
Circulation improves
140
Benefits of Quitting

• Quitting at age 60, 50, 40, or 30 gains,
  respectively, about 3,6,9,or 10 years of life
  expectancy
• (Doll and Peto 2004)
• Cessation at age 50 halved the health hazards
  cessation at age 30 avoids almost all the risk
• (Doll and Peto 2004)

141
Smoking Cessation

• Smoking Cessation should be an integral part of
  all health professional roles
• Smoking Cessation is one of the best health
  investments for both the individual and society

• 
  
  

142
Who Can Support Smokers?

• Health care professionals from multi disciplinary
  /multi sectorial backgrounds
• Consultants
• General Practitioners
• Pharmacists
• Irish Cancer Society
• National Smokers Quitline
• HSE Smoking Cessation Counsellors
• Health Promoting Hospitals Network

143
Smoking Cessation Interventions based on Stages
of Change (Prochaska Di Clemente)
144
Evidence Based Smoking Cessation Interventions

• Brief opportunistic advice
• One to One intensive support
• Group Support (smokers clinic)
• Self Help materials
• Quitlines
• Pharmacotherapy (NRT, Zyban, Champix)

145
Evidence for Brief Intervention

• Smoking Cessation rates are increased from 1 -
  5 with Brief Intervention from GPs
• Increased rates of cessation are shown when the
  Doctor uses a Motivational Interviewing approach
  and specific pharmaceutical aids

146
5 As for Brief Intervention
147
National Smokers Quitline

• 5,971 people called in the first month
• 18,400 calls prior to the Smoke Free at Work
  legislation between Oct 03 and March 04
• 47,200 calls to date since the relaunch of the
  National Smokers Quitline
• (March 07)

148
6 Month Evaluation of Quitline

• Conducted by Behaviour and Attitudes on behalf of
  Irish Cancer Society and Health Promotion Unit,
  Dept of Health
• Six months from Nov 03 to Apr 04
• Almost 7,000 (33) quit
• 72 has attempted to quit on at least one other
  occasion
• 64 had been smoking for more than 15 years
• Average period off cigarettes is around 21 weeks

149
One Year Evaluation

• 4,350 people (22) had achieved ultimate success
  (had not had a cigarette for one year)
• 60 of those who quit say the Quitline was either
  a significant or an important aspect of helping
  them stay off.

150
Third anniversary of the ban 29th March 2007

• 95 compliance with legislation
• 98 of all workers report that their work
  atmosphere has not been smoky since the
  legislation came into effect
• 32,000 inspections were completed by the EHOS
• Source Office of Tobacco Control annual report
  2006

151
Health impacts
All Ireland Bar Study

• Among non-smokers, cotinine concentrations in the
  saliva declined by 80 in the Republic and 20 in
  Northern Ireland
• Workrelated exposure to secondhand smoke dropped
  significantly in the Republic but dropped only
  slightly in Northern Ireland
• A significant drop in the proportion of bar staff
  experiencing respiratory symptoms
• (Ref BMJ 2005, S.Allwright et al)

152
What Progress Has Been Made?

• Taxation,CPI
• Ban tobacco sales to under 18s (2000)
• Advertising, sponsorship and promotion
• NRT free to medical card holders (2001)
• Research Institute for a Tobacco Society (2001)
• Dedicated smoking cessation specialists
• National Smokers Quitline (2003)
• Smoke free at work legislation (2004)
• Banning of point of sale advertising (2007)
• Abolition of ten pack cigarettes (31st May 2007)

153
Irish Cancer Society

• The Irish Cancer Society provide a range of
  services
• Smoking cessation training for Health care
  professionals
• Promotion delivery of the National Smokers
  Quitline
• National Smokers Quitline
• 1850 201 203

154
Thank youIrish Cancer Societywww.cancer.iewww.o
tc.iewww.hse.iewww.ashireland.ie
155
The Irish Cancer Society welcomes you
to
Lung Cancer A Conference for Health Care
Professionals
Thursday 29th March 2007 Stillorgan Park Hotel,
Co. Dublin
Kindly supported by
156
Dr. Barry OConnell
Consultant Respiratory Physician, St. Jamess
Hospital, Dublin
157
Prof. Cliona OFarrelly
Research Immunologist, Education Research
Centre, St. Vincents University Hospital, Dublin
Chairperson, Cancer Research Ireland
158
The Irish Cancer Society welcomes you
to
Lung Cancer A Conference for Health Care
Professionals
Thursday 29th March 2007 Stillorgan Park Hotel,
Co. Dublin
Kindly supported by