Nearly One-Third Have Scans Requiring Follow-Up

By Brenda L. Mooney

At the VA Portland, OR, Healthcare System, one of eight VA facilities chosen to develop a comprehensive a lung cancer screening system,  Christopher Slatore, MD, MS, and Mark Deffebach, MD,  stand next to a CT scanner, like those used in their research. VA photo

At the VA Portland, OR, Healthcare System, one of eight VA facilities chosen to develop a comprehensive a lung cancer screening system, Christopher Slatore, MD, MS, and Mark Deffebach, MD, stand next to a CT scanner, like those used in their research. VA photo

BETHESDA, MD — When it comes to the war against lung cancer, Walter Reed National Military Medical Center (WRNMMC)  is on the front lines.

The reason? Military servicemembers and veterans are at much greater risk of developing lung cancer — and at lower risk of survival — than other Americans, primarily because of higher smoking rates as well as dangerous occupational exposures, according to research.

With a lung cancer screening program first established at WRNMMC in 2012, “rates of suspected and confirmed early stage lung cancer have exceeded our expectations and are a direct result of screening our patients, which often have a significant smoking history,” said Army Col. Craig Shriver, MD, director of the facility’s Murtha Cancer Center (MCC).

“Currently, 30% of our patients have a CT scan that needs to be followed closely,” Shriver told U.S. Medicine. “Of all the screening CT scans, we have detected early stage cancer in almost 5% of scans being performed.”

The program was put into place after the National Lung Screening Trial (NLST) published results in 2011. It indicated that patients at high risk for lung cancer based on smoking history and age gained a 20% mortality benefit from annual lung cancer screening with low-dose computed tomography (LDCT) for three years, compared to those screened with chest radiography.

“The importance of this program was determined after the NLST trial results were published,” Shriver recounted. “Understanding new literature and how it may be applied is a cornerstone of military medicine. The program was developed after a committee reviewed the literature, and then they attempted to apply it to our beneficiaries. We believed a program like this could be introduced and it would result in a direct benefit to our beneficiaries.”

In 2013, the pilot program was expanded to four major military medical centers as well as eight sites in the VHA system, with about 8,000 new lung cancer cases a year. The demonstration project was conducted at the VA New York Harbor, Durham, NC, VAMC; Ralph H. Johnson VAMC in Charleston, SC; Cincinnati VAMC; VA Ann Arbor, MI, Healthcare System, Portland, OR, VAMC; San Francisco VAMC; and Minneapolis VA Healthcare System. Technical support to develop clinical reminders and a project database is being provided by the Pittsburgh Veterans Engineering Resource Center.

The VHA’s Lung Cancer Screening Demonstration Project (LCSDP) was completed last year, and screening now is recommended for veterans 55 to 80 who have smoked one pack per day for 30 years (or a comparable amount, such as ½ pack per day for 60 years or two packs a day for 15 years) and are still smoking or have quit less than 15 years ago and who don’t have medical conditions that might limit expected life to less than five years.

That criteria likely covers a lot of veterans and active-duty personnel.

The national Centers for Disease Control and Prevention notes that, in 2011, 24.0% of all active-duty military personnel reported currently smoking cigarettes, compared with 19.0% of civilians, with the smoking rates highest in those who have been deployed. During 2007-2010, meanwhile, male veterans aged 25 — 64 years were significantly more likely to be current smokers than nonveterans — 29.0% vs. 24.0%.

A 2014 presentation by Corey A. Carter, MD, chief of Thoracic Oncology for the Murtha Cancer Center (MCC) at Walter Reed National Military Medical Center (WRNMMC), pointed out that 47% of Vietnam veterans are smokers, with 70% having smoked at some point. The percentage of current smokers is similar for Gulf War veterans.

Carter’s presentation also noted that World War II and Korean War veterans have 35% excess lung cancer mortality over the general population

Smoking isn’t the only issue, however. Military personnel are much more likely to have been exposed to Agent Orange, radon, asbestos chromium, diesel exhaust, pesticides, pollutants and particulate matter from burn pits, oil well fires and destruction of chemical weapons, according to the Lung Cancer Alliance.

“The only current link in exposure is Agent Orange exposure during Vietnam,” the group said. “Tracking our exposures has been a focus of the lung cancer-screening program. Risk factors contributing from other military exposures are unknown. We know servicemembers are often exposed to diesel and jet fuels, oil fires, dust storms and burn pits. These potential risk factors are tracked during initial evaluation and updated with each screening visit.”

In fact, lung cancer has been deemed service-connected for in theater Vietnam veterans, and higher rates of the deadly disease were reported in Gulf War veterans in a 2010 study and a 2014 update.

Some of the problem is linked to the U.S. military services’ long love affair with cigarettes. It wasn’t until 1975 that the military stopped issuing cigarettes as part of k-rations and 1996 when it stopped subsiding tobacco. That final year, the DoD spent $30 million subsidizing those products provided to servicemembers.

Cigarettes sold on military bases remained at a substantial discount for the next five years, but, in 2001, the DoD required that cigarettes sold at their facilities must be within in 5% of local prices and, four years later, that their costs be equal to local prices.

Before the lung cancer screening program, no routine screening was available for patients without symptoms of lung cancer or another abnormality that required a chest CT. Once the lung cancer screening program was being established, Walter Reed decided to follow two criteria based on the National Comprehensive Cancer Network’s (NCCN) screening guidelines. One closely tracks Medicare reimbursement guidelines for lung cancer screening and makes the program available to patients 55-80 who have at least a 30-pack-a-year history of smoking and who currently smoke or who quit smoking fewer than 15 years ago. The second criteria allows screening of patients 50 and older who have at least a 20-pack-a-year history of smoking and who have one additional risk factor, such as a family history of cancer, pulmonary fibrosis, or past exposure to toxic chemicals such as asbestos, radon, agent orange, or silica/silicon.”

“We apply these guidelines to decide who will undergo screening,” Shriver added. “Any TRICARE beneficiary can request evaluation of risk factors and if the meet the eligibility criteria for screening.”

Any current smokers being screened are referred to a cessation program.

“A screening program is designed for early detection of cancer,” Shriver pointed out. “Our program requires all patients be seen for smoking cessation if a patient is currently smoking. We have seen an increase in smoking cessation and a reduction in the amount a patient smokes in our patients being referred to our screening program.”

As to the reduction in lung cancer mortality, he points out that the study is a long-term one. “We have to assume that the approximate 5% detection of early stage lung cancer has resulted in improved survival for these patients,” Shriver said.