EDITORIALS An official ATS/ERS/JRS/ALAT clinical practice guideline: treatment of idiopathic pulmonary fibrosis. An update of the 2011 clinical practice guideline. Am J Respir Crit Care Med 2015;192:e3–e19. 2. Cottin V. Interstitial lung disease. Eur Respir Rev 2013;22:26–32. 3. Wilson KC, Raghu G. The 2015 guidelines for idiopathic pulmonary fibrosis: an important chapter in the evolution of the management of patients with IPF. Eur Respir J 2015;46:883–886. 4. Cottin V, Richeldi L. Neglected evidence in idiopathic pulmonary fibrosis and the importance of early diagnosis and treatment. Eur Respir Rev 2014;23:106–110. 5. Raghu G, Collard HR, Egan JJ, Martinez FJ, Behr J, Brown KK, Colby TV, Cordier JF, Flaherty KR, Lasky JA, et al.; ATS/ERS/JRS/ALAT Committee on Idiopathic Pulmonary Fibrosis. An official ATS/ERS/ JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011;183:788–824. 6. Mallick S. Outcome of patients with idiopathic pulmonary fibrosis (IPF) ventilated in intensive care unit. Respir Med 2008;102: 1355–1359. 7. Gaudry S, Vincent F, Rabbat A, Nunes H, Crestani B, Naccache JM, Wolff M, Thabut G, Valeyre D, Cohen Y, et al. Invasive mechanical ventilation in patients with fibrosing interstitial pneumonia. J Thorac Cardiovasc Surg 2014;147:47–53. 8. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med 2014;370:980. 9. Fernandez-P ´ erez ´ ER, Yilmaz M, Jenad H, Daniels CE, Ryu JH, Hubmayr RD, Gajic O. Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease. Chest 2008;133:1113–1119.
10. Baydur A. Mechanical ventilation in interstitial lung disease: which patients are likely to benefit? Chest 2008;133:1062–1063. 11. Terragni P, Ranieri VM, Brazzi L. Novel approaches to minimize ventilator-induced lung injury. Curr Opin Crit Care 2015;21:20–25. 12. Hoopes CW, Kukreja J, Golden J, Davenport DL, Diaz-Guzman E, Zwischenberger JB. Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg 2013;145:862–867, discussion 867–868. 13. Hayanga AJ, Aboagye J, Esper S, Shigemura N, Bermudez CA, D’Cunha J, Bhama JK. Extracorporeal membrane oxygenation as a bridge to lung transplantation in the United States: an evolving strategy in the management of rapidly advancing pulmonary disease. J Thorac Cardiovasc Surg 2015;149:291–296. 14. Inci I, Klinzing S, Schneiter D, Schuepbach RA, Kestenholz P, Hillinger S, Benden C, Maggiorini M, Weder W. Outcome of extracorporeal membrane oxygenation as a bridge to lung transplantation: an institutional experience and literature review. Transplantation 2015;99:1667–1671. 15. Trudzinski FC, Kaestner F, Schafers ¨ H-J, Fahndrich ¨ S, Seiler F, Bohmer ¨ P, Linn O, Kaiser R, Haake H, Langer F, et al. Outcome of patients with interstitial lung disease treated with extracorporeal membrane oxygenation for acute respiratory failure. Am J Respir Crit Care Med 2016;193:527–533. 16. Lehr CJ, Zaas DW, Cheifetz IM, Turner DA. Ambulatory extracorporeal membrane oxygenation as a bridge to lung transplantation: walking while waiting. Chest 2015;147:1213–1218.
Copyright © 2016 by the American Thoracic Society
Just Say No! Smoking Abstinence Works Lung cancer still remains the leading cause of cancer death in the United States, more than 50 years after the original Surgeon General’s report. In addition, diseases are continuing to be added to the list of risks from smoking, including renal failure, intestinal ischemia, and hypertensive heart disease (1). Smoking cessation, and better yet, lifelong abstinence, remain the best approaches to lowering this dreadful toll (2). Public health measures in the United States are continuing to lower the prevalence of adult smoking, and a current encouraging estimate from the Centers for Disease Control and Prevention for 2014 is a prevalence of 16.8% in the civilian, noninstitutionalized population that is willing to be interviewed (3). Data collection on e-cigarette use began in 2014, and prevalence is estimated at 3.7%. There are now 5 million fewer smokers, at 40.0 million smokers, down from 45 million smokers in 2005. Those individuals aged 65 years or older have the lowest smoking rate, at 8.5%, but this has not changed recently. Unfortunately, the persistence of smoking is seen most commonly in lower socioeconomic groups; for example, the prevalence of smoking in those on Medicaid is estimated to be 29.1%. Screening of high-risk current or former smokers for lung cancer with three annual low-dose computerized tomography (LDCT) scans has been shown to reduce lung cancer mortality by 20% in the definitive NLST (National Lung Screening Trial) (4). There has been a concern that screening may lead to a sense of false reassurance and might encourage smoking resumption or discourage cessation. In this issue of the Journal, Tanner and colleagues (pp. 534–541) review available data from the NLST to assess the effect of smoking abstinence at entry into the study with
476
subsequent mortality (5). Reassuringly, lower mortality is seen for those who have the longest periods of smoking abstinence. Furthermore, coupling smoking abstinence with lung cancer screening with LDCT results in even a further decline in lung cancer mortality. There was, on average, a 9% annual decline in lung cancer mortality for each year of smoking abstinence coupled with screening. Fifteen years of smoking cessation at time of trial entry and LDCT screening led to a lung cancer mortality risk reduction of 38%. A subset of the NLST was analyzed comprising non-Hispanic white and non-Hispanic black individuals (47,902 vs. 2,361, respectively), with 24,190 current and 26,073 former smokers. The full NLST data set does not have information about smoking cessation or persistence during the trial, which limited the analysis to some extent. Information at study entry, including standard demographic, smoking, and comorbid conditions, was assessed. Nonlinear effects of pack-years and quit-years were assessed through quadratic forms of the two variables. Time to lung cancerspecific and overall mortality were the outcomes of interest. The lowest hazard rates for lung cancer mortality were seen in those who smoked the least and had the longest duration of smoking cessation at trial entry. Of importance, this effect was lessened by increasing pack-year history. Current smokers at trial entry were more likely to be African American and less educated. Reassuringly, however, the benefit of smoking cessation was more pronounced among African Americans. Black former smokers, which included 794 individuals at trial entry, had a hazard rate for lung cancer mortality of
American Journal of Respiratory and Critical Care Medicine Volume 193 Number 5 | March 1 2016
EDITORIALS 0.53 (confidence interval, 0.28–1.0) compared with whites. This is very reassuring, as there is evidence that African Americans are at higher risk for lung cancer at lower smoking intensities than whites. There are other analyses of smoking cessation done with data from the NLST. One that Tanner and colleagues mention, by Tammem¨agi and colleagues, did show that after the three rounds of screening in the Lung Screening Study subset of the trial, 77% of the current smokers at the time of trial entry continued to smoke. The article by Tammem¨agi and colleagues had additional highly encouraging information (6). Current smokers were evaluated for smoking cessation, and results were also analyzed by findings on LDCT. Those with normal scans did show a decline in smoking prevalence that continued for the 7 years of assessment (38.2% quit rate). Those with abnormal scans had higher cessations rates; the more abnormal the scan, the higher the rates (43.3% quit: suspicious for lung cancer, new or changed). Other work from the American College of Radiology Imaging Network subset of the NLST assessed smoking cessation advice from primary care providers seen by the NLST participants (7). Unfortunately, as least by participant self-report, the providers were not as thorough in providing smoking cessation advice as they might have been. Of the 5As (ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%) recommended by the U.S. Public Health Service, the options that were more time consuming to offer were offered less frequently. Tanner and colleagues mention similar findings in a survey of thoracic oncologists (5). Clearly, all of us as health care providers need to do more. As part of the Centers for Medicare & Medicaid Services National Coverage Decision for LDCT screening, smoking cessation counseling must be offered (8). It will be critical to assess how smoking cessation effectiveness works in a broader, more community-based setting. Also, even within the NLST, there is a broad variation of risk of lung cancer death when a risk model algorithmic approach, including additional variables outside of smoking cessation, is used. In one analysis of lung cancer death, the lowest risk quintile had no discernible benefit from screening, although the power was low (9). Therefore, more efficient screening strategies may use different criteria than the NLST, excluding those at lower risk while including those outside NLST criteria who are at identifiable high risk. Comparing this type of risk model threshold to the U.S. Preventive Services Task Force criteria in the PLCO (Prostate Lung Colorectal and Ovarian Cancer Screening Trial) chest X-ray arm demonstrates that fewer individuals would need to be screened (8.8%), and 12.4% more lung cancers would be detected (10). In their recommendations for lung cancer screening, the task force acknowledges the importance of this risk assessment and encourages more research in the area (11). Implementation of lung cancer screening will be a serious challenge that must be linked to smoking cessation efforts in those who are current smokers at the time they enter a screening program, both for Centers for Medicare & Medicaid Services reimbursement and for medical appropriateness. There is no substitute for effective tobacco control policies that prevent nonsmokers from starting and support smokers in stopping. Effective measures include bans on tobacco advertising, increases in tobacco taxes, and smoke-free workplaces (12). Screening should be a stop-gap
Editorials
measure until these and other strong antismoking measures bring to an end the tragedy of smoking-related lung cancer. n Author disclosures are available with the text of this article at www.atsjournals.org. Christine D. Berg, M.D. Department of Radiation Oncology and Molecular Radiation Sciences Johns Hopkins Medicine Baltimore, Maryland and Division of Cancer Epidemiology and Prevention National Cancer Institute Bethesda, Maryland
References 1. Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE, Ockene JK, Prentice RL, Speizer FE, Thun MJ, et al. Smoking and mortality: beyond established causes. N Engl J Med 2015;372:631–640. 2. Jha P, Peto R. Global effects of smoking, of quitting, and of taxing tobacco. N Engl J Med 2014;370:60–68. 3. Jamal A, Homa DM, O’Connor E, Babb SD, Caraballo RS, Singh T, Hu SS, King BA. Current cigarette smoking among adults: United States, 2005-2014. MMWR Morb Mortal Wkly Rep 2015;64: 1233–1240. 4. Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365: 395–409. 5. Tanner NT, Kanodra NM, Gebregziabher M, Payne E, Hughes Halbert C, Warren GW, Egede LE, Silvestri GA. The association between smoking abstinence and mortality in the National Lung Screening Trial. Am J Respir Crit Care Med 2016;193:534–541. 6. Tammemagi ¨ MC, Berg CD, Riley TL, Cunningham CR, Taylor KL. Impact of lung cancer screening results on smoking cessation. J Natl Cancer Inst 2014;106:dju084. 7. Park ER, Gareen IF, Japuntich S, Lennes I, Hyland K, DeMello S, Sicks JD, Rigotti NA. Primary care provider-delivered smoking cessation interventions and smoking cessation among participants in the National Lung Screening Trial. JAMA Intern Med 2015;175: 1509–1516. 8. Centers for Medicare & Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG00439N). Baltimore, MD: Centers for Medicare & Medicaid Services [accessed 2015 Feb 22]. Available from: http://www.cms.gov/ medicare-coverage-database/details/nca-decision-memo.aspx? NCAId=274 9. Kovalchik SA, Tammemagi M, Berg CD, Caporaso NE, Riley TL, Korch M, Silvestri GA, Chaturvedi AK, Katki HA. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med 2013;369:245–254. 10. Tammemagi ¨ MC, Church TR, Hocking WG, Silvestri GA, Kvale PA, Riley TL, Commins J, Berg CD. Evaluation of the lung cancer risks at which to screen ever- and never-smokers: screening rules applied to the PLCO and NLST cohorts. PLoS Med 2014;11: e1001764. 11. Moyer VA; U.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160:330–338. 12. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs: 2014. Atlanta, GA: Centers for Disease Control and Prevention; 2014 [accessed 2016 Feb 1]. Available from: http://www.cdc.gov/tobacco/ stateandcommunity/best_practices/pdfs/2014/comprehensive.pdf
Copyright © 2016 by the American Thoracic Society
477
10. Baydur A. Mechanical ventilation in interstitial lung disease: which patients are likely to benefit? Chest 2008;133:1062–1063. 11. Terragni P, Ranieri VM, Brazzi L. Novel approaches to minimize ventilator-induced lung injury. Curr Opin Crit Care 2015;21:20–25. 12. Hoopes CW, Kukreja J, Golden J, Davenport DL, Diaz-Guzman E, Zwischenberger JB. Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg 2013;145:862–867, discussion 867–868. 13. Hayanga AJ, Aboagye J, Esper S, Shigemura N, Bermudez CA, D’Cunha J, Bhama JK. Extracorporeal membrane oxygenation as a bridge to lung transplantation in the United States: an evolving strategy in the management of rapidly advancing pulmonary disease. J Thorac Cardiovasc Surg 2015;149:291–296. 14. Inci I, Klinzing S, Schneiter D, Schuepbach RA, Kestenholz P, Hillinger S, Benden C, Maggiorini M, Weder W. Outcome of extracorporeal membrane oxygenation as a bridge to lung transplantation: an institutional experience and literature review. Transplantation 2015;99:1667–1671. 15. Trudzinski FC, Kaestner F, Schafers ¨ H-J, Fahndrich ¨ S, Seiler F, Bohmer ¨ P, Linn O, Kaiser R, Haake H, Langer F, et al. Outcome of patients with interstitial lung disease treated with extracorporeal membrane oxygenation for acute respiratory failure. Am J Respir Crit Care Med 2016;193:527–533. 16. Lehr CJ, Zaas DW, Cheifetz IM, Turner DA. Ambulatory extracorporeal membrane oxygenation as a bridge to lung transplantation: walking while waiting. Chest 2015;147:1213–1218.
Copyright © 2016 by the American Thoracic Society
Just Say No! Smoking Abstinence Works Lung cancer still remains the leading cause of cancer death in the United States, more than 50 years after the original Surgeon General’s report. In addition, diseases are continuing to be added to the list of risks from smoking, including renal failure, intestinal ischemia, and hypertensive heart disease (1). Smoking cessation, and better yet, lifelong abstinence, remain the best approaches to lowering this dreadful toll (2). Public health measures in the United States are continuing to lower the prevalence of adult smoking, and a current encouraging estimate from the Centers for Disease Control and Prevention for 2014 is a prevalence of 16.8% in the civilian, noninstitutionalized population that is willing to be interviewed (3). Data collection on e-cigarette use began in 2014, and prevalence is estimated at 3.7%. There are now 5 million fewer smokers, at 40.0 million smokers, down from 45 million smokers in 2005. Those individuals aged 65 years or older have the lowest smoking rate, at 8.5%, but this has not changed recently. Unfortunately, the persistence of smoking is seen most commonly in lower socioeconomic groups; for example, the prevalence of smoking in those on Medicaid is estimated to be 29.1%. Screening of high-risk current or former smokers for lung cancer with three annual low-dose computerized tomography (LDCT) scans has been shown to reduce lung cancer mortality by 20% in the definitive NLST (National Lung Screening Trial) (4). There has been a concern that screening may lead to a sense of false reassurance and might encourage smoking resumption or discourage cessation. In this issue of the Journal, Tanner and colleagues (pp. 534–541) review available data from the NLST to assess the effect of smoking abstinence at entry into the study with
476
subsequent mortality (5). Reassuringly, lower mortality is seen for those who have the longest periods of smoking abstinence. Furthermore, coupling smoking abstinence with lung cancer screening with LDCT results in even a further decline in lung cancer mortality. There was, on average, a 9% annual decline in lung cancer mortality for each year of smoking abstinence coupled with screening. Fifteen years of smoking cessation at time of trial entry and LDCT screening led to a lung cancer mortality risk reduction of 38%. A subset of the NLST was analyzed comprising non-Hispanic white and non-Hispanic black individuals (47,902 vs. 2,361, respectively), with 24,190 current and 26,073 former smokers. The full NLST data set does not have information about smoking cessation or persistence during the trial, which limited the analysis to some extent. Information at study entry, including standard demographic, smoking, and comorbid conditions, was assessed. Nonlinear effects of pack-years and quit-years were assessed through quadratic forms of the two variables. Time to lung cancerspecific and overall mortality were the outcomes of interest. The lowest hazard rates for lung cancer mortality were seen in those who smoked the least and had the longest duration of smoking cessation at trial entry. Of importance, this effect was lessened by increasing pack-year history. Current smokers at trial entry were more likely to be African American and less educated. Reassuringly, however, the benefit of smoking cessation was more pronounced among African Americans. Black former smokers, which included 794 individuals at trial entry, had a hazard rate for lung cancer mortality of
American Journal of Respiratory and Critical Care Medicine Volume 193 Number 5 | March 1 2016
EDITORIALS 0.53 (confidence interval, 0.28–1.0) compared with whites. This is very reassuring, as there is evidence that African Americans are at higher risk for lung cancer at lower smoking intensities than whites. There are other analyses of smoking cessation done with data from the NLST. One that Tanner and colleagues mention, by Tammem¨agi and colleagues, did show that after the three rounds of screening in the Lung Screening Study subset of the trial, 77% of the current smokers at the time of trial entry continued to smoke. The article by Tammem¨agi and colleagues had additional highly encouraging information (6). Current smokers were evaluated for smoking cessation, and results were also analyzed by findings on LDCT. Those with normal scans did show a decline in smoking prevalence that continued for the 7 years of assessment (38.2% quit rate). Those with abnormal scans had higher cessations rates; the more abnormal the scan, the higher the rates (43.3% quit: suspicious for lung cancer, new or changed). Other work from the American College of Radiology Imaging Network subset of the NLST assessed smoking cessation advice from primary care providers seen by the NLST participants (7). Unfortunately, as least by participant self-report, the providers were not as thorough in providing smoking cessation advice as they might have been. Of the 5As (ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%) recommended by the U.S. Public Health Service, the options that were more time consuming to offer were offered less frequently. Tanner and colleagues mention similar findings in a survey of thoracic oncologists (5). Clearly, all of us as health care providers need to do more. As part of the Centers for Medicare & Medicaid Services National Coverage Decision for LDCT screening, smoking cessation counseling must be offered (8). It will be critical to assess how smoking cessation effectiveness works in a broader, more community-based setting. Also, even within the NLST, there is a broad variation of risk of lung cancer death when a risk model algorithmic approach, including additional variables outside of smoking cessation, is used. In one analysis of lung cancer death, the lowest risk quintile had no discernible benefit from screening, although the power was low (9). Therefore, more efficient screening strategies may use different criteria than the NLST, excluding those at lower risk while including those outside NLST criteria who are at identifiable high risk. Comparing this type of risk model threshold to the U.S. Preventive Services Task Force criteria in the PLCO (Prostate Lung Colorectal and Ovarian Cancer Screening Trial) chest X-ray arm demonstrates that fewer individuals would need to be screened (8.8%), and 12.4% more lung cancers would be detected (10). In their recommendations for lung cancer screening, the task force acknowledges the importance of this risk assessment and encourages more research in the area (11). Implementation of lung cancer screening will be a serious challenge that must be linked to smoking cessation efforts in those who are current smokers at the time they enter a screening program, both for Centers for Medicare & Medicaid Services reimbursement and for medical appropriateness. There is no substitute for effective tobacco control policies that prevent nonsmokers from starting and support smokers in stopping. Effective measures include bans on tobacco advertising, increases in tobacco taxes, and smoke-free workplaces (12). Screening should be a stop-gap
Editorials
measure until these and other strong antismoking measures bring to an end the tragedy of smoking-related lung cancer. n Author disclosures are available with the text of this article at www.atsjournals.org. Christine D. Berg, M.D. Department of Radiation Oncology and Molecular Radiation Sciences Johns Hopkins Medicine Baltimore, Maryland and Division of Cancer Epidemiology and Prevention National Cancer Institute Bethesda, Maryland
References 1. Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE, Ockene JK, Prentice RL, Speizer FE, Thun MJ, et al. Smoking and mortality: beyond established causes. N Engl J Med 2015;372:631–640. 2. Jha P, Peto R. Global effects of smoking, of quitting, and of taxing tobacco. N Engl J Med 2014;370:60–68. 3. Jamal A, Homa DM, O’Connor E, Babb SD, Caraballo RS, Singh T, Hu SS, King BA. Current cigarette smoking among adults: United States, 2005-2014. MMWR Morb Mortal Wkly Rep 2015;64: 1233–1240. 4. Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365: 395–409. 5. Tanner NT, Kanodra NM, Gebregziabher M, Payne E, Hughes Halbert C, Warren GW, Egede LE, Silvestri GA. The association between smoking abstinence and mortality in the National Lung Screening Trial. Am J Respir Crit Care Med 2016;193:534–541. 6. Tammemagi ¨ MC, Berg CD, Riley TL, Cunningham CR, Taylor KL. Impact of lung cancer screening results on smoking cessation. J Natl Cancer Inst 2014;106:dju084. 7. Park ER, Gareen IF, Japuntich S, Lennes I, Hyland K, DeMello S, Sicks JD, Rigotti NA. Primary care provider-delivered smoking cessation interventions and smoking cessation among participants in the National Lung Screening Trial. JAMA Intern Med 2015;175: 1509–1516. 8. Centers for Medicare & Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG00439N). Baltimore, MD: Centers for Medicare & Medicaid Services [accessed 2015 Feb 22]. Available from: http://www.cms.gov/ medicare-coverage-database/details/nca-decision-memo.aspx? NCAId=274 9. Kovalchik SA, Tammemagi M, Berg CD, Caporaso NE, Riley TL, Korch M, Silvestri GA, Chaturvedi AK, Katki HA. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med 2013;369:245–254. 10. Tammemagi ¨ MC, Church TR, Hocking WG, Silvestri GA, Kvale PA, Riley TL, Commins J, Berg CD. Evaluation of the lung cancer risks at which to screen ever- and never-smokers: screening rules applied to the PLCO and NLST cohorts. PLoS Med 2014;11: e1001764. 11. Moyer VA; U.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160:330–338. 12. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs: 2014. Atlanta, GA: Centers for Disease Control and Prevention; 2014 [accessed 2016 Feb 1]. Available from: http://www.cdc.gov/tobacco/ stateandcommunity/best_practices/pdfs/2014/comprehensive.pdf
Copyright © 2016 by the American Thoracic Society
477
