Lung cancer screenings can uncover treatable emphysema in patients

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When patients aged 50 years or older have a significant history of smoking, primary care physicians often order lung cancer screenings with low-dose computed tomography (LDCT) scans. Recent evidence indicates that more can be done with these LDCT scans than just detect cancer: They can also detect emphysema, a severe form of chronic obstructive pulmonary disease (COPD) for which nonsurgical treatment options are expanding.

Lung cancer is the second most common cancer and the leading cause of cancer-related death in the United States, with about 226,700 new diagnoses expected in the next year. Annual LDCT screenings are now recommended for people over 50 with a smoking history of 20 or more pack-years. More than 14 million Americans are eligible.

Patients with emphysema have damaged alveoli (air sacs), which results in air trapping inside the lungs. When there is air trapping, the lungs become hyperinflated, the chest may appear fuller or have a barrel-chested appearance, and breathing becomes difficult, causing patients to experience shortness of breath. With fewer alveoli, less oxygen moves into your bloodstream. As a result, physical activity is decreased and there is a deterioration or negative impact on the quality of life. While most cases of COPD/emphysema are diagnosed as a result of symptom-prompting and are found with advanced disease during routine clinical care, research published in The Annals of the American Thoracic Society shows that emphysema is detected in 24% to 31% of patients undergoing lung cancer screening. This means that for millions of Americans, these scans can serve a dual purpose: detecting both cancer and emphysema.

Advanced treatment options are now available

Narinder S. Shargill, PhD
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As new treatment options emerge, early detection of emphysema is more likely to lead to additional and effective interventional care than in the past — because positive outcomes depend heavily on identifying candidates early, before the disease progresses and limits treatment effectiveness. Traditionally, the standard of care for patients with advanced emphysema has included medical management consisting of medications (bronchodilators and/or corticosteroids (inhalers)), pulmonary rehabilitation, oxygen supplementation, and, in the most severe cases, lung volume reduction surgery or lung transplantation. Yet, there has long been a gap in options between noninvasive medical management and more high-risk surgical approaches. Many patients remain symptomatic despite optimal medical management, and surgical procedures carry significant risk, making them seldom used.

Today, a minimally invasive standard of care option called bronchoscopic lung volume reduction (BLVR) is available to help address this treatment gap for select patients with severe COPD/emphysema.

In the typical BLVR procedure, FDA-approved Zephyr Endobronchial Valves (EBVs), about the size of a pencil eraser, are bronchoscopically placed in the most diseased part of the lung. Without the need for cutting or incisions, the one-way valves allow trapped air to escape, reducing hyperinflation and helping inhaled oxygen reach healthier lung tissue. This can make breathing easier, reduce the shortness of breath and help patients increase their activity levels. The procedure is supported by strong clinical evidence and is now recommended in COPD management guidelines (GOLD). Furthermore, it is a reversible procedure, as the valves can be removed if necessary.

While BLVR treatment is not a cure for the disease, it is an effective intervention method that can help certain patients with severe emphysema regain independence in their daily lives. Many patients report being able to walk longer distances, climb the stairs without extreme breathlessness, and complete everyday tasks — such as shopping or household chores — with greater ease¹.

Complications of the ZephyrEndobronchial Valve treatment can include but are not limited to pneumothorax, worsening of COPD symptoms, hemoptysis, pneumonia, dyspnea and, in rare cases, death.

Valve placement can be economically sustainable

In addition to yielding positive clinical outcomes, new research indicates that BLVR is economically sustainable for organizations that provide interventional pulmonology. A recent analysis from Beth Israel Deaconess Medical Center in Boston evaluated the potential value of the new treatment option and found that a BLVR program can lead to patient referrals for a medical center and is economically viable.

Artificial intelligence-powered detection

So how are eligible patients initially identified? In some cases, clinicians reviewing CT scans may notice some degree of emphysematous destruction, hyperinflation of the lungs or an abnormal shape (flattening) of the diaphragm. New artificial intelligence (AI) tools are also emerging to support early detection by analyzing LDCT scan images and flagging and quantifying radiographic evidence of emphysema. In one cohort, such tools found that between 10.5% and 18% of lung cancer screening CT scans had a high level of emphysema.

Integrated platforms can help cross-reference CT findings with other patient data — such as pulmonary function test results, comorbidities and smoking history — to assess whether patients may meet eligibility criteria for additional treatment options, including EBV therapy.

What primary care physicians can do

The next challenge is increasing lung cancer screening participation. In 2020, there were approximately 8.5 million adults eligible for lung cancer screening, yet only 6.5% (about 552,500 people) were screened that year. Physicians and other clinicians can play a proactive role in improving this rate. According to the American Cancer Society (ACS), patients are more likely to get screened after an “empathetic, comprehensive conversation with a health care professional.”

“The No. 1 reason people give for not getting a lung cancer screening test is that their health care provider didn’t talk to them about it at all, or didn’t talk to them thoroughly,” said Robert Smith, PhD, senior vice president for early cancer detection science at ACS.

ACS supports a team-based approach to assess eligibility and risk, including educating patient-facing staff to collaborate on the referral process. ACS also mentions the value of coordinated care of eligible patients: “Some of the highest lung cancer screening rates are achieved in settings where the provider can refer the patient to a clinic where everything is managed under one roof: risk assessment, shared decision-making, smoking-cessation support, screening referral and follow-up tracking.”

Better reporting leads to better outcomes

Another priority is standardizing radiological reporting for emphysema identified during lung cancer screening. Clear, consistent documentation and communication with both patients and referring providers can help ensure follow-up and appropriate care planning.

Lung cancer screening is inherently valuable, and its benefits increase when other addressable conditions — like emphysema — are identified in the process. With new, minimally invasive treatment options available, physicians and other clinicians can help more patients access the care they need by encouraging screening, initiating conversations, and building pathways for timely diagnosis and intervention.

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Narinder Singh Shargill, PhD, is vice president of global medical affairs at Pulmonx.