Month: September 2024

Combo CT Screening Detects More Disease

Posted on by Brian Casey

A CT lung cancer screening program that also offered abdominal non-contrast CT scans detected a large number of abnormalities outside the lung in a population of people with smoking histories. The combined approach could offer a more efficient way to detect multiple pathologies in a single patient visit. 

CT lung cancer screening is gaining momentum globally, but clinicians and researchers continue to look for ways to make it more valuable. 

  • That’s a good thing, because smoking is a risk factor not just for lung cancer, but also other pathologies like abdominal aortic aneurysm (AAA) – so why not screen for those at the same time?

In a paper in European Urology, U.K. researchers describe their Yorkshire Kidney Screening Trial (YKST), which sought to detect kidney cancer by piggybacking on the county’s existing CT lung cancer screening program. 

  • Abdominal non-contrast CT exams were offered at the same time as thoracic CT lung screening scans to high-risk people who met the lung program’s screening criteria, namely aged 50-85 and more than 30 pack-years of smoking history. 

In all, 4k people accepted the offer to get additional abdominal CT scans, which had the following findings …

  • 64% of patients had normal findings, while another 20% had images that required additional review but no further action.
  • 5.3% had a new serious finding.
  • Serious findings were broken down as follows: renal stones ≥ 5 mm (3%), AAA (1.5%), renal mass/complex cysts (0.62%), kidney cancers (0.25%), and other cancers (0.25%).
  • It took 13 minutes of additional time to perform the abdominal CT scan.

Researchers said the prevalence of additional disease in YKST was within the range of other U.K. screening programs, such as for colorectal cancer (0.16-0.61%) and breast cancer (0.92%). 

  • The high prevalence of AAA was “unexpected,” especially since many AAA cases were found in people who aren’t covered by existing AAA screening programs. 

The Takeaway

As with recent research combining CT lung screening with coronary artery calcium (CAC) scoring, the new study shows that lung screening offers an opportunity to screen for more than just lung cancer. By detecting additional disease, combo screening has the potential to flip the script when it comes to screening’s cost-benefit ratio. 

Why the FDA’s Density Rule Matters

Posted on by Brian Casey

The FDA’s new rules on reporting breast density to women getting mammograms went into effect on September 10. The implementation has been expected for some time, but this week’s rollout generated a wave of positive press coverage that highlights the importance both of breast density awareness and of breast screening.

The FDA in March 2023 said it would implement a national standard requiring providers to inform women of their breast density, which can obscure lesions on conventional X-ray mammography. 

  • Breast density is also a risk factor for cancer, and patient advocacy groups had been pressuring the FDA to set a standard to replace what has become a patchwork of state-by-state notification rules. 

The FDA’s rules have been incorporated into the Mammography Quality Standards Act, and require that … 

  • Mammography reports include a plain-language patient summary with “an overall assessment of breast density.” 
  • The summary must include specific language that defines breast density, explains its ramifications for detection and cancer risk, and suggests the need for additional imaging tests.

A novel aspect of the new rules is that they were mostly driven by patients – women like JoAnn Pushkin and the late Nancy Cappello who as patients discovered first-hand the shortcomings of X-ray-based mammography for women with dense breast tissue. 

What’s next? Density-awareness proponents are now turning their attention to reimbursement, which for supplemental imaging is inconsistent across the U.S.

  • A fix for the problem – the Find It Early Act – is working its way through Congress, and women’s health advocates lobbied on Capitol Hill this week to try to push the legislation through before the end of the current Congressional session. 

The new reporting landscape also creates opportunities for better software tools to detect and manage breast density and better predict risk in patients with dense breast tissue. 

  • Clinicians already realize that women with dense breasts not only need different screening modalities like MRI and ultrasound, but that they might also require more frequent screening due to their heightened cancer risk. 

The Takeaway

The FDA’s new breast density rules matter for a variety of reasons, from showing the power of patients to change their imaging experience to outlining a future in which risk plays a more prominent role in breast screening. While more work remains to be done, this is a good time to savor the triumph.

Lung Screening’s Star Turn at WCLC 2024

Posted on by Brian Casey

The World Conference on Lung Cancer (WCLC) is underway in San Diego this week, and CT lung cancer screening has had a starring role at the meeting. The sessions come as lung screening continues to build momentum through 2024. 

Low-dose CT lung screening got the green light from the USPSTF over a decade ago, but screening rates are still mired in the single digits in many regions. 

  • The evidence backing LDCT’s life-saving value has been building, however, and around the world countries are launching national screening programs to counter the smoking epidemic, the leading cause of preventable cancer death worldwide.

Sessions at WCLC 2024 have highlighted this progress, with many speakers focusing on ways to boost screening compliance or use tools like AI to detect more lung cancers. 

Presentations on early lung cancer detection have included the following findings… 

  • Three years of lung screening starting in 2021 in Quebec produced a lung cancer detection rate of 1.6% in the first screening round, with 85% of cancers stage I or II.
  • Advanced practitioner nurses are being trained in Australia to assess pulmonary nodules to alleviate workforce challenges when the country’s national lung screening program starts in July 2025. 
  • Using Coreline Soft’s AVIEW algorithm to read baseline LDCT exams helped BioMILD researchers move to a triennial screening interval without missing cancers. 
  • The QUILS system for lung cancer quality assurance helped assess quality across multiple LDCT screening sites in Kentucky.
  • Over 10 years in which 2.3k patients were scanned, researchers found a 3.7% lung cancer detection rate and 100% survival for early-stage cancer.
  • Among 4.2k patients, those who got screened had more stage I-II disease (72% vs. 37%) and higher rates of surgery-only treatment (56% vs. 25%) at three years. 
  • Using PanCan criteria to manage suspicious lung nodules worked better than Lung-RADS in 4.5k people screened, with fewer workup referrals (2.8% vs. 7.4%) and better PPV for high-risk malignancy (48% vs. 18%).

The Takeaway

This is just a selection of the exciting research being presented at WCLC 2024. It seems evident that CT lung screening’s future as a mainstream cancer test is closer than ever.

Imaging News from ESC 2024

Posted on by Brian Casey

The European Society of Cardiology annual meeting concluded on September 2 in London, with around 32k clinicians from 171 countries attending some 4.4k presentations. Organizers reported that attendance finally rebounded to pre-COVID numbers. 

While much of ESC 2024 focused on treatments for cardiovascular disease, diagnosis with medical imaging still played a prominent role. 

  • Cardiac CT dominated many ESC sessions, and AI showed it is nearly as hot in cardiology as it is in radiology. 

Major imaging-related ESC presentations included…

  • A track on cardiac CT that underscored CT’s prognostic value:
    • Myocardial revascularization patients who got FFR-CT had lower hazard ratios for MACE and all-cause mortality (HR=0.73 and 0.48).
    • Incidental coronary artery anomalies appeared on 1.45% of CCTA scans for patients with suspected coronary artery disease.
  • AI flexed its muscles in a machine learning track:
    • AI of low-dose CT scans had an AUC of 0.95 for predicting pulmonary congestion, a sign of acute heart failure. 
    • Echocardiography AI identified HFpEF with higher AUC than clinical models (0.75 vs. 0.69).
    • AI of transthoracic echo detected hypertrophic cardiomyopathy with AUC=0.85.

Another ESC hot topic was CT for calculating coronary artery calcium (CAC) scores, a possible predictor of heart disease. Sessions found … 

  • AI-generated volumetry of cardiac chambers based on CAC scans better predicted cardiovascular events than Agatston scores over 15 years of follow-up in an analysis of 5.8k patients from the MESA study. 
  • AI-CAC with CT was comparable to cardiac MRI read by humans for predicting atrial fibrillation (0.802 vs. 0.798) and stroke (0.762 vs. 0.751) over 15 years, which could give an edge to AI-CAC given its automated nature.
  • An AI algorithm enabled opportunistic screening of CAC quantification from non-gated chest CT scans of 631 patients, finding high CAC scores in 13%. Many got statins, while 22 got additional imaging and 2 intervention.
  • AI-generated CAC scores were also highlighted in a Polish study, detecting CAC on contrast CT at a rate comparable to humans on non-contrast CT (77% vs. 79%), possibly eliminating the need for additional non-contrast CT.  

The Takeaway

This week’s ESC 2024 sessions demonstrate the vital role of imaging in diagnosing and treating cardiovascular disease. While radiologists may not control the patients, they can always apply knowledge of advances in other disciplines to their work.

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