It was just before sunrise on a brisk Tuesday morning, and inside a nondescript white room at Columbus Regional Hospital, seven medical professionals are gathered around a television screen poring over an image of a patient’s lungs.
The doctors observed something in one of the lungs that had concerned them — a “high-risk” nodule that had an elevated risk of being cancerous. It was the fifth suspicious nodule they had reviewed that morning.
The good news is that medical professionals from every specialty needed to treat early-stage lung cancer were reviewing the images together.
The doctors are part of CRH’s Lung Nodule Review Board, a multi-disciplinary team of radiologists, radiation oncologists, cardiothoracic surgeons, a pulmonologist, a coordinator and a nurse practitioner who meet at the hospital every Tuesday morning to fast-track the diagnosis and treatment of lung nodules that could be cancerous.
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The bad news, however, is that if this particular nodule that was identified did turn out to be cancer, it would be the latest in a startling trend that CRH officials have seen as the number of low-cost lung cancer screenings has increased since 2017.
The prevalence of lung cancer among Bartholomew County patients is twice the rate found in an authoritative national study of high-risk individuals diagnosed with the disease.
“We’ve found double the national average in Bartholomew County,” said Dr. Greg Dedinsky, cardiothoracic surgeon at Columbus Regional Hospital, who is on the Lung Nodule Review Board.
In 2017 and 2018, CRH’s Lung Screening Program detected 23 cases of lung cancer out of 1,113 screenings, according to data from the hospital system.
Approximately 63 percent of the patients screened were from Bartholomew County, and 21 of the 23 cancers were found in Columbus residents, according to Sarah Abel, lung navigator who coordinates the Lung Nodule Review Board.
The remaining two cases were found in patients from Butlerville, near North Vernon, and Vevay, a town on the Indiana side of the Ohio River in Switzerland County.
Patient characteristics
The patients screened by CRH officials were typically between the ages of 55 and 80 years old, had a history of “heavy smoking” and were smoking at the time of the screening or had quit in the 15 years prior to the screening.
Heavy smoking is defined as having a smoking history of “30 pack years,” which is the equivalent of smoking one pack per day for 30 years or two packs per day for 15 years, CRH officials said.
The national figures come from the National Lung Screening Trial, a study by the National Cancer Institute that compared the effectiveness of two methods for detecting lung cancer, low-dose computerized tomography, or CT, scans and standard chest X-rays.
The trial found, among other things, an overall national lung cancer incidence rate of 1.13 percent.
In 2017 and 2018, the rate among Bartholomew County residents screened by CRH officials was trending at around 2.9 percent, according to data provided by CRH. The overall rate among all patients screened in the program was 2.1 percent.
Based on the prevalence rate in the national trial, CRH officials should have expected to find approximately 13 cases of lung cancer in Bartholomew County. Instead, they found 21.
Dedinsky said the higher local prevalence rate was likely because Bartholomew County-area residents tend to be “under-screened and they smoke a lot.”
Smoking tobacco is responsible for around 90 percent of lung cancer cases in the U.S., according to the American Lung Association.
Bartholomew County, for its part, has a higher smoking rate than the state and national averages and has the second highest smoking rate among neighboring counties, according to data from the Indiana State Department of Health.
As of January, an estimated one in four adults in Bartholomew County smoke. In Jennings County, one in three adults smoke.
In Brown County, 18 percent of adults are smokers, and Jackson County has an adult smoking rate of 21 percent.
Hamilton County has the lowest smoking rate in Indiana, at 10 percent, while Miami County had the highest smoking rate in the state, 44 percent, according to state figures.
The state average in Indiana is 21.8 percent, or roughly one in five adults. The national average is 17.1 percent.
However, smoking is not the only risk factor for lung cancer.
Other factors
Long-term exposure to radon is the second-leading cause of lung cancer in the U.S., according to the American Lung Association.
Radon is a radioactive gas that is released when uranium, thorium or radium in soil decays, according to the National Cancer Institute. The gas is invisible, odorless and tasteless, and it can seep into buildings or groundwater. When breathed in, radon particles can damage cells in the lungs and long-term exposure can lead to lung cancer.
Bartholomew and Jennings counties have a higher than average potential for radon exposure, according to the U.S. Environmental Protection Agency. Brown County and Jackson County have moderate potential.
Additional risk factors for lung cancer include exposure to high levels of air pollution, genetic factors, as well as exposure to certain hazardous materials, including asbestos, uranium, arsenic, cadmium, chromium, nickel and some petroleum-based products.
Between 10 and 15 percent of new cases of lung cancers are detected in people who have never smoked, according to LUNGevity Foundation, an organization that seeks to raise awareness about lung cancer and increase funding for scientific research geared toward increasing survival rates of lung cancer.
Established on Valentine’s Day in 2017, the local Lung Nodule Review Board brings together doctors from a variety of specialties — radiologists, radiation oncologists, cardiothoracic surgeons, a pulmonologist, a coordinator and a nurse practitioner — to work collectively to diagnose lung nodules and map out treatment plans for patients.
CRH’s Lung Nodule Review Board was modeled after a similar review board at Deaconess Hospital in Evansville, Abel said.
CRH’s Lung Nodule Review Board meets every Tuesday morning in the Cancer Center at Columbus Regional Hospital. CRH officials allowed a Republic reporter to sit in at the end of the Lung Nodule Review Board’s meeting on March 19, but removed any personally identifying information of any patients before allowing reporters into the room. The Republic had no knowledge of who any of the patients were or any details of their cases.
Dr. Deepankar Sharma, interventional pulmonologist at Columbus Regional Hospital, who is on the Lung Nodule Review Board, said the idea behind the Lung Cancer Screening Program is to detect and treat lung cancers in early stages, when the disease has a much higher chance of being cured. So far, the screening program has been a success, he said.
“Seventy percent of (the cases) we have found are in stages 1 and 2,” Sharma said. “… There’s a huge contrast between (detecting lung cancer) in the early stages and the late stages, and that is what this screening has changed. We went from finding most of these cancers in late stages. Now we are finding most of these cancers in early stages.”
Sharma said stage 1 or 2 lung cancer has a 80 percent chance of being cured and patients typically have a life expectancy of at least five years. Patients with stage 3 or 4 lung cancer typically have a life expectancy of nine months to one year and, at most, a 15 percent chance of being cured.
Early-stage lung cancer has no symptoms, the doctors said. Symptoms, like coughing up blood, chest pain or a cough that doesn’t go away, are usually not noticeable until the cancer has spread to other parts of the body and is much more difficult to cure.
“Lung cancer, over the years, has had very high mortality — more than breast, prostate and colon (cancers) combined,” Sharma said.
The five-year survival rate for lung cancer is 18.6 percent, three times lower than colon cancer, according to the American Lung Association. The five-year survival rate for breast cancer is 89.6 percent. For prostate cancer, it’s 98.2 percent.
The rate of lung cancer deaths in Bartholomew County is 47.5 deaths per 100,000 residents — 13.6 percent higher than the national average. The statewide average in Indiana is 50.7 deaths per 100,000 residents.
Lung cancer is most prevalent in older people, with most cases being diagnosed in patients who are at least 65 years old, according to the American Cancer Society.
The American Cancer Society estimates that there will be around 228,150 new cases of lung cancer in the U.S. this year, as well as approximately 142,670 deaths from lung cancer in 2019. Lung cancer was the most common cancer worldwide in 2018, with 2.1 million new cases and 1.8 million deaths last year.
Doctors typically treat early-stage lung cancers by surgically removing the tumor, or if surgery is not possible, radiation, according to Dr. Mark Henderson, radiation oncologist at Columbus Regional Hospital, who is on the local review board.
Patients are often diagnosed with lung cancer by performing a biopsy on suspicious growths or nodules or analyzing sputum, a mixture of saliva and mucus that is coughed up the respiratory tract, under a microscope, according to the Mayo Clinic.
Henderson said late-stage lung cancer is harder to cure because it often spreads to other parts of the body.
“The thing about cancers, and especially lung cancer, is that they don’t just sit there in the lung and grow,” he said. “Because if that’s all they did, then in later-stage cancers, we’d have a decent chance of curing it. What they do is they spread to the lymph nodes and in the middle of the chest and/or spread somewhere else in the body. Once they’ve done that, they’re very difficult to cure.”
Cost barriers
Despite the potentially life-saving benefits of detecting lung cancer at an early stage, the main barrier to getting screened has traditionally been cost, according to Dedinsky.
Bill Algee, imaging services director at Columbus Regional Hospital, said CRH has been doing low-dose lung scans since 2015. It initially cost $99 to get screened. By November 2017, CRH had dropped the price to $25 in an effort to encourage more people to get screened.
In January and February this year, CRH did 133 low-dose lung scans, according to Algee. CRH did 62 during the same period in 2018 and 14 during the same period in 2016.
“We did not want the money component to be a limiting factor for people deciding, ‘Should I get this or not?,’ which is why we have priced our scans at a very low level,” Dedinsky said. “… This is public health. We live in a county that’s got a high smoking rate, and you’ve got a lot of agricultural and industrial exposure. This is the easiest screening. All (patients) have to do is lay down.”
Currently, CRH uses low-dose CT scans to screen for lung cancer. The scans are non-invasive, painless and take around five minutes, according to Dedinsky, who emphasized the importance of getting screened.
“Just say, for instance, there are 40,000 people living in Columbus, and 25 percent of them smoke,” he said. “That’s 10,000 people. We’ve screened 10 percent. There’s a huge population of unscreened people out there. If we found 20 cancers in two years with 1,000 patients, that means there are around 180 cancers out there right now (in Columbus) that are curable. That’s why this screening is so important.”
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Columbus Regional Heath lung cancer screenings cost $25 and are done at Columbus Diagnostic Imaging at 790 Creekview Drive. The screening procedure is non-invasive, painless and takes around five minutes to complete, according to CRH officials.
To be eligible for a screening, patients must be between the ages of 55 and 80 years old, have a history of heavy smoking and are a current smoker or have quit in the past 15 years.
Heavy smoking is defined as smoking one pack per day for 30 years, or two packs per day for 15 years.
For more information, call 812-669-1628 or visit crh.org/service-centers/lung-institute/lung-cancer-screening.
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Columbus Regional Health uses low-dose computerized tomography, or CT, scans to screen for lung cancer.
A low-dose CT scan uses computer processing to create a series of X-ray images of a body part or organ, in this case, the lungs, according to the Mayo Clinic. CT scans are often more detailed than standard X-rays and can be used to identify a variety of medical conditions, including head trauma, bone fractures, lung nodules, among others. It is called a “low-dose” scan because it uses around six times less radiation than regular CT scans, according to Bill Algee, director of imaging services at Columbus Regional Hospital.
The scanner is a doughnut-shaped machine that takes up an entire room, Algee said. The machine takes around 1,330 X-ray images at different angles in approximately five minutes while the patient lays flat on a platform that moves slowly through the "doughnut hole" of the machine. Low-dose CT scans are non-invasive, painless and take about five minutes to complete. Computer software then compiles a series of image files that doctors can scroll through.
Low-does CT scans are considered more effective at detecting certain early-stage lung cancers, according to the National Lung Screening Trial, a study by the National Cancer Institute that compared the effectiveness of two methods for detecting lung cancer, low-dose CT scans and standard chest X-rays.
The trial observed 53,454 current or former smokers ages 55 to 74 at 33 medical centers across the country over the course of seven years, according to the trial’s findings, which were published in the New England Journal of Medicine in 2011. To be included in the trial, participants had to have had a smoking history of “30 pack years,” which is the equivalent of smoking one pack per day for 30 years or two packs per day for 15 years.
The trial found that low-dose CT scans detected certain types of early-stage lung cancers more frequently than standard chest X-rays, according to the trial’s finding. Because low-dose CT scans found more cases of early-stage lung cancer, the authors of the study concluded that participants who were screened with low-dose CT scans had a “15 to 20 percent lower risk of dying from lung cancer than participants who received standard chest X-rays,” according to the trial’s findings. In other words, the use of low-dose CT scans resulted in “three fewer deaths per 1,000 people.”
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