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  • Lung Cancer Screening

    LUNG CANCER SCREENING: A MAJOR ROLE IN PREVENTATIVE CARE

    By: Jolene Cannaday DNP, AGPCNP-C

               

               On August 1st we observed World Lung Cancer Day, a day of observance that started in 2012 to help raise awareness and promote overall lung health. Many NPs work in primary care where preventative screening plays a major role. The importance of lung cancer screening is part of this preventative mindset. The United States Preventative Services Taskforce (USPSTF) currently has a Grade B recommendation for lung cancer screening via low-dose computed tomography (LDCT) for 50 – 80-year-old adults who have a 20 pack-year smoking history, currently smoke, or have quit smoking within the past 15 years1. The USPSTF recommends that screening be discontinued if a patient has not smoked for 15 years, or if they have health issues that greatly limit life expectancy or limit their ability to have lifesaving surgery or treatments1. When screening a patient’s smoking history remember that one pack-year is the equivalent of smoking an average of 1 pack, 20 cigarettes, every day for one year.  On average when calculating this, I ask patients to think about the greatest number of cigarettes they have smoked daily for the longest period of time, because at times a patient’s smoking history may be varied. 

                Lung cancer was the second most common cancer and the leading cause of cancer-related death among men and women in the United States in 20202.  Screening is an important preventative measure in lung cancer, as many patients with lung cancer presented with metastatic or later disease2.  Lung cancer has 2 main categories of classification. The first classification is non-small cell lung cancer (NSCLC) which includes adenocarcinoma, squamous cell, and large cell cancers. The second classification is small cell lung cancer which is considered the more aggressive of the two major categories and has lower survival rates. Approximately 80% to 85% of lung cancers are in the NSCLC category3. Risk factors for lung cancer include smoking, which accounts for 90% of all lung cancers, and radiation therapy, environmental exposures, family history, race/ethnicity, and other lung diseases4

                Therefore, lung cancer screening is a pertinent discussion to have with your higher risk patients. Ensure that each patient is screened for smoking history, which will help determine which patients to further discuss this key element of preventative care. During the month of August promote lung cancer awareness and discuss lung cancer screening with other colleagues in your practice. Create an atmosphere of prevention and guideline-based care.

    References

    1. S Preventative Services Task Force. Lung Cancer Screening. Published March 2021.Accessed July 10, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
    1. National Cancer Institute. Surveillance, Epidemiology, and End Results Program: Cancer Stat Facts: lung and bronchus cancer. Accessed July 24, 2022. https://seer.cancer.gov/statfacts/html/lungb.html
    2. American Cancer Society. Key statistics for lung cancer. Published 2017. Accessed July 10, 2022. http://www.cancer.org/cancer/lung-cancer/about/key-statistics.html
    3. American Cancer Society. What is lung cancer? Published 2019. Accessed July 10, 2022. http://www.cancer.org/cancer/lung-cancer/about/what-is.html
  • cigarettes

    Tobacco and Vaping

    Madison Davis MPH Candidate, Brown University School of Public Health

     

    Background

    Vaping is an ongoing, dangerous, trend among adolescents. The increase in harmful side effects associated with vaping has led to concern among providers and public health officials. A vape, or an e-cigarette, allows individuals inhale a heated aerosol that usually contains nicotine1. A monitoring study in 2019 concluded that the prevalence of vaping increased two-fold among eighth grade, tenth grade, and twelfth grade students between 2017 and 20191. It is important to observe the increase in vaping among young individuals because of the detrimental effects nicotine has on developing teenagers2. During the adolescent period, generally defined as between 12 and 18 years of age, there are critical changes in cognitive and executive function, working memory, reward processing, emotional regulation, and motivated behavior2

    Going all the way back to your biochemistry class you took years ago, we are going to dive into the specific physiological effects of nicotine on the developing brain. The nicotinic acetylcholine receptors (nAChRs) are ligand-gated ion channels found throughout the brain2. These channels are responsible for regulating agonist affinity, ion selectivity, desensitization, and downstream signaling2. Given its versatile function, nAChRs plays a vital role in the central and peripheral nervous system2. However, these receptors have a high affinity for (or really enjoy binding to) nicotine which causes desensitization in the brain of a smoker2. There are other subtypes of the receptor that experience similar effects in the caudal brain region which plays an important role in the nicotine addiction pathway2. The activation of regions involved with the nicotine addiction pathway (that have high concentrations of nAChR receptors) causes nicotine-induced firing and activity of dopamine neurons in the brain2. This process occurs in many different brain regions affecting a variety of systems2. Nicotine also plays a similar and important role in the ascending serotonin system3.

    All of this means that the limbic system, which controls cognition, emotion, and drug reward, is very vulnerable to developmental issues when exposed to nicotine particularly during adolescence2. This sensitivity to nicotine suggests that smoking is not only associated with mood disorders, but may also be the cause4.

    Not only are there severe effects on the brain and nervous system, but also there can be major damage to the lungs of those who smoke. A 2019 study looked at the vaping-associated lung injuries in individuals who using vapes/e-cigerettes5. The presence of diacetyl in vapes is known to cause lung injuries5. The warning signs for providers is discussed further below. 

    Health Law

    In 2009, the Tobacco Control Act and “Deeming Rule” were passed to allow the FDA to establish regulations on cigarettes and new tobacco products including e-cigarettes6. More recently, in 2019, the federal government increased the age requirement to purchase e-cigarettes from 18 to 21 years of age6. In 2020, they went a step further to halt the sale of flavored cartridges and prevent the online sale of e-cigarettes in order to dissuade younger people from purchasing them6. Future law directions include a proposed regulation on the amount of nicotine that can be present in an e-cigarettes6

    Details for Providers

    Individuals who begin smoking during their adolescent life are more likely to use other drugs, engage in high-risk sexual behavior, and develop psychiatric disorders when compared to nonsmoking adolescents7,8. Given the clear developmental impact that nicotine has on the emotional, cognitive, and addiction pathways of the brain, this is where providers may see deficits in their patients who smoke2.  

    For patients with vaping-associated lung injuries, they may present with mild respiratory symptoms including persistent cough, shortness of breath, or chest pain5. However, there is not a clear clinic guideline for this type of illness. Instead, as a provider, you can make the diagnosis by establishing a temporal relationship between vaping and symptoms, rule-out other potential causes for symptoms, and determine if there is improvement with the cessation of smoking5. In regard to radiological findings, a hypersensitive pneumonitis pattern that was improved with cessation of smoking has been reported5. Additionally, diffuse alveolar hemorrhage, which presents with cough, fever, difficulty breathing, and sometimes coughing up blood, has been found as well5. Other conditions include acute lung injury, acute eosinophilic pneumonia organizing pneumonia, lipoid pneumonia, and giant cell interstitial pneumonia7.

    As a provider it is important to screen patients for smoking history and advise on the potential dangers of vaping particularly between the ages of 12 and 18 years. Furthermore, the cessation of smoking has been found to help improve associated symptoms and may be a valuable first step in treatment7

     

    References

    1. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Trends in adolescent vaping, 2017–2019. New England Journal of Medicine. 2019;381(15):1490-1491.
    2. Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain. The Journal of physiology. 2015;593(16):3397-3412.
    3. Bang SJ, Commons KG. Age-dependent effects of initial exposure to nicotine on serotonin neurons. 2011;179:1-8.
    4. John U, Meyer C, Rumpf H-J, Hapke U. Smoking, nicotine dependence and psychiatric comorbidity—a population-based study including smoking cessation after three years. Drug and alcohol dependence. 2004;76(3):287-295.
    5. Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP. Imaging findings of vaping-associated lung injury. AJR Am J Roentgenol. 2020;214(3):498-505.
    6. Laura Summers M. Curbing the Youth Vaping Pandemic: A Review of How Utah’s Laws and Policies Compare Nationally and to Other States. 2021.
    7. Lai S, Lai H, Page JB, McCoy CB. The association between cigarette smoking and drug abuse in the United States. Journal of addictive diseases. 2000;19(4):11-24.
    8. Rashad I, Kaestner R. Teenage sex, drugs and alcohol use: problems identifying the cause of risky behaviors. Journal of health economics. 2004;23(3):493-503.

     

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