COPD: early detection, screening and

case-finding: what is the evidence?

Prof. Jan-Willem Lammers, Md PhD

Department of Respiratory Diseases

Page 2 - © IPCRG 2012

«If you test one smoker

with cough every day

You will diagnose

one patient

with COPD

a week»

Page 3 - © IPCRG 2012

.

Should we

screen ALL

smokers for

COPD?

Page 4 - © IPCRG 2012

• A clinical diagnosis of COPD should be considered

in any patient who has dyspnea, chronic cough or

sputum production, and/or a history of exposure to

risk factors for the disease.

• Spirometry is required to make the diagnosis; the

presence of a post-bronchodilator FEV1/FVC < 0.70

confirms the presence of persistent airflow

limitation and thus of COPD.

Global Strategy for Diagnosis, Management and Prevention of COPD.

Diagnosis of COPD

Does screening for disease save lives in

asymptomatic adults? N. Saquib et al. Int J Epidemiol 2015, 1-14

• Cancer, Heart and Vascular Diseases, type 2 Diabetes

& COPD

• 48 RCT’s and 9 meta-analyses: disease – specific or

all-cause mortality

• “Reductions in disease-specific mortality were

uncommon and reductions in all-case mortality were

very uncommon”

• No data on COPD reported

Early diagnosis in COPD: PRO

• Patients with undiagnosed COPD have more health problems a

• High prevalence of co-morbidities b

– Diabetes, heart- en vascular diseases, osteoporosis, depression

• COPD is progressive and irreversibel c

– Deterioration of lung fucntion can not be restored

– Accelerated decrease in lung function must be stopped

• Largest decrease in lung function and changes in lung parenchyma in early stages of COPD d

aMapel D, et al. Value Health 2008; bDecramer M, et al. COPD

2008; c Hogg J, Lancet 2004; d Decramer M, et al. Lancet 2009

Page 7 - © IPCRG 2012

The challenge of early detection

Pulmonary damage

Intermittent

symptoms

Breathlessness

Obstruction

Screenings bias

Page 10 - © IPCRG 2012

Who to screen?

With active screening you will find a lot of smokers

with COPD, earlier unrecognised COPD

27% of the smokers,

40-55 years, had COPD

85% of those had mild

COPD

Mild COPD

Moderate COPD

Severe

COPD

Stratelis G et al. Br J Gen Pract 2004; 54:201-6

Screening for Chronic Obstructive Pulmonary Disease Using

Spirometry: Summary of the Evidence for the U.S. Preventive

Services Task Force Ann Intern Med. 2008;148(7):535-543

Screening for Chronic Obstructive Pulmonary Disease Using

Spirometry: Summary of the Evidence for the U.S. Preventive

Services Task Force Ann Intern Med. 2008;148(7):535-543

Conclusion: Screening for COPD using spirometry is likely to identify a predominance of patients with mild to moderate airflow obstruction

who would not experience additional health benefits if labeled as having COPD. Hundreds of patients would need to undergo spirometry

to defer a single exacerbation.

COPD detected with screening: impact on

patient management and prognosis

COPD detected with screening: impact on patient management and prognosis Loes Bertens , Eur Resp J, 2014

• Frail elderly > 65 yrs

• Dyspnea or exercise intolerance

• 386 screened: 84 = 21,8 % new diagnosis of COPD

• Changes in drug prescriptions were infrequent during

12-mo follow-up

• Hospitalisations: overall 25.9 % , 32,1 % in screen-

detected COPD

COPD detected with screening: impact on

patient management and prognosis

COPD detected with screening: impact on patient management and prognosis Loes Bertens , Eur Resp J, 2014

How to screen: Lung Cancer and COPD: sharing the

same risk factor

New Engl J Med; 2006

Dutch-Belgian Lung Cancer Screening

Trial: NELSON

• NELSON trial – Dutch-Belgian lung cancer screening

trial

– University Medical Centers of Utrecht, Groningen and Leuven (Belgium) and Haarlem Hospital

• Inclusion criteria – >50 years of age

– >20 pack years smoking

– <10 years quit smoking

– Walking 2 flights of stairs

Dutch-Belgian Lung Cancer Screening

Trial: NELSON

• NELSON trial – Dutch-Belgian lung cancer screening

trial

– University Medical Centers of Utrecht, Groningen and Leuven (Belgium) and Haarlem Hospital

• Inclusion criteria – >50 years of age

– >20 pack years smoking

– <10 years quit smoking

– Walking 2 flights of stairs

Study design NELSON

7907

Pulmonary Function Tests

• Random sub-selection of subjects underwent

repeat spirometry (n=2,254)

– age: 59.8 5.3 yrs (mean SD)

• FEV1/FVC

– baseline: 72.2 9.4%

– follow-up: 69.3 9.9%

– <70% at baseline: 32.9%

Identification of Chronic Obstructive

Pulmonary Disease in Lung Cancer

Screening Computed Tomographic Scans

• 1140 male participants of the NELSON-study

• Heavy (former) smokers, 50-75 years

• Inspiratory and Expiratory CT-scans

• Assessment of emphysema, airway wall

thickening, air-trapping

• Pulmonary Function Tests: FEV1 , FEV1/FVC

Mets et al. (2011). JAMA 306(16):1775-1781

Identification of Chronic Obstructive

Pulmonary Disease in Lung Cancer

Screening Computed Tomographic Scans

– COPD patients can be detected with only inspiratory

CT scans (sensitivity 63 %, specificity 88% as

compared to PFT)

– CT – emphysema

– CT-airtrapping

– CT-airway wall thickening

Mets et al. (2011). JAMA 306(16):1775-1781

Contribute to COPD detection on low-

dose CT - scans

Conclusions CT and screening

• Screening for lung cancer with CT-scans appears to be

highly effective.

• Automatic quantification of emphysema, air-trapping

and airway wall thickening on low-dose CT-scans is

feasible.

• Additional findings related to chronic obstructive

pulmonary disease and cardiovascular disease are

common in lung cancer screening and may provide an

opportunity to increase screening benefits at minimal

cost in the future.

Case-finding in general practice

• Netherlands a

– Spirometry in smokers

– In every 5-6 smokers, 1 smoker with airway obstruction

• Poland b

– Spirometry in patients >40 years (smokers and non-smokers)

– 9% airway obstruction (19 % known with COPD)

• Poland c

– Spirometrie in smokers (>10 pack years, >40 years)

– 24% unknown airway obstruction

avan Schayck C, et al. BMJ 2002; bBednarek M, et al.

Thorax 2008; cZielinksi J, et al. Chest 2001

Case-finding: NICE and IPCRG

• National Institute of Clinical Excellence (NICE)

– (Ex-)smokers >35 years

– Chronic respiratory complaints

• International Primary Care Respiratory Group (IPCRG)b

– Smokers >35 years

– Chronic respiratory complaints

– High risk COPD according to IPCRG questionnaire (>17)

aNICE. Management of COPD in adults in primary and secondary care.

London. 2010 ; bPrice, et al. Prim Car Respir J 2009

Unrecognized Heart Failure and Chronic

Obstructive Pulmonary Disease (COPD) in Frail

Elderly Detected Through a Near-Home Targeted

Screening Strategy

Yvonne van Mourik, J Am Board Fam Med November-December 2014 27:811-821

• Frail elderly

• Questionaires > assessment

• Diagnosis confirmed by expert panel

• 395/ 570 (69 %): dyspnoea or reduced exercise tolerance

• New Heart Failure: 127 (33,5 %)

• Unrecognised COPD: 65 (16,8 %)

Unrecognized Heart Failure and Chronic Obstructive Pulmonary

Disease (COPD) in Frail Elderly Detected Through a Near-Home

Targeted Screening Strategy

Yvonne van Mourik, J Am Board Fam Med November-December 2014 27:811-821

SYMPTOMS

(chronic) Cough

Sputum Dyspnoea, wheezing

Wait loss

RISK FACTORS

Smoking

Age > 40 yrs

Occupation

SPIROMETRY

NHG: case-finding COPD

è

è

è

Take home message

• There is significant underdiagnosis of COPD

• Spirometry may be used to reduce underdiagnosis of COPD, but CT may be better for smoking induced diseases

• Case-finding of COPD is to be preferred above screening