CT Scan Screening for Lung Cancer: Risk Factors for Nodules and Malignancy in a High-Risk Urban Cohort

Low-dose computed tomography (CT) for lung cancer screening can reduce lung cancer mortality. The National Lung Screening Trial reported a 20% reduction in lung cancer mortality in high-risk smokers. However, CT scanning is extremely sensitive and detects non-calcified nodules (NCNs) in 24-50% of subjects, suggesting an unacceptably high false-positive rate. We hypothesized that by reviewing demographic, clinical and nodule characteristics, we could identify risk factors associated with the presence of nodules on screening CT, and with the probability that a NCN was malignant.We performed a longitudinal lung cancer biomarker discovery trial (NYU LCBC) that included low-dose CT-screening of high-risk individuals over 50 years of age, with more than 20 pack-year smoking histories, living in an urban setting, and with a potential for asbestos exposure. We used case-control studies to identify risk factors associated with the presence of nodules (n=625) versus no nodules (n=557), and lung cancer patients (n=30) versus benign nodules (n=128).The NYU LCBC followed 1182 study subjects prospectively over a 10-year period. We found 52% to have NCNs >4 mm on their baseline screen. Most of the nodules were stable, and 9.7% of solid and 26.2% of sub-solid nodules resolved. We diagnosed 30 lung cancers, 26 stage I. Three patients had synchronous primary lung cancers or multifocal disease. Thus, there were 33 lung cancers: 10 incident, and 23 prevalent. A sub-group of the prevalent group were stable for a prolonged period prior to diagnosis. These were all stage I at diagnosis and 12/13 were adenocarcinomas.NCNs are common among CT-screened high-risk subjects and can often be managed conservatively. Risk factors for malignancy included increasing age, size and number of nodules, reduced FEV1 and FVC, and increased pack-years smoking. A sub-group of screen-detected cancers are slow-growing and may contribute to over-diagnosis and lead-time biases

Entrepreneurial resilience

The final publication is available at Springer via DOI TBCThe vast majority of businesses in all countries - between 70% and 95% - are micro-businesses, i.e. enterprises that employ fewer than ten people (OECD, 2017). Their impact on the economies and societies in which they operate is therefore significant, collectively acting as important sources of employment, growth and innovation (ibid, 2017). However, the existence of many of these businesses is often precarious, especially in the early stages of their development. Many newly created businesses fail within the first few years of life with mortality rates ranging from around 10% (UK, USA, Sweden) to 45% (Slovak Republic) in the first year (ibid, 2017). As a result, the entrepreneurial activity to create and manage these businesses is very demanding and exposes entrepreneurs to situations which would be expected to create high levels of stress among the general population (e.g. a rapidly changing and unpredictable environment, high responsibility, high workload). The demands of business start-up and ownership could be expected to create a higher risk of mental health problems. Isolation and long working hours could contribute to an increased risk of depression. Moreover, for many entrepreneurs, their business ventures are personal passions and their self-worth and well-being can be intimately connected to the success of those ventures (Murnieks, Mosakowski and Cardon, 2014). On a practical level, the pressures are often high and can create anxiety as personal financial well-being is often directly related to the ability to close the next deal. Furthermore, Spivak, McKelvie and Haynie (2014) highlight a possible “dark side” of entrepreneurship outcomes, finding that habitual entrepreneurs can suffer from symptoms of behavioural addictions - withdrawal-engagement patterns, obsessive thoughts, and negative emotions - arising from repeated venture creation activities. However, at the same time, Baron, Franklin and Hmieleski (2016) find that entrepreneurs experience lower stress compared to other occupational groups when creating new ventures. Baron et al (2016) suggest self-selection effects as the underlying mechanism producing entrepreneurs that are above average (as a group) in their capacity to handle stress effectively, arguing that those who persist in entrepreneurship acquire this capacity, the resilience to handle the stressors and challenges of their entrepreneurial context