Ask an expert: Q&A

We have asked experts in lung cancer screening from around the world for their advice on setting up and running lung cancer screening programmes. We are grateful to the following experts for sharing their expertise:  

Dr Stephen Lam

Dr Matthew Callister

Dr David Baldwin

Dr James Mulshine 

How was the programme established? How was it implemented?

Dr Stephen Lam

The Pan-Canadian Early Detection of Lung Cancer Study was started in 2007 to address the question how lung cancer screening can be implemented in Canada efficiently if the randomized trials in the US and Europe showed a significant lung cancer mortality reduction benefit with low-dose CT (LDCT) screening. The study tested the first web-based risk prediction tool in English and French for recruiting high risk ever smokers online or by phone. The eight centres across Canada also aimed at developing screening expertise and infrastructure.

Following demonstration of the efficacy and cost-effectiveness of using the Prostate, Lung, Colorectal and Ovarian (PLCO) risk prediction tool to identify high risk individuals for screening, a pilot study was initiated in Ontario to determine the operational issues for province-wide organized screening program implementation. The Ontario pilot initially involved three sites in 2017 but has expanded to four sites in 2019. Meanwhile, pilot studies were initiated in British Columbia (BC) and Alberta to compare PLCO risk prediction tool versus the US Preventive Services Task Force (UPSTF) age and pack-years selection criteria.

The BC pilot is also part of the International Lung Screening Trial (ILST) involving Canada, Australia, Hong Kong and Spain. In addition to comparing PLCO and USPSTF selection criteria, ILST is also examining other risk factors such as genetic susceptibility and air pollution. The Canadian Partnership Against Cancer is developing an organized screening program business proposal as well as a lung nodule management position paper to guide provinces and territories to plan and implement lung cancer screening across Canada.

Dr Matthew Callister

Unlike most screening programmes in the United Kingdom, this programme is a randomised controlled trial funded by a charity, Yorkshire Cancer Research. The study’s aim is to test targeted low-dose computed tomography (LDCT) screening in community settings focusing on deprived areas in Leeds. Information about the participants is gathered from primary care data. The study comprises 90,000 people, with one half taking part in the screening programme, while the other half are not aware their data will be used for comparison. Individuals for both groups are selected at random and inclusion criteria for entry into the cohort to be screened includes being registered with a participating General Practice, registered as a current or ex-smoker, and aged between 55 and 80 years. The outcomes will be compared between both groups, whereby a cost-benefit analysis of lung cancer screening will be produced.

During a telephone assessment, a triage team will ask participants in the intervention group a series of questions about aspects of their lung health. They use three sets of criteria, the United States Preventive Services Task Force (USPSTF), Prostate, Lung, Colorectal and Ovarian (PLCO) and Liverpool Lung Project (LLP) criteria to decide whether the individual is eligible to be screened.

Dr David Baldwin

Following the publication of the US National Lung Cancer Screening Trial and the UK Lung Screen Trial, a series of pilot screening programmes were implemented in the UK. These were funded by the NHS and, in Nottingham, by the Roy Castle Lung Cancer Foundation, a national patient group.  The programmes were supported by local leaders in the field and by a number of Members of Parliament. The results of these pilots, along with sound advice on policy, has led the NHS in England to commit over £70 million to a larger screening programme, with a view to rolling this out. Furthermore, a recent review of cancer screening in the UK recommended that the UK public health service should now take on the management of these programmes to ensure that they are delivered to all of the UK countries and have a secure funding stream.

The nature of the NHS, free at the point of service, means that there is a good chance of widespread participation, although this will depend on the method of recruitment. Participants will be identified through primary care records and further assessed for risk of lung cancer either at a face to face “Lung Health Check” or via a telephone call. Scanning will be with a mixture of mobile and fixed site scanners. A great deal of planning has occurred including the production of standardised protocols and quality assurance. The initial pilot programme targets the areas in which high risk groups live, identified through incidence and mortality rates. The programme is ambitious because of capacity issues in the NHS.

Dr James Mulshine

The results of the National Lung Screening Trial (NLST) have been instrumental in informing the implementation and roll out of most screening programmes in the United States. Based on the recommendation of the United States Preventive Services Task Force (USPSTF), a number of professional societies, such as the National Comprehensive Cancer Network (NCCN) published lung cancer screening guidelines. The USPSTF recommends annual low-dose CT screening for lung cancer in adults aged between 55 and 80 years old who have ever smoked.

However, the broad adoption of the NLST’s recommendations is advancing slowly. Assembling relevant teams of complementary disciplines to responsibly deliver high quality screening care is challenging. In addition, finding at-risk individuals and effectively communicating about the benefits of lung cancer screening is also demanding. Mounting evident is being collected and is informing professional guidelines such as with LungRADS from the American College of Radiology and making lung cancer screening workups more accurate and efficient.

 
Is the programme advertised to the public? If so, how?

Dr Stephen Lam

To increase enrolment, the screening program was advertised to both general practitioners and the general public.

General practitioners were educated on the benefits of lung cancer screening and were given criteria to assess whether an individual is at high risk. They were also provided with referral forms to send those identified as high risk for screening. A varying stream of individuals were enrolled in the trial via this pathway, however, the majority of those referred are more likely to be eligible. 

Facebook was used to target the wider population. With a high hit rate, it has engaged the public, making them consider this as an important part of looking after their health, leading to more people enrolling for screening. However, more people being reached through Facebook are not eligible to partake in the screening trial as they do not fall into the at-risk population, categorised by having a six-year risk of more than 1.5% using the PLCOm2012 risk prediction tool

Dr Matthew Callister

Invitation for a lung health check is by postal invitation. With permission from local General Practitioners (GP), these invitations are sent on GP-headed paper and digitally signed by the person’s own GP. The invitation letter is accompanied by a low-burden leaflet explaining the Lung Health Check process. Two follow-up letters are sent to people not responding to the initial invitation. These reminder letters are extremely effective, with the response to the first reminder greater than to the initial invitation. 

As our study includes a non-invited control population, dedicated advertising has not been used locally, although the study has featured in local newpapers, radio and TV intermittently to date.

Dr David Baldwin

Advertising is predominately done by placing leaflets in GP practices in the areas in which the screening programmes take place. However, approximately 25 percent of people signing up have such a low risk of lung cancer and so are not eligible for screening.

A more effective way to enrol people to the programme is therefore to target high risk groups by using data gathered in primary care to identify smokers and if they would meet the eligibility criteria to join the programme.

Dr James Mulshine 

In the US, there is currently no consensus when it comes to advertising lung cancer screening programmes to the wider population. Therefore, the public is exposed to conflicting as well as very complex information about the benefits and risks of screening tests, and that can considerably affect participation rates.

One approach could be to work with local media outlets to tailor specific content for target audiences. Those messages need to include information about the benefits of getting tested, how screening can present an opportunity to improve health, and how it can help people adopt a healthy lifestyle.  An important benefit of lung cancer screening is the frequent detection in eligible groups.

 

 
What are the take up rates? Are they as expected?

Dr Stephen Lam

Uptake for screening in Canada is good and screening has been popular, in part due to the fact that people are very concerned about their health.

In Canada, between 12 to 15 percent of people aged 55 and above in the general population have been or are smokers. In the trial, 50 percent of the people enrolled are smokers, showing that the screening attracts current smokers to take part, providing the opportunity for smoking cessation in addition to LDCT screening.

Dr Matthew Callister

To date, 25,000 people have been invited to the trial taking place in Leeds, and 51% have responded, contacting the telephone triage line for a lung cancer risk assessment. 30% of those responding have attended for LDCT screening. The proportion of people responding to initial invitation is higher than was expected (anticipated 45%) but the proportion of those who respond and get scanned is lower than we had predicted (expected 48% of those responding). This lower rate of eligibility is partly due to people being coded as ever-smokers in their Primary Care record, but in fact being never smokers (and thus ineligible for screening).

Dr David Baldwin

The rates of lung cancer screening take up in Nottingham are variable. Initially, when just one letter was sent out the response rate was low, at approximately 20 percent. However, sending reminders to people has proved to be very helpful and made a big difference, with participation rates reaching 50 percent.

Dr James Mulshine

The introduction of national cancer screening programmes for cervical, breast and colon cancer have all been protracted efforts.A major barrier to lung cancer screening is the structure of the U.S. health care system. This is because a large proportion of the eligible population may not have easy access to many healthcare services. In both inner city as well as rural setting with existing health delivery challenges, screening participation rates are low, further exacerbating existing social and health inequalities.

In the US, fortunately the Accountable Care Act made lung cancer screening a federally reimbursable service for most citizens. However, there are still barriers to this service for both clinicians as well as at-risk individual, regarding a lack of understanding as to risks and benefits of lung cancer screening. Busy healthcare professionals have also been reluctant to engage their patients in discussions about this new screening service when so many other more established healthcare needs are already demanding attention.

 

How do you engage with the ‘hard to reach’ groups such as those in remote locations?

Dr Stephen Lam

The programme has a good enrolment rate, across many different demographic areas. With trials taking place in different geographical settings such as rural and urban areas, the trials seek to target a diverse population. The one area that could be improved is the enrolment in deprived areas, with further sites potentially being located in rural areas. 

Dr Matthew Callister

There is evidence from other screening programmes that GP-endorsed invitation increases uptake.

One of the main barriers to participation in the UK Lung Screening Pilot was concern about travel to the screening centre. In an attempt to address this, the Lung Health Checks in Leeds take place in mobile units parked in convenient community locations. However, as there has been no trial directly comparing fixed site versus mobile screening, it is impossible to determine the impact of this strategy in isolation.

Dr David Baldwin

Work is ongoing to understand the most effective ways to engage with ‘hard to reach’ groups. However, experiences thus far have suggested that people are more likely to attend a screening if they receive an invitation from their GP. A reason for this could be that people would prefer to be told to attend screening by their GP rather than understanding the details of lung cancer screening and why it is important.

Individuals from the most deprived group, the lowest fifth, account for 40 percent of the ‘hard to reach’ group. Therefore, a local approach using GP invitations may be better suited to this segment of the group. But for the other 60 percent of the ‘hard to reach’ group, there is a need for information to be communicated simply and effectively.

The programme has received a grant from Horizon 2020 to use experienced public sector profiles to explore the best channels and wording to maximise uptake of screening among the ‘at-risk’ group as a whole.

Dr James Mulshine

Community access to population-based screening programmes can be limited by high downstream screening costs or the inability to access screening clinics due to factors such as distance. Health authorities need to develop screening campaigns that target the at-risk population associated with sustainable and coordinated screening management.

Models of success to address these complex logistical issues exist in the US. States like Delaware have deployed networks of nurse navigators who have clinical knowledge­ and who are also able to offer individual assistance to patients on a range of issues to assist with lung health, including smoking cessation. They help individuals overcome healthcare system barriers by providing educational resources, and by facilitating informed decision making throughout the cancer continuum. This approach has enabled authorities in Delaware to free-up additional health resources and build a holistic and community-based approach to screening. 

While mobile screening vans have been widely introduced to improve screening access for disadvantaged groups, there is a lack of compelling evidence on their effectiveness and cost-effectiveness. An alternative approach to reducing social and geographic inequalities would be to leverage existing transport infrastructure to facilitate access to screening facilities, thereby reducing the costly impacts of temperamental mobile scanners or traffic which may prevent scanners from reaching their destination in time for appointments.

Mobile screening units also have to cover the cost of recruiting a dedicated and experienced team and maintaining resources throughout the project. In order to get lung cancer screening to all at-risk individuals in a sustainable fashion, it is essential to continue to evolve ever more efficient approaches to implementing this critical, albeit costly, new early detection approach.

 

What have been / continue to be the main challenges to implementing the programme? How have you overcome these?

Dr Stephen Lam

One of the challenges faced is sustaining the flow of recruitment to the program. In the beginning, people were eager to be screened. However, as time passes with screening becomes less of a novelty, it has become increasingly difficult to find people to reach who would be eligible for screening but have not yet been screened.

Linked to this, timely engagement with those signing up for screening is essential. Failing to do so risks losing much of the population as enthusiasm tends to disappear relatively quickly.

More broadly, as the screening program is in limited locations across the province, people have reported accessibility as a key challenge. This could be in the form of travelling to the hospital where the pilot site is taking place, parking or looking for the CT unit at the hospital.

If uptake rates are high, resources can be a key challenge in the initial stage. Balancing the right level of healthcare professionals and a realistic timeline from screening to diagnosis is essential to ensuring patients receive results, diagnosis and treatment in a timely manner without stretching resources to unrealistic levels.

Dr Matthew Callister

One of the greatest challenges with running a large screening programme is the logistical support and organisation required to manage the flow of patients, scans, reports and clinical outcomes. This can be greatly aided by well-designed IT systems to coordinate all this activity. Even with well-designed systems, there still needs to be a system of audits and checks to ensure that participants end up in the correct destination (ongoing screening, surveillance scanning, lung cancer clinic, referral to other specialities).

Workforce issues are a significant challenge to delivering screening on a large scale, particularly in radiology. For the Yorkshire Lung Screening Trial, a consortium of thoracic radiologists have been recruited to report the scans, and are paid on a per-scan basis. Incorporating this activity into the job plans of NHS radiology departments would be challenging in some hospitals. In addition, extra capacity is needed down-stream in the lung cancer investigation and treatment pathway (e.g. especially PET-CT scans, percutaneous lung biopsies and thoracic surgery capacity).

Delivery of screening in community settings brings with it additional challenges that do not apply to established fixed sites (e.g. power, water, sewage, internet connectivity), and requires suitable sites for locating the mobile units.

Dr David Baldwin

Often, messaging around lung cancer and screening can be complex and so it is important to find the right way to communicate the message to individuals in a way that can be understood. To do so, there is a need for research into the most effective ways to communicate, to understand the level of detail that would be beneficial as well as the most appropriate messaging.

Travel is one of the main accessibility challenges that needs to be overcome. Whilst mobile CT scanners are good for screening people in hard to reach areas, there is a case for developing good transport links to hospitals as it is easier to manage screening programmes in hospitals and is more cost-effective.

Two of the biggest challenges requiring urgent attention are a shortage of both equipment and healthcare professionals. While signing lots of people up to partake in the trial is a positive sign that the public are starting to take their health seriously, if there isn’t enough equipment to complete the scans, the programme will likely be unsuccessful.

In terms of human capacity, a shortage of doctors, nurses, and radiographers threatens how quickly the programme can be implemented. Given this challenge, it is important to ensure that people are working efficiently and only undertaking necessary tests.

Dr James Mulshine

One of the main challenges in designing screening programmes is the context within which lung cancer screening is being framed. Over the next decades, chronic conditions are expected to become the main cause of disability and death and will have enormous healthcare costs for societies and governments. Half of global resources could be consumed by caring for people with tobacco-related chronic diseases. Therefore, the integrated burden of tobacco-exposure needs to be recognised as an existential threat to global public health. 

Thoracic CT screening programmes offer a unique public health opportunity to tackle a range of tobacco-related chronic diseases beyond lung cancer such as chronic obstructive pulmonary diseases, and heart diseases.

Communication between health authorities and policy makers need to evolve to recognise screening as a method for the prevention and management of thoracic tobacco-related diseases. It is through effective discussions that there can be economic benefits that allows for resources to be applied more strategically.

 

What other advice would you give to anyone starting a lung cancer screening programme?

Dr Stephen Lamb

Planning well, using resources efficiently and making the whole pathway accessible is the key to implementing a successful screening program. Screening is highly cost-effective with the cost equating to approximately CAN $20,000 per year of life gained. Integrating smoking cessation services also encouraged at-risk individuals to stop smoking.

Involving patient advocacy organisations in the reporting stage is also recommended as they have experience in patient engagement and can therefore assist those receiving results in a more sensitive way than other healthcare professionals. Emphasising screening is the only option available for former smokers to reduce lung cancer risk would help to drive the message across.

Dr Matthew Callister

Successfully engaging primary care colleagues is critical to the success of the programme, as use of GP-endorsed invitation is likely to be important for encouraging uptake.

A well-designed IT system can make a huge difference to the efficiency of the screening service, and potentially reduce staff costs in terms of processing the screening outputs (automated generation of letters etc. reduces demand on clinician time). Smooth referral pathways for common incidental findings (e.g. renal lesions, pulmonary fibrosis, bronchiectasis) also facilitates efficient patient flow. 

A key way to maximise improved outcomes from lung cancer screening is to co-locate smoking cessation services with the screening service. Over three quarters of current smokers attending for lung screening have agreed to meet with a Smoking Cessation Practitioner (SCP) in the Yorkshire Lung Screening Trial. The SCPs are co-located on the mobile units, and have immediate access to nicotine replacement therapy and other evidence-based smoking cessation interventions. Smoking cessation and lung cancer screening have additive effects on mortality reduction, and an effective smoking cessation service is likely to considerably improve the cost-effectiveness of screening process.

Dr David Baldwin

 The UK has developed a short and pragmatic protocol which has been mandated, outlining the cost-effectiveness, quality assurance, safe running, nursing standards of lung cancer screening programmes.

As such, writing pragmatic protocols that can be implemented and measured in the same way is key to implementing a successful screening programme. It’s essential to collect as much data as possible when running the programme. The data collected can then be analysed to understand which areas of the programme are effective and which aren’t, and the approach can be adapted accordingly. The willingness of healthcare professionals delivering the programme to be flexible and adaptive is therefore essential.

Dr James Mulshine

Health authorities need to engage the public in a partnership to optimize the health benefits of early disease detection. For example, over the lifetime of an individual with a long history of tobacco exposure, there is a continuous risk of developing lung cancer. 

Furthermore, individuals involved in the screening process have considerable control over their health risks relative to lifestyle choices. Factors such as smoking cessation, improving diet and increasing exercise may together exceed the aggregate health benefit of medical screening interventions.

Future initiatives should be about creating a supportive environment in which individuals can sustain their health using precise imaging tools that can give dynamic information about the health impact of their lifestyle allowing individuals to make informed health choices.