November is Lung Cancer Awareness Month – a time to reflect on why progress in survival on lung cancer lags so significantly behind other cancers, and what can be done to change it. The Lung Cancer Policy Network, an international group of clinicians, patients, researchers and industry representatives jointly committed to improving survival from lung cancer, and ensuring it is given due policy priority.
Like others in the lung cancer community, we welcomed the inclusion of lung cancer screening1 in the recently revised draft EU Council recommendations on cancer screening. However, it is vital that the final recommendations fully reflect the state of the evidence and provide Member States the foundation they need to advance implementation of effective lung cancer screening programmes as a matter of priority.
Early detection, with screening at its core, is essential to reduce mortality from lung cancer, which currently causes more deaths than any other cancer.2 3 Whilst preventing or supporting people to stop smoking is the most effective way to reduce the risk of lung cancer4, it is not sufficient on its own. People who have stopped smoking remain at a three times higher risk of lung cancer for at least a decade compared to people who have never smoked.5 And smoking is not the only risk factor for lung cancer – up to a quarter of cases occur in people who have never smoked.6 Early detection – ensuring diagnosis occurs at an early stage when treatments are most effective — is therefore essential to improve outcomes for people whose cancer could not be prevented.7 If detected at an early stage, a person’s probability of living for five years is between 68-89%; if detected at a late stage, that figure drops dramatically to 10%.7
There is now a proven effective and safe screening tool for lung cancer: low dose computed tomography (LDCT). Evidence from multiple randomised clinical trials, conducted in Europe8 and internationally9, and several meta-analyses has shown conclusively that screening with LDCT can reduce mortality from lung cancer by up to one quarter in high risk individuals.10 11 This magnitude of benefit is on par with that for breast, colorectal and cervical screening.7 LDCT screening is also safe and does not lead to a large number of false-positive results or subsequent unnecessary procedures or treatments.12 In light of this evidence, several countries — Czech Republic, Croatia, Poland and also the United States and South Korea, have implemented nation-wide screening programmes. In Europe, Italy, Hungary, Romania, Slovakia and the United Kingdom13 have committed to large-scale implementation on the basis of clinical and cost-effectiveness data.
The World Health Organisation recommends that all countries abide by the principles set out by Wilson and Jungner in 1968 to guide decisions about whether to invest in a given screening programme.14 LDCT screening meets all the Wilson and Jungner criteria. The first is that any screening programme should address a serious public health problem: lung cancer causes more deaths than any other cancer and its prevalence will continue to be significant even if smoking rates gradually decrease across Europe. Another criterion is that all primary prevention methods should be exhausted before a screening programme is considered: LDCT screening is complementary to anti-tobacco policies and smoking cessation programmes. Screening has been shown to provide a teaching moment that helps people quit smoking, and combining screening with smoking cessation enhances the cost-effectiveness of screening.
System readiness is key for the success of any screening programme, but thankfully, we are not starting from scratch with lung cancer screening. Several decades of implementation research from around the world have shown that a phased approach to implementing screening is both feasible and effective.15 Countries that have implemented nation-wide programmes have comprehensive protocols to guide clinical assessment of any lung cancer nodules detected through screening and quality assurance of all scans performed. The EU can also learn from the experience of countries like Australia16 and Canada17, who have developed comprehensive guidance to ensure system readiness for implementation, and others like the United Kingdom18 where pilot programmes have been ongoing for many years.
Another important consideration is cost. Several studies have shown that LDCT screening is a cost-effective investment, comparing well with other population-based screening strategies. 19-23 It is also likely to be more efficient: fewer people need to be screened for lung cancer to prevent one death than for breast or colorectal cancer screening.9 24 25
A final, and critical, consideration, is equity. LDCT screening follows a targeted approach, so that only individuals at highest risk of lung cancer are invited to take part in screening.15 Several risk prediction tools have been developed to help programmes identify populations at highest risk of lung cancer based on a combination of factors including age, smoking status, ethnicity, presence of other conditions, and socioeconomic position.15 The use of these tools should thus help each Member State target screening to those who need it most — including more socially disadvantaged groups, who often are at highest risk of lung cancer. This targeted approach also promises to enhance the impact of screening in terms of reducing mortality, as well as its cost-effectiveness.
As the EU Council deliberates the final wording for their screening recommendations, we urge them not to waste this opportunity and fulfil its mandate to help reduce mortality from cancer across our societies. We have already lost too much time and too many lives in Europe because of a lack of clear guidance focused on the implementation of lung cancer screening. The time to act is now.
The Lung Cancer Policy Network is a global multi-stakeholder initiative set up by the Lung Ambition Alliance (founded by the International Association for the Study of Lung Cancer, Global Lung Cancer Coalition, AstraZeneca and Guardant Health). The Network is funded by AstraZeneca, Guardant Health, Johnson & Johnson and Medtronic. Secretariat is provided by The Health Policy Partnership, an independent health research and policy consultancy. All Network outputs are non-promotional, evidence based and shaped by the members, who provide their time for free.
You can read the above article in full – with references – here.