Building evidence to inform future roll-out of lung cancer screening in Estonia

We examine the key evidence used to inform the development of a national screening programme for lung cancer in Estonia from 2021 to date.
 

Establishing pilot studies

In Estonia, a feasibility study took place across three family physician practices in 2021, aiming to test systematic enrolment of participants in lung cancer screening.^{1 2} In 2022, following a high rate of screening uptake, a regional pilot study was initiated in Tartu county.² The pilot is designed to compare two ways of assessing screening eligibility (smoking status vs. risk score), and to gather further evidence of screening uptake at larger scale.^{1 3} The ongoing pilot study also aims to evaluate all aspects of lung cancer screening within the health system, including the screening process, the role of screening coordinators, cost-efficiency and health system readiness for larger-scale implementation.

The pilot study, which is funded by Estonian Health Insurance Fund, involves working with family physicians and nurses to enrol participants.⁴ The eligibility criteria for the study is people living in Tartu County aged 55–74 years with increased risk of lung cancer. This includes a smoking history of 20 or more pack-years and those who have quit smoking in the last 15 years, and/or PLCO_m2012noRace risk score over 1.5%.⁴

In the first two years of the study, 7,746 LDCT scans were performed with 62 cases of lung cancer detected.¹ The programme facilitated detecting and diagnosing lung cancer at an earlier stage, with surgical treatment taking place in 67% of cases in the first year of the study.⁴

The rate of screening uptake was 79% in the first year of the pilot study; initial results from the second year demonstrated similar uptake.¹ The pilot highlighted that screening coordinators are essential to navigating participants through the screening process. Due to several challenges the screening pilot has currently been paused with the hope of restarting in January 2025.¹
 

Assessing requirements for implementation

In parallel with the pilot study, a comprehensive gap analysis was performed, identifying several challenges that should be addressed before a national screening programme can be implemented optimally in Estonia. The issues identified were:¹

• Limited numbers of:
• radiologists with specialised training in chest imaging
• general practitioners and resources for general practitioners to assist with screening, especially in the initial years of set up
• screening coordinators
• Insufficient availability and uneven distribution of CT scanners
• A lack of reimbursement of screening at the national level.

Following this gap analysis, possible solutions for the challenges were considered to underpin planning for screening implementation.
 

Developing a national implementation plan

A stepwise implementation plan has been developed to ensure a successful and well-structured roll-out across Estonia. The plan outlines clear timelines and milestones for each phase, recognising the resource constraints and varying capacities across the country. Screening will be rolled out county by county, starting in areas where contemporary CT scanners are available.¹ A mobile CT unit will be used from 2025 to help roll-out and ensure wider availability of screening.¹

Family physicians and nurses are crucial to ensuring people are enrolled in screening programmes for lung cancer. The family physicians are supported by screening coordinators who help to navigate participants along the patient pathway, from the initial LDCT scan through to management of screening findings.¹

The wealth of evidence that has been created and continues to be developed from the pilot study, and analyses will help to inform the effective future roll-out of a screening programme.