The Lung Cancer Policy Network welcomes the inclusion of targeted lung cancer screening in the EU Commission’s draft recommendation: A new approach on cancer screening. The recommendations are a positive step in addressing the devasting public health burden of lung cancer, the deadliest cancer in Europe.

However, aspects of the proposal could be strengthened, to fully reflect the wealth of evidence available to guide the implementation of low-dose computed tomography (LDCT) screening for lung cancer in the European Union (EU) (please refer to the Network’s earlier submission to the European Commission).

There is compelling European and international evidence that LDCT screening reduces mortality from lung cancer high-risk individuals. It has the potential to shift diagnosis to an earlier stage, when treatments are more effective.

We have already lost too much time and too many lives because of a lack of clear guidance focused on the implementation of lung cancer screening.¹ The timing is thus pivotal for the updated recommendations. Member States need to act urgently on this evidence and to advance with implementation.

Specifically, the Network would like to see the following in the recommendations:

• Explicit recognition of the well-established evidence base for lung cancer screening implementation. Lung cancer screening should be presented as a standalone recommendation, and considered for implementation based on the same parameters used to approve breast, cervical and colorectal cancer screening.
• Greater detail on the proposed ‘step-wise’ approach recommended in relation to lung cancer screening. Given the substantive evidence base for LDCT screening, the recommendations should call on all EU Member States to look at how it can feasibly be implemented within their national contexts, applying the learning from existing implementation of LDCT screening in Europe and around the world to rapidly progress their own efforts.
• A shorter review period for lung cancer screening and clear targets for implemented programmes to strive towards, to ensure momentum in implementation.

The Network’s response in detail

Below we take a closer look at the benefits of screening and the evidence that informed the Network’s suggested additions and amendments to the screening recommendations.

The benefits of screening for lung cancer are clear

The early detection of lung cancer via screening offers a significant opportunity to reduce the burden of cancer. Lung cancer is the most common cause of cancer-related deaths, accounting for around one fifth of all deaths from cancer.² But this does not have to be the case. As the symptoms of lung cancer are difficult to discern in the early stages of the disease,^{3 4} targeted LDCT screening of high-risk populations is the most effective way to achieve early detection. Early detection via screening has the potential to shift the stage of diagnosis from a late to an early stage, significantly increasing survival rates.^{5 6}

Figure 1. Stages of lung cancer diagnosed inside and outside of a screening programme⁷

A closer look at areas of the recommendation to be to strengthened

1. The evidence base for lung cancer screening is highly advanced.

Lung cancer screening should be presented as a standalone recommendation, and considered for implementation based on the same parameters used to approve breast, cervical and colorectal cancer screening to recognise this evidence.

Countries across Europe should be supported to progress at pace with the implementation of LDCT screening for lung cancer based on the extensive evidence of its effectiveness in decreasing lung cancer mortality. The 2020 publication of the Dutch–Belgian Randomised Lung Cancer Screening Trial (NELSON) confirmed the findings of the US National Lung Screening Trial (NLST) more than a decade before, that targeted LDCT screening of people who smoke or used to smoke heavily can significantly reduce deaths from lung cancer; this was also demonstrated with a recent meta-analysis on nine lung cancer randomised controlled trials, seven of which were from Europe.^{9 10 11}. Furthermore, the Cochrane collaborative group has issued a meta-analysis showing a lung cancer mortality reduction of 21% and an overall mortality reduction of 5%.¹²

The evidence is also clear that LDCT screening:

• does not lead to a large number of false-positive results or subsequent unnecessary procedures or treatments^{8 13 14}
• is expected to be a cost-effective investment, comparing well with other population-based screening strategies, including those in place for colorectal, breast and cervical cancers¹⁵
• is within accepted economic thresholds^16-18
• is expected to be more efficient than other screening programmes in terms of the number of people who need to be screened to prevent one cancer-related death.¹⁹

2. A step-wise approach to lung cancer screening should explicitly call for countries to progress to the next step of implementation.

The step-wise approach proposed in the recommendations is valuable, ensuring that countries carefully plan for the implementation of screening programmes in a feasible manner within their national contexts, with clear protocols in place.  But without further clarification, there is a danger that the current wording of the recommendation leads to a step backwards, hindering progress by suggesting evidence that is already well established be revisited.

This point was emphasised in the Network’s recent round-table event, by Dr Robbins:

Recent mapping by the Lung Cancer Policy Network of the implementation of lung cancer screening shows that there are currently at least 56 implementation studies taking place across the globe, 27 of which are ongoing across Europe. These build on earlier findings from numerous randomised controlled trials. Such evidence from real-world practice provides important learnings that can guide other countries towards implementation.

Our interactive map clearly demonstrates implementation evidence translating into action, and a more robust EU screening recommendation has the potential to add to this progress. Seven countries have successfully initiated national LDCT lung cancer screening programmes. Three of these are in the EU (Poland, Croatia and the Czech Republic) and another three EU countries have formally committed to implementation. Australia also has a recent recommendation to implement, and the UK National Screening Committee recently updated its screening recommendations in favour of implementing an organised national lung cancer screening programme in high-risk individuals via LDCT.

Fifteen excellent examples of the different approaches that countries around the world have taken to screening implementation are detailed as case studies in the Network’s Lung cancer screening: learning from implementation report. These include Croatia’s national lung cancer population screening programme, which was launched in 2020, and the UK’s Targeted Lung Health Check model, which used a phased approach to grow the number of sites offering screening.^{20 21}

3. A shorter review period will promote momentum in implementation.

With the recommendations calling for clear and tangible targets to be set for any new cancers that need to be tackled, the Network would like to see a more ambitious review period for lung cancer. The proposal stipulates a review time of three years following programme implementation and then subsequently every four years. However, given the strength of the evidence for LDCT lung cancer screening and the number of ongoing or completed implementation studies across the EU, the Network would recommend a shorter review time for lung cancer screening, such as two years.

Furthermore, we would like to see clear targets outlined in the recommendation for the provision of lung cancer screening. For example, in line with the aspirations highlighted around ensuring that 90% of the EU population who qualify for breast, cervical and colorectal screenings are offered screening by 2025, the recommendation could extend this to targets set for lung cancer screening. These targets could be informed by current EU screening activity taking place in the Czech Republic, Croatia and Poland; the Czech Republic aims to recruit 10% of the eligible population for screening, while Poland and Croatia aim to recruit 20% of the eligible population in their early stages.

Click here to read the full text of the Lung Cancer Policy Network’s Proposed amendments to the EU Commission draft recommendation on cancer screening.