Lung cancer screening: your questions answered

We share responses from members of the Lung Cancer Policy Network to questions raised during a webinar exploring different approaches to implementing a lung cancer screening programme. The webinar also highlighted the framework to support the implementation of low-dose computed tomography lung cancer screening and a series of policy briefs recently developed by the Network.

We were delighted that the webinar was attended by people from over 30 different countries, including industry representatives, patient organisations, clinicians and academics.
 

Which imaging system is most suitable to use for screening for lung cancer?

The evidence points to low-dose computed tomography (LDCT) as the most suitable imaging system for lung cancer screening.

LDCT scanning of the chest is an accurate imaging technique that has a greater sensitivity than chest X-ray in detecting lung cancer at any stage. It is routinely used in screening programmes for lung cancer.

The US National Lung Screening Trial (NLST), Dutch-Belgian Lung Cancer Screening Trial (NELSON) and UK Lung Screening (UKLS) trial have provided conclusive evidence that LDCT screening reduces lung cancer mortality.
 

Should smoking cessation interventions be included in a lung cancer screening programme?

In short, yes. The longer answer is that the precise intervention is yet to be universally agreed on. Combined use of behavioural interventions and medication has been found to produce the largest cessation effects, but evidence also indicates several treatments are effective when used alone.

Smoking cessation interventions can greatly enhance the impact of lung cancer screening programmes. A recent systematic review found that when it was delivered during lung cancer screening programmes, smoking cessation resulted in increased quit rates compared with usual care, with more intensive interventions the most effective. Further, modelling the impact of joint screening and smoking cessation has demonstrated a reduction in lung cancer mortality and an extended lifespan than screening alone.

Many countries already recognise smoking cessation as crucial to their own national screening programmes, including Australia, Canada and the UK.
 

How can awareness of lung cancer screening programmes be increased, especially among underserved populations?

Targeted approaches to help mitigate inequities in lung cancer and remove barriers to participation should be embedded throughout the screening programme. Co-designing the programmes with communities at risk of lower uptake is crucial. Many countries have begun instituting such initiatives:

• targeted invitation methods to lung cancer screening for Māori communities in Aotearoa New Zealand
• strategies to increase participation in lung cancer screening among First Nations, Inuit and Métis people in several Canadian provinces: engagement in decision-making, development of culturally appropriate material, financing of medical transportation
• community pharmacy referral services in England and Wales as an alternative route to lung cancer diagnosis for socioeconomically deprived communities.

The number of risk factors associated with lung cancer seems to be increasing – how does this impact eligibility for lung cancer screening?

Tobacco smoking is a well-established risk factor for lung cancer, with many of the clinical trials investigating the efficacy of LDCT screening using smoking as a risk factor. As a consequence, smoking is recognised in the U.S. Preventive Services Task Force and UK National Screening Committee eligibility criteria for lung cancer screening, among others. However, there is growing recognition that risk factors, and therefore eligibility criteria, need to reflect local epidemiology. A wealth of evidence for a variety of risk factors is currently being compiled, for example:

• A decline in smoking rates in Western countries has coincided with a rise in lung cancer incidence among people who had never smoked, particularly women. This trend is also emerging in other parts of the world e.g. more than 90% of Taiwanese women diagnosed with lung cancer are never smokers.
• There is an established scientific link between air pollution and a number of conditions, including lung cancer. Researchers estimate that globally hundreds of thousands of lung cancer deaths annually are attributable to particulate matter air pollution, which is common in industrial areas.
• Numerous genetic alterations (mutations, additions, deletions or rearrangements) have been associated with an increased risk of lung cancer. Several targeted therapies have been approved to treat people with non-small cell lung cancer with different genetic alterations, and so screening these populations will enable faster referral and treatment.
• Individuals with respiratory conditions, such as chronic obstructive pulmonary disorder (COPD) or asthma, have a higher risk of developing lung cancer, irrespective of their smoking status.
• There is a strong scientific basis for the potential oncogenicity of e-cigarettes and e-liquids. Further research could help determine whether tighter control and regulation of these products is needed, due to current concern of significant future public health implications.

The eligibility criteria for lung cancer screening should ideally be flexible and adapt to include those at highest risk in a given context. Further research into the effectiveness of screening using different eligibility criteria is needed before they can be recommended for inclusion in national standards and guidelines.
 

As screening programmes are rolled out, more people will be screened, accruing a greater cost – how can the willingness of governments to support screening programmes be maintained if their cost increases?

The cost-effectiveness of LDCT screening among targeted populations is well established, with experts suggesting it compares favourably with population-based cancer screening programmes.

Lung cancer screening should be an integral part of all national cancer control plans if countries wish to reduce the societal toll of cancer and other non-communicable diseases. In support of this, eligibility criteria (and the supporting evidence) must be frequently updated and clearly communicated to governments, as the cost-effectiveness of screening is closely related to how the screening population is defined.

We would like to thank all webinar attendees as well as the expert panellists and speakers:

• Professor David Baldwin – University of Nottingham, UK
• Dr Joelle Fathi – GO2 Foundation for Lung Cancer, USA
• Ms Ebba Hallersjö Hult – Vision Zero Cancer, Sweden
• Dr Claudia Henschke – Mount Sinai Hospital, USA
• Dr Karen Kelly – International Association for the Study of Lung Cancer
• Professor Stephen Lam – University of British Columbia, Canada
• Dr Hilary Robbins – International Agency for Research on Cancer/World Health Organization
• Professor Edyta Szurowska – University Clinical Centre & Medical University of Gdańsk, Poland

If you’ve missed the webinar, you can watch it here.