Implementation of lung cancer screening: what are the main issues?

Abstract

Two large-scale RCTs have shown computed tomography (CT) lung cancer screening to be efficacious in reducing lung cancer mortality (8-24% in men, 26-59% in women). However, lung cancer screening implicitly means personalised and risk-based approaches. Health care systems' implementation of personalised screening and prevention is still sparse, and likely to be of variable quality, because of important remaining uncertainties, which have been incompletely addressed or not at all so far. Further optimisation of lung cancer screening programs is expected to reduce harms and maintain or enhance benefit for eligible European citizens, whilst significantly reducing health care costs. Some main uncertainties (e.g., Riskbased eligibility, Risk-based screening intervals, Volume CT screening, Smoking Cessation, Gender and Sex differences, Cost-Effectiveness) are discussed in this review. 4-IN-THE-LUNG-RUN (acronym for: Towards INdividually tailored INvitations, screening INtervals and INtegrated co-morbidity reducingstrategies in lung cancer screening) is the first multi-centred implementation trial on volume CT lung cancer screening amongst 24,000 males and females, at high risk for developing lung cancer, across five European countries, started in January 2020. Through providing answers to the remaining questions with this trial, many EU citizens will swiftly benefit from this high-quality screening technology, others will face less harms than previously anticipated, and health care costs will be substantially reduced. Implementing a new cancer screening programme is a major task, with many stakeholders and many possible facilitators but also barriers and obstacle.

Hesitancy around low-dose CT screening for lung cancer

“…Appropriate risk stratification optimises the benefiteharm ratio of LCS and is therefore key to successful implementation. 28,29 However, how the target population should be defined, identified and invited is open for discussion. Initial rates of uptake in the United States were as low as 1.9% of eligible individuals being screened, 30 only increasing to around 16.3% in some states by 2017.…”

“…35 On a larger scale, this approach would allow for true targeted population screening, with the option to account for other factors such as comorbidities, in line with recent recommendations from Van der Aalst et al in improving the uptake of those most at risk of lung cancer. 29 Pilot services are also investigating the ability of mobile scanners compared to hospital sites to widen access and optimise uptake of the screening invitation. 34,36,37 NLST screened participants based on two factors, age and smoking history.…”

Lung cancer and Covid-19: lessons learnt from the pandemic and where do we go from here?

“…There is no national lung screening programme at present in the UK; while a number of pilots are underway, lung cancer screening is still some way off in the UK, although it is under consideration by its National Screening Committee. There are significant hurdles—including imaging capacity, workforce considerations and reluctance, particularly amongst more deprived groups, to accept offers of screening 69 . it is also important to take a cautious approach to implementation of lung cancer screening—its benefits are confined to higher-risk groups and, as with any form of cancer screening, there is potential for over-diagnosis, particularly if recruitment to screening is not sufficiently targeted 70 .…”

Thoracic surgery in the Netherlands

“…A Dutch-initiated randomized lung cancer screening trial, known as the NELSON trial, has recently proven to result in a decrease in lung cancer mortality by 26% and to be cost-effective in the Netherlands (67)(68)(69). Although lung cancer screening programs are currently implemented in several European centers (70), screening for lung cancer with low-dose computed tomography is presently not yet implemented in the Netherlands because of legal restrictions (67).…”