The UK Lung Cancer Screening Trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer

Abstract

BackgroundLung cancer kills more people than any other cancer in the UK (5-year survival < 13%). Early diagnosis can save lives. The USA-based National Lung Cancer Screening Trial reported a 20% relative reduction in lung cancer mortality and 6.7% all-cause mortality in low-dose computed tomography (LDCT)-screened subjects.ObjectivesTo (1) analyse LDCT lung cancer screening in a high-risk UK population, determine optimum recruitment, screening, reading and care pathway strategies; and (2) assess the psychological consequences and the health-economic implications of screening.DesignA pilot randomised controlled trial comparing intervention with usual care. A population-based risk questionnaire identified individuals who were at high risk of developing lung cancer (≥ 5% over 5 years).SettingThoracic centres with expertise in lung cancer imaging, respiratory medicine, pathology and surgery: Liverpool Heart & Chest Hospital, Merseyside, and Papworth Hospital, Cambridgeshire.ParticipantsIndividuals aged 50–75 years, at high risk of lung cancer, in the primary care trusts adjacent to the centres.InterventionsA thoracic LDCT scan. Follow-up computed tomography (CT) scans as per protocol. Referral to multidisciplinary team clinics was determined by nodule size criteria.Main outcome measuresPopulation-based recruitment based on risk stratification; management of the trial through web-based database; optimal characteristics of CT scan readers (radiologists vs. radiographers); characterisation of CT-detected nodules utilising volumetric analysis; prevalence of lung cancer at baseline; sociodemographic factors affecting participation; psychosocial measures (cancer distress, anxiety, depression, decision satisfaction); and cost-effectiveness modelling.ResultsA total of 247,354 individuals were approached to take part in the trial; 30.7% responded positively to the screening invitation. Recruitment of participants resulted in 2028 in the CT arm and 2027 in the control arm. A total of 1994 participants underwent CT scanning: 42 participants (2.1%) were diagnosed with lung cancer; 36 out of 42 (85.7%) of the screen-detected cancers were identified as stage 1 or 2, and 35 (83.3%) underwent surgical resection as their primary treatment. Lung cancer was more common in the lowest socioeconomic group. Short-term adverse psychosocial consequences were observed in participants who were randomised to the intervention arm and in those who had a major lung abnormality detected, but these differences were modest and temporary. Rollout of screening as a service or design of a full trial would need to address issues of outreach. The health-economic analysis suggests that the intervention could be cost-effective but this needs to be confirmed using data on actual lung cancer mortality.ConclusionsThe UK Lung Cancer Screening (UKLS) pilot was successfully undertaken with 4055 randomised individuals. The data from the UKLS provide evidence that adds to existing data to suggest that lung cancer screening in the UK could potentially be implemented in the 60–75 years age group, selected via the Liverpool Lung Project risk model version 2 and using CT volumetry-based management protocols.Future workThe UKLS data will be pooled with the NELSON (Nederlands Leuvens Longkanker Screenings Onderzoek: Dutch–Belgian Randomised Lung Cancer Screening Trial) and other European Union trials in 2017 which will provide European mortality and cost-effectiveness data. For now, there is a clear need for mortality results from other trials and further research to identify optimal methods of implementation and delivery. Strategies for increasing uptake and providing support for underserved groups will be key to implementation.Trial registrationCurrent Controlled Trials ISRCTN78513845.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 40. See the NIHR Journals Library website for further project information.

Expanding the role of radiographers in reporting suspected lung cancer: A cost-effectiveness analysis using a decision tree model

“…The prevalence of lung cancer amongst presenting patients was assumed to be 13%. 27 Sensitivity and specificity of CT scan was taken from Aberle et al 28 The hourly cost of a radiographer (£53) and a radiologist (£156) were taken from a detailed costing study. 29 Costs per hour calculated by Lockwood for a reporting radiographer is based on salary, on-costs and education (postgraduate certificate for both CT head and CXR) rather than the examination/modality reported or output per hour.…”

“…The £53 per hour radiographer costs is transferable to our model. 27 We assumed that reporting a CXR would take two minutes, 30 generating reporting costs of £5.20 for a radiologist and £1.77 for a radiographer in addition to the cost of the CXR. 31 The diagnosis cost for cases re-presenting at emergency departments was assumed to be the cost of an emergency department visit in addition to the cost of a CXR and a CT scan.…”

EU Policy on Lung Cancer CT Screening 2017

“…Dedicated training and educational programmes directed to European radiologists, radiology technicians, pulmonologists, and thoracic surgeons focused on the best way to manage indeterminate lung nodules and indolent screen detected tumours will be critical to minimise invasive procedures, risks for healthy subjects, costs, and overtreatments. To this end, a common management protocol should be adopted based on the most innovative imaging software (volumetry and volume doubling time) together with recent knowledge from clinical experience [6,10,11,12]. Nodule size thresholds and in surveillance, the volume doubling time are useful methods to differentiate malignant dangerous lung lesions from benign or premalignant indolent tumours as shown by the investigators of the NELSON study [6,11], combined with selective use of PET scan [13,14].…”

“…a Undertake a literature search in order to identify alternative approaches to lung cancer screening, which will be considered in the fully developed EU Policy document - to include references such as [10,11,18,19,20,21,22]. …”

Risk assessment in relation to the detection of small pulmonary nodules

“…The latter is best termed "Interval Imaging Rate" and may, in screening programmes, merely mean continuing in the programme rather than referral to the MDT. For this reason, all category three lesions in the UKLS trial without cancer (or called indeterminate nodules) were reported separately as false positives warranting interval imaging (19).…”