Lung cancer screening - gaining consensus on next steps - proceedings of a closed workshop in the UK

Lung cancer is the most common cause of cancer death in the UK, and survival from the disease is persistently poor. Efforts to improve outcomes for patients have focused on ways of reducing late diagnosis of the disease, and access to optimal treatment. Research on lung cancer screening has so far provided some evidence of an impact on lung cancer mortality, but there is some debate about whether implementation of a national screening programme should await further trial data, principally that from the NELSON trial. The ongoing poor outcomes and the belief amongst some clinicians that there is sufficient evidence has prompted several local projects testing out lung screening in their communities, sometimes referred to as lung health checks or proactive approaches to high-risk individuals. Funding from NHS England has been forthcoming to support this. Acknowledging roll-out of such activities, which effectively constitute local lung screening in the absence of a NSC recommendation, it was timely to bring key national stakeholders together with academic and clinical experts, to agree a way forward. Cancer Research UK therefore convened a closed workshop in March 2018, involving national and international expertise. This paper outlines the proceedings, key discussion points, highlighted research gaps, and areas of consensus and next steps.

Recent advances in the management of lung cancer

Historically, the prognosis for individuals diagnosed with lung cancer has been bleak. However, the past 10 years have seen important advances in treatment and diagnosis which have translated into the first improvements seen in lung cancer survival. This review highlights the major advances in treatments with curative intent, systemic targeted therapies, palliative care and early diagnosis in lung cancer. We discuss the pivotal research that underpins these new technologies/strategies and their current position in clinical practice.

Recent advances in the management of lung cancer

Historically, the prognosis for individuals diagnosed with lung cancer has been bleak. However, the past 10 years have seen important advances in treatment and diagnosis which have translated into the first improvements seen in lung cancer survival. This review highlights the major advances in treatments with curative intent, systemic targeted therapies, palliative care and early diagnosis in lung cancer. We discuss the pivotal research that underpins these new technologies/strategies and their current position in clinical practice.

Geographical variations in the use of cancer treatments are associated with survival of lung cancer patients

Introduction

Lung cancer outcomes in England are inferior to comparable countries. Patient or disease characteristics, healthcare-seeking behaviour, diagnostic pathways, and oncology service provision may contribute. We aimed to quantify associations between geographic variations in treatment and survival of patients in England.

Methods

We retrieved detailed cancer registration data to analyse the variation in survival of 176,225 lung cancer patients, diagnosed 2010-2014. We used Kaplan-Meier analysis and Cox proportional hazards regression to investigate survival in the two-year period following diagnosis.

Results

Survival improved over the period studied. The use of active treatment varied between geographical areas, with inter-quintile ranges of 9%–17% for surgical resection, 4%–13% for radical radiotherapy, and 22%–35% for chemotherapy. At 2 years, there were 188 potentially avoidable deaths annually for surgical resection, and 373 for radical radiotherapy, if all treated proportions were the same as in the highest quintiles. At the 6 month time-point, 318 deaths per year could be postponed if chemotherapy use for all patients was as in the highest quintile. The results were robust to statistical adjustments for age, sex, socio-economic status, performance status and co-morbidity.

Conclusion

The extent of use of different treatment modalities varies between geographical areas in England. These variations are not attributable to measurable patient and tumour characteristics, and more likely reflect differences in clinical management between local multi-disciplinary teams. The data suggest improvement over time, but there is potential for further survival gains if the use of active treatments in all areas could be increased towards the highest current regional rates.

Impact of radiographer immediate reporting of chest X-rays from general practice on the lung cancer pathway (radioX): study protocol for a randomised control trial

Background

Diagnostic capacity and suboptimal logistics are consistently identified as barriers to timely diagnosis of cancer, especially lung cancer. Immediate chest X-ray (CXR) reporting for patients referred from general practice is advocated in the National Optimal Lung Cancer Pathway to improve time to diagnosis of lung cancer and to reduce inappropriate urgent respiratory medicine referral for suspected cancer (2WW) referrals. The aim of radioX is to examine the impact of immediate reporting by radiographers of CXRs requested by general practice (GP) on lung cancer patient pathways.

Methods

A two-way comparative study that will compare the time to diagnosis of lung cancer for patients. Internal comparison will be made between those who receive an immediate radiographer report of a GP CXR compared to standard radiographer GP CXR reporting over a 12-month period. External comparison will be made with a similar, neighbouring hospital trust that does not have radiographer CXR reporting. Primary outcome is the effect on the speed of the lung cancer pathway (diagnosis of cancer or discharge). Secondary outcomes include the effect of the pathway on efficiency including the number of repeat CXRs performed in a timely fashion for suspected infection and the effect of immediate reporting of GP CXRs on patient satisfaction.

Discussion

The radioX trial will examine the hypothesis that immediate reporting of CXRs referred from GP reduces the time to diagnosis of lung cancer or discharge from the lung cancer pathway.

Trial registration

International Standard Randomised Controlled Trial Number ISRCTN21818068. Registered on 20 June 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2268-x) contains supplementary material, which is available to authorized users.

EU Policy on Lung Cancer CT Screening 2017

BACKGROUND

Lung cancer kills more Europeans than any other cancer. In 2013, 269,000 citizens of the EU-28 died from this disease. Lung cancer CT screening has the potential to detect lung cancer at an early stage and improve mortality. All of the randomised controlled trials and cohort low-dose CT (LDCT) screening trials across the world have identified very early stage disease (∼70%); the majority of these LDCT trial patients were suitable for surgical interventions and had a good clinical outcome. The 10-year survival in CT screen-detected cancer was shown to be even higher than the 5-year survival for early stage disease in clinical practice at 88%.

METHODS

Setting up of an EU Commission expert group can be done under Article 168(2) of the Treaty on the Functioning of the European Union, to develop policy and recommendation for Lung cancer CT screening. The Expert Group would undertake: (a) assist the Commission in the drawing up policy documents, including guidelines and recommendations; (b) advise the Commission in the implementation of Union actions on screening and suggest improvements to the measures taken; (c) advise the Commission in the monitoring, evaluation and dissemination of the results of measures taken at Union and national level.

RESULTS

This EU Expert Group on lung cancer screening should be set up by the EU Commission to support the implementation and suggest recommendations for the lung cancer screening policy by 2019/2020.

CONCLUSION

Reduce lung cancer in Europe by undertaking a well-organised lung cancer CT screening programme.

Lung cancer screening-low dose CT for lung cancer screening: recent trial results and next steps

Screening for lung cancer using low-dose CT has already been implemented in North America following the results of the National Lung Screening Trial. Outside North America, clinicians and researchers are addressing issues that may have a major impact on the success of screening programmes by reviewing results of existing trials and by designing new research and pilot programmes. This review summarizes the work that has been done to try to answer the remaining questions and highlights potential barriers which may affect screening uptake and cost-effectiveness.

Impact of low-dose CT screening on smoking cessation among high-risk participants in the UK Lung Cancer Screening Trial

Background

Smoking cessation was examined among high-risk participants in the UK Lung Cancer Screening (UKLS) Pilot Trial of low-dose CT screening.

Methods

High-risk individuals aged 50–75 years who completed baseline questionnaires were randomised to CT screening (intervention) or usual care (no screening control). Smoking habit was determined at baseline using self-report. Smokers were asked whether they had quit smoking since joining UKLS at T₁ (2 weeks after baseline scan results or control assignment) and T₂ (up to 2 years after recruitment). Intention-to-treat (ITT) regression analyses were undertaken, adjusting for baseline lung cancer distress, trial site and sociodemographic variables.

Results

Of a total 4055 individuals randomised to CT screening or control, 1546 were baseline smokers (759 intervention, 787 control). Smoking cessation rates were 8% (control n=36/479) versus 14% (intervention n=75/527) at T₁ and 21% (control n=79/377) versus 24% (intervention n=115/488) at T₂. ITT analyses indicated that the odds of quitting among screened participants were significantly higher at T₁ (adjusted OR (aOR) 2.38, 95% CI 1.56 to 3.64, p<0.001) and T₂ (aOR 1.60, 95% CI 1.17 to 2.18, p=0.003) compared with control. Intervention participants who needed additional clinical investigation were more likely to quit in the longer term compared with the control group (aOR 2.29, 95% CI 1.62 to 3.22, p=0.007) and those receiving a negative result (aOR 2.43, 95% CI 1.54 to 3.84, p<0.001).

Conclusions

CT lung cancer screening for high-risk participants presents a teachable moment for smoking cessation, especially among those who receive a positive scan result. Further behavioural research is needed to evaluate optimal strategies for integrating smoking cessation intervention with stratified lung cancer screening.

Trial registration number

Results, ISRCTN 78513845

The impact of trained radiographers as concurrent readers on performance and reading time of experienced radiologists in the UK Lung Cancer Screening (UKLS) trial

Objectives

To compare radiologists’ performance reading CTs independently with their performance using radiographers as concurrent readers in lung cancer screening.

Methods

369 consecutive baseline CTs performed for the UK Lung Cancer Screening (UKLS) trial were double-read by radiologists reading either independently or concurrently with a radiographer. In concurrent reading, the radiologist reviewed radiographer-identified nodules and then detected any additional nodules. Radiologists recorded their independent and concurrent reading times. For each radiologist, sensitivity, average false-positive detections (FPs) per case and mean reading times for each method were calculated.

Results

694 nodules in 246/369 (66.7%) studies comprised the reference standard. Radiologists’ mean sensitivity and average FPs per case both increased with concurrent reading compared to independent reading (90.8 ± 5.6% vs. 77.5 ± 11.2%, and 0.60 ± 0.53 vs. 0.33 ± 0.20, respectively; p < 0.05 for 3/4 and 2/4 radiologists, respectively). The mean reading times per case decreased from 9.1 ± 2.3 min with independent reading to 7.2 ± 1.0 min with concurrent reading, decreasing significantly for 3/4 radiologists (p < 0.05).

Conclusions

The majority of radiologists demonstrated improved sensitivity, a small increase in FP detections and a statistically significantly reduced reading time using radiographers as concurrent readers.

Key Points

• Radiographers as concurrent readers could improve radiologists’ sensitivity in lung nodule detection.

• An increase in false-positive detections with radiographer-assisted concurrent reading occurred.

• The false-positive detection rate was still lower than reported for computer-aided detection.

• Concurrent reading with radiographers was also faster than single reading.

• The time saved per case using concurrently reading radiographers was relatively modest.

Electronic supplementary material

The online version of this article (doi:10.1007/s00330-017-4903-z) contains supplementary material, which is available to authorized users.

Place of Death in Patients with Lung Cancer: A Retrospective Cohort Study from 2004-2013

Introduction

Many patients with cancer die in an acute hospital bed, which has been frequently identified as the least preferred location, with psychological and financial implications. This study looks at place and cause of death in patients with lung cancer and identifies which factors are associated with dying in an acute hospital bed versus at home.

Methods and Findings

We used the National Lung Cancer Audit linked to Hospital Episode Statistics and Office for National Statistics data to determine cause and place of death in those with lung cancer; both overall and by cancer Network. We used multivariate logistic regression to compare features of those who died in an acute hospital versus those who died at home.

Results

Of 143627 patients identified 40% (57678) died in an acute hospital, 29% (41957) died at home and 17% (24108) died in a hospice. Individual factors associated with death in an acute hospital bed compared to home were male sex, increasing age, poor performance status, social deprivation and diagnosis via an emergency route. There was marked variation between cancer Networks in place of death. The proportion of patients dying in an acute hospital ranged from 28% to 48%, with variation most notable in provision of hospice care (9% versus 33%). Cause of death in the majority was lung cancer (86%), with other malignancies, chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD) comprising 9% collectively.

Conclusions

A substantial proportion of patients with lung cancer die in acute hospital beds and this is more likely with increasing age, male sex, social deprivation and in those with poor performance status. There is marked variation between Networks, suggesting a need to improve end-of-life planning in those at greatest risk, and to review the allocation of resources to provide more hospice beds, enhanced community support and ensure equal access.