Lung cancer kills more people each year than any other cancer because it’s common and because the majority of patients only start to show symptoms after the disease is already advanced. Despite this there is no screening for lung cancer, in stark contrast to established programmes for breast, cervical or colon cancer.
In the US, the National Lung Screening Trial (NLST) in 2010 showed a 20% increase in lives saved among a test group that had received low-dose CT scans, compared to those who had only had a chest radiograph. It was a major development and this year the US Preventative Services Task Force, an independent panel of non-government experts in prevention and evidence-based medicine including doctors and nurses, recommended lung cancer screening in the US.
A recent review I wrote with colleagues, and published in Lancet Oncology, considered the prospects of implementing CT scanning for lung cancer in Europe within the next four years. It could happen but there will be some hurdles along the way.
This side of the Atlantic
The US healthcare system differs significantly from that of the UK and the rest of Europe and cost-effectiveness is a significant factor in any decision on this side of the Atlantic.
We don’t yet know how cost-effective the NLST was – data have not yet been published – but estimates vary. The actuarial calculation estimated the cost per life-year saved in the 50 to 64-year-old age group to be below US$19,000 (£12,000), which is an amount that compares favourably with screening for cervical, breast, and colorectal cancers in the US. But the annual combined screening/smoking cessation therapy programmes at age 50 years costs were estimated between US$130,500 to US$159,700 (using something called the quality-adjusted life years measurement.
These costs will be a key issue for countries including the UK (to be determined by the National Institute of Clinical Excellence) and these will strongly be influenced by the design of the screening programme.
One in four
There is progress towards this. NELSON, the Dutch-Belgian lung cancer screening study, is a randomised control trial that suggests a reduction in lung cancer mortality of at least 25% but we await publication of the data in 2015. After that a pooling of European trials, including NELSON-derived data, should give us mortality data and cost effectiveness for Europe and the UK.
The awaited outcome of these trials will potentially provide confirmation that we can save lives and it will be cost-effective for high-risk individuals.
But, as we pointed out in our review, there are some important issues to be addressed. Of these, the most crucial are how long the intervals would be between screening events, and issues relating to harms and benefits – for example, no screening is 100% reliable so what happens if someone gets a false positive result? We would also need to include effective education about why people should stop smoking, because this is a significant driver behind so many cases of lung cancer. Success in this would also help improve cost-effectiveness.
Even with the optimisation of low-dose CT screening – such as improvements in identifying people at high-risk, imaging techniques, diagnosis of potentially cancerous nodules and better surgical approaches – it’s still going to be challenging to implement any programme given the present economic climate and the lack of funding for programmes that already exist.
But the public have to know about these issues because it has the potential to save a significant number of lives – if you have up to a quarter better chance of surviving lung cancer because it was detected earlier then it would be worth it. And to that end we need to have a national debate.