Detecting lung cancer earlier: your questions answered

Our November webinar on the earlier detection of lung cancer was attended by people from 11 countries and included clinicians, academics and representatives of patient organisations. During the event, our panel received more questions than they had time to answer; therefore, we asked some of our expert speakers to address them here.
 

Where lung cancer screening is not yet widely implemented, what can health systems do to ensure earlier detection?

It is difficult to comprehensively implement lung cancer screening in all health systems, especially in places where resources are limited. Many countries are also facing workforce shortages in radiology and other specialties; this will impact their ability to perform lung cancer screening at scale.

Where screening programmes are not yet widely available, one of the biggest challenges will be to educate primary care professionals so they can recognise symptoms and risk factors, and swiftly refer to specialist care. This will increase the chances of early detection, diagnosis and eventual treatment. In parallel, health systems should be ready to support robust cancer care pathways so that when patients are referred from primary care, they reach a specialist in a timely manner.

Top-down incentives can also help. For example, in the US, while reimbursement for lung cancer screening is available from Medicare, screening is not considered a quality measure; therefore, it is poorly implemented. Less than 10% of those eligible are currently being screened. If it were considered a quality measure for care, it would go a long way toward building lung cancer screening as a standard in primary care settings.
 

What action can be taken to improve coverage of screening for people at high risk of lung cancer?

Equitable coverage and access to screening are crucial. We know that lung cancer is linked to smoking, and the rate of smoking in England, for example, is four times higher in the most deprived areas than in the least deprived. It is important to analyse these differential risk factors to target screening for high-risk groups and have the most impact.
 

What is the role of incidental pulmonary nodule (IPN) management in helping detect lung cancer earlier?

IPNs are lesions in the lung that are found outside of a screening programme. They are an opportunity to detect lung cancer earlier in those who are ineligible for low-dose computed tomography (LDCT) screening; this is important because, in some populations, almost half of lung cancer cases occur in people who are ineligible for screening. People with IPNs must be tracked to ensure they receive appropriate follow-up care.

Countries need to develop and implement pathways to ensure that people with IPNs receive timely and appropriate care. You can learn more about optimal IPN management in the Network’s report, Enhancing the earlier detection of lung cancer: effective management of incidental pulmonary nodules.

What are the screening recommendations and criteria for people who have never smoked and people with a family history of lung cancer?

There are a range of risk factors for lung cancer – including age, smoking status and exposure to air pollution (especially in people who do not smoke) – and we need to ensure that screening continues to be available for those at highest risk of developing lung cancer. Globally, 15–20% of men and more than 50% of women with lung cancer have never smoked – and these figures are increasing, particularly in East Asia.

People with first-degree relatives who have been diagnosed with lung cancer are at increased risk of developing the disease. Insights from the TALENT study in Taiwan led to the screening of people who have never smoked; risk factors and a family history of lung cancer were included as one aspect of  determining the population that was eligible for screening. People with a family history of lung cancer are screened at age 45 for women, and 50 for men, both of which are earlier than the usual screening age for other high-risk demographics.
 

What role could innovative technologies, including artificial intelligence (AI), play in LDCT scan interpretation as part of lung cancer screening programmes?

We are on the cusp of significant changes in how we leverage innovative technologies (including AI) in cancer care. For any intervention, it is important to proceed in an organised manner, assessing efficacy, quality and safety against current practice before implementing at scale. That being said, innovative technologies, including AI, can assist in scan interpretation, supporting radiologists by easing workload challenges and creating more cost-effective and streamlined processes. AI’s potential in data processing and data extraction at scale might also assist in the identification of high-risk individuals.
 

How do we raise awareness of lung cancer screening and its benefits among eligible populations, to improve uptake?

Different populations require slightly different and tailored approaches to lung cancer screening invitation. Providing information that uses plain language, and is offered in different languages, has been shown to have high patient engagement and acceptance. Working closely with community health centres is also crucial for reaching as many people as possible, including non-responders; this includes the sharing of resources and mobilisation strategies, such as knocking on doors, when screening programmes become available in a community. There is also potential in using enrolled patients to disseminate information and recruit others who are eligible for screening. A good example of these strategies comes from the UK Targeted Lung Health Check Programme, which saw promising results in increasing lung cancer detection rates among the most high-risk demographics as well as reducing mortality among the most deprived groups, thereby reducing inequalities.
 

What are the priority research areas in lung cancer screening globally?

A next step in research and policy will be to understand populations who are not eligible for screening but still at high risk of lung cancer. There are many things we still don’t understand. For example, in the TALENT study, women who had never smoked had similar lung cancer detection rates at LDCT as high-risk individuals with an extensive smoking exposure history. More research is needed to understand the underlying causes of these findings, whether detection of these cases yields long-term benefit, and whether we can identify people who have never smoked but are at sufficiently high risk to benefit from LDCT screening. One way to do this will be to leverage biomarkers as part of lung cancer screening; emerging evidence shows their significant potential to optimise the screening process (e.g. to further refine selection criteria). Furthering our understanding of the underlying risk factors of lung cancer could also help reduce the stigma that is attached with lung cancer, especially for the smoking population.

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

• Professor John Field – University of Liverpool, UK
• Tiffany Gowen – American College of Radiology, US
• Dr Mattias Johansson – International Agency for Research on Cancer, France
• Lauren Pretorius – Campaigning for Cancer, South Africa
• Dr Luis E. Raez – Memorial Cancer Institute, US
• Dr Lucía Viola – Fundación Neumologica Colombiana, Luis Carlos Sarmiento Angulo Cancer Treatment and Research Center, Colombia
• Professor Pan Chyr Yang – National Taiwan University, Taiwan

Watch the webinar here