9 August 2023

We spoke with Network member Professor Pan-Chyr Yang, Chair Professor and former President of the National Taiwan University, who shared his experience of setting up a national lung cancer screening programme.

 

What were the key steps to implementing a lung cancer screening programme in Taiwan?

 

Conducting a pilot study

Since 2014, the Ministry of Health and Welfare has subsidised the Taiwan Lung Cancer Society’s Taiwan Lung Cancer Screening for Never-Smoker Trial (TALENT), led by me and my team from the National Taiwan University College of Medicine. Importantly, the most recent findings of the TALENT study have shown that having a family history of lung cancer is a significant risk factor for developing the disease. This is especially interesting for Taiwan, which has a high prevalence of lung cancer that is not related to smoking – only one-third of cases are attributed to smoking.
 

Building the evidence base for LDCT screening implementation

In response to the growing evidence base for lung cancer screening, the Health Promotion Administration (HPA) of the Ministry of Health and Welfare has held strategic meetings on the topic with several organisations: Taiwan Lung Cancer Society, Taiwan Society of Pulmonary and Critical Care Medicine, Taiwan Radiological Society, Taiwan Society of Thoracic Surgeons, and related professional groups. The attendees used a cost-effectiveness analysis and review of scientific evidence as the basis for discussions around the potential benefits of lung cancer screening, appropriate eligibility criteria and the resourcing needs for the programme.
 

Creating clear screening recommendations

In 2020, the Taiwan Lung Cancer Society revised its Consensus Declaration on Low-Dose Computed Tomography (LDCT) Screening for Lung Cancer in Taiwan based on overwhelming empirical data and successful international examples. The declaration recommended that people aged 50–80 who have a smoking history of more than 30 pack-years and have either quit within the past 15 years or continued to smoke, undergo LDCT screening for lung cancer. People with a family history of lung cancer are also advised to participate in screening. This guidance revision marked the beginning of the national lung cancer screening programme in Taiwan.

 

Who were the key stakeholders involved in setting up the programme, and how did they contribute?

To understand the feasibility of implementing a lung cancer screening programme in Taiwan, the HPA consulted a group of experts and professional organisations. It collaborated with the Taiwan Radiological Society to standardise and regulate CT equipment acquisition and CT image protocols, including exposure factors and image reconstruction. Forms regarding personal risk factors, nodule reporting and follow-up reporting were also created. These were finalised after several discussions with lung cancer societies, associations, non-governmental organisations and medical experts.

The HPA then worked with medical experts, lung cancer societies, associations and government departments to develop the initial stage of the National Lung Cancer Prevention and Control Plan (2022–25). The plan encompasses various aspects of lung cancer, including prevention, screening, treatment and research, with screening forming an integral part of its secondary prevention strategy to achieve early detection and treatment.
 

Are there aspects of the design of the Taiwanese lung cancer screening programme that are particularly interesting for those considering implementation?

The Taiwan Lung Cancer Screening Programme, which was launched nationally in July 2022, has various aspects of interest, such as its eligibility criteria, the inclusion of smoking cessation and the consideration given to quality assurance and accessibility.

Regarding the eligibility criteria, the programme provides biannual LDCT screening to two eligible groups. The first group are individuals aged 50–74 (in line with other established screening programmes) with a smoking history of 30 or more pack-years. The second group are people with a family history of lung cancer: men aged 50–74 and women aged 45–74.

Lung cancer screening services in other countries are typically targeted towards people who smoke heavily, but the TALENT study has shown that a family history of lung cancer is the most indicative risk factor for non-smoking-related lung cancer for people in Taiwan.

By offering lung cancer screening to citizens with a family history of lung cancer or a history of heavy smoking, Taiwan has become the first country to take this important step in cancer prevention.

Key learnings include:

  • The programme has a focus on integrating lung cancer screening and smoking cessation services, and offering smoking cessation to those who have a positive result on the carbon monoxide breath test is mandatory. This approach is intended to both encourage people who currently smoke to quit and improve the effectiveness of the screening programme.
  • HPA took steps to ensure high-quality services conduct peer reviews of CT scans and reports, provide education and training, and carry out on-site visits. This was achieved by partnering with professional groups to monitor the quality assurance index.
  • To increase the accessibility of lung cancer screening services, HPA engaged with local governments and actively recruited hospitals to participate in the project. Various communication channels were used, including press conferences, press releases, TV, internet and radio, to raise public awareness and encourage eligible individuals to undergo screening.

 

What were the initial outcomes of the programme?

Between July and December 2022, a total of 23,487 individuals received lung cancer screening and 319 cases of lung cancer were detected.

The vast majority of individuals (87%) were diagnosed at an early stage (stage 0–1), where the opportunity for curative treatment is much greater. This underscores the importance of early detection in improving outcomes for people with lung cancer.
 

What does the future of lung cancer screening look like in Taiwan?

We anticipate that the eligibility criteria for the screening programme can be further refined as necessary. These refinements can be based on the evidence being generated to support population-based LDCT lung cancer screening for people with other non-smoking risk factors, such as air pollution, oil fumes, occupational exposure and a history of lung disease. Furthermore, various supporting research programmes are ongoing in Taiwan, and the empirical data they generate will serve as a reference for any revisions to the eligibility criteria and will play a part in enriching the evidence base.

To find out more about Professor Pan-Chyr Yang, read his member profile.

 

The Lung Cancer Policy Network is publishing brief case studies of countries that have implemented LDCT screening; you can read other examples here.

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