15 April 2024

We explore key steps in the iterative process that led to the government’s commitment to implementing a national screening programme for lung cancer in England. We also discuss the importance of building a national evidence base for lung cancer screening, with insights from Network members Professor David Baldwin and Professor John Field.

 

Learning from pilots and trials

Over the past 20 years, randomised controlled trials and meta-analyses from locations around the world have demonstrated that low-dose computed tomography (LDCT) screening for lung cancer significantly reduces mortality from the disease.1-4 Findings from these landmark studies led to further research specific to the UK and England, including:

  • UK Lung Cancer Screening (UKLS) pilot trial5
  • Liverpool Healthy Lung Programme6
  • Lung Health Check pilot, Manchester7
  • Lung Screen Uptake Trial (LSUT)8
  • West London lung screening pilot trial9
  • Yorkshire Lung Screening Trial (YLST)10
  • SUMMIT study.11

These UK-based trials, pilots and studies explored different aspects of the screening process in order to lay the foundations for a national programme, including how best to identify and engage potential participants. They also analysed cancer detection rates and cost-effectiveness.

In the YLST and the SUMMIT study, potential participants were triaged in an initial telephone assessment based on lung cancer risk. If the person met the eligibility criteria, they would then be scheduled for an LDCT scan as part of a lung health appointment. This allowed the recruitment process to focus on eligible participants. Smoking cessation services were also available as part of the lung health appointment.

It was found that participation rates could be increased using a targeted outreach approach in collaboration with primary care (LSUT) compared with a population-level approach (UKLS). Other trials, such as the Liverpool Healthy Lung Programme and the YLST, utilised similar targeted methods for recruiting eligible participants to improve screening uptake.

Other notable findings included the successful use of mobile screening in the Lung Health Check pilot in Manchester.⁷ 12 This pilot incorporated lung cancer screening as part of a holistic lung health check offered in a mobile unit that travelled around communities and was often situated near local shopping centres. This was also designed to reduce barriers to screening participation by reducing travel requirements and increasing accessibility.

The Manchester Lung Health Check pilot resulted in over 80% of lung cancer being detected at an early stage, Similarly, around 85% of the lung cancers picked up through screening in the UKLS trial were early stage. These trials also demonstrated the potential cost-effectiveness of lung cancer screening in England – a crucial factor in establishing a national screening programme for lung cancer.

‘The structure of the National Health Service has been pivotal in our ability to rapidly implement a screening programme for lung cancer. Our job now is to roll this out fully while ensuring that standards are maintained through effective quality assurance.’

Professor David Baldwin

From pilots to the Targeted Lung Health Check (TLHC) programme

Following the findings of these trials, NHS England (NHSE) launched the Targeted Lung Health Check (TLHC) programme in 2019. The TLHC protocol encompasses the lessons learned from previous studies, including identifying methodologies and high-risk individuals to increase participation in cancer screening.

The TLHC programme uses primary care records to identify people with a documented smoking history; those who meet the criteria (listed below) are then contacted for further risk stratification.14 This method minimises contact with people who are ineligible, thereby reducing costs and avoiding any potential distress caused by being contacted about cancer screening.

Currently, the TLHC programme utilises the following recruitment strategy:

  • People aged 55–74 years who are registered with a GP practice and who currently or formerly smoke are invited for a Lung Health Check.
  • Telephone appointments determine a potential participant’s suitability for an LDCT scan. These appointments assess individual risk by using the LLPv2 and PLCOm2012 risk models.13

So far, over 2,000 lung cancers have been diagnosed through screening offered via the TLHC programme despite it only being available in certain areas of the country.14 Over 75% of these cancers were diagnosed at an early stage, with 61% of those being identified as early as stage I. This rate is significantly higher than the 28.9% of lung cancers that are diagnosed at stages I and II without non-symptomatic screening.

 

The national rollout of lung cancer screening in England

Based on the efficacy of the TLHC, the UK government announced in June 2023 that a screening programme for lung cancer would be rolled out nationally in England.14 Following the recruitment approach established in the TLHC programme, the programme will use primary care patient records to identify people aged 55–74 years with a history of smoking and invite them for screening.

Screening leaders in England have identified areas that require particular attention to ensure the optimal rollout of the national programme, including:

  • Maximising uptake among the eligible population:
  • Acknowledging inequities within the eligible population and taking steps to organise an accessible screening programme
  • Engaging newly eligible people for LDCT screening for lung cancer
  • Integrating smoking cessation services with the screening programme for lung cancer
  • Ensuring adequate LDCT capacity
  • Scheduling LDCT screening for people with previous negative scans
  • Managing incidental findings of lung cancer
  • Strengthening the workforce
  • Streamlining and connecting computer systems.

Focusing on these key areas will improve the uptake, efficiency and effectiveness of a national lung cancer screening programme. The national rollout in England is expected to be complete in 2029 and aims to invite more than 6 million eligible people for lung cancer screening.

 

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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References

  1. National Lung Screening Trial Research T, Aberle DR, Adams AM, et al. 2011. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5): 395-409

  2. De Koning HJ, van de Aalst CM, de Jong PA, et al. 2020. Reduced Lung Cancer Mortality with Volume CT Screening in the NELSON trial. N Engl J Med 382(6): 503-13

  3. Bonney A, Malouf R, Marchal C, et al. 2022. Impact of low-dose computed tomography (LDCT) screening on lung cancer-related mortality. Cochrane Database Syst Rev 8(8): CD013829

  4. Henschke CI, McCauley DI, Yankelevitz DF, et al. 2001. Early lung cancer action project: a summary of the findings on baseline screening. Oncologist 6(2): 147-52

  5. Field JK, Vulkan D, Davies MPA, et al. 2021. Lung cancer mortality reduction by LDCT screening: UKLS randomised trial results and international meta-analysis. Lancet Reg Health Eur 10: 100179

  6. Ghimire B, Maroni R, Vulkan D, et al. 2019. Evaluation of a health service adopting proactive approach to reduce high risk of lung cancer: The Liverpool Healthy Lung Programme. Lung Cancer 134: 66-71

  7. Crosbie PA, Balata H, Evison M, et al. 2019. Implementing lung cancer screening: baseline results from a community-based ‘Lung Health Check’ pilot in deprived areas of Manchester. Thorax 74(4): 405-09

  8. Quaife SL, Ruparel M, Beeken RJ, et al. 2016. The Lung Screen Uptake Trial (LSUT): protocol for a randomised controlled demonstration lung cancer screening pilot testing a targeted invitation strategy for high risk and ‘hard-to-reach’ patients. BMC Cancer 16: 281

  9. Bartlett EC, Kemp SV, Ridge CA, et al. 2020. Baseline Results of the West London lung cancer screening pilot study – Impact of mobile scanners and dual risk model utilisation. Lung Cancer 148: 12-19

  10. Crosbie PA, Gabe R, Simmonds I, et al. 2020. Yorkshire lung screening trial (YLST): Protocol for a randomised controlled trial to evaluate invitation to community-based low-dose ct screening for lung cancer versus usual care in a targeted population at risk. BMJ open 10(9): e037075

  11. Verghese P, Horst C, Dickson J, et al. 2021. P17 The SUMMIT study: results processing time. Thorax 76(Suppl 1): A94

  12. Crosbie PA, Balata H, Evison M, et al. 2019. Second round results from the Manchester ‘Lung Health Check’ community-based targeted lung cancer screening pilot. Thorax 74(7): 700-04

  13. NHS England National Cancer Programme. 2019. Targeted Screening for Lung Cancer with Low Radiation Dose Computed Tomography; Standard Protocol prepared for the Targeted Lung Health Checks Programme. Available from: https://www.england.nhs.uk/publication/targeted-screening-for-lung-cancer/ [Accessed 13/01/2023]

  14. Department of Health & Social Care. New lung cancer screening roll out to detect cancer sooner. Available from: https://www.gov.uk/government/news/new-lung-cancer-screening-roll-out-to-detect-cancer-sooner [Accessed 11/04/2024]