The screening programme for lung cancer in the Canadian province of British Columbia

Lung cancer in Canada

Lung cancer is the most commonly diagnosed type of cancer, is the leading cause of cancer-related deaths among Canadians and survival rates remain the lowest among all cancer types in the country.¹ In recognition of the urgent need to detect lung cancer earlier and improve outcomes, the Canadian Task Force on Preventive Health Care published a national guideline in 2016 recommending implementation of lung cancer screening.¹

To accelerate the implementation of screening, the Canadian Partnership Against Cancer offered dedicated funding to provinces, for the delivery to take place at a regional level.² All ten provinces accepted this funding and so far six have launched screening programmes:²

• British Columbia has a fully implemented lung cancer screening programme. Through BC Cancer, the province is spending approximately $2.75 million per year to cover the programme’s operating costs.³ An additional $1.93 million from the BC Cancer Foundation funded specialised scan interpretation software, while the Canadian Partnership Against Cancer contributed nearly $800,000 to help launch the initiative.³
• Ontario and Nova Scotia have partially implemented their screening programmes.
• Alberta, Quebec, and Newfoundland and Labrador have implemented pilot programmes.
• Saskatchewan, Manitoba, New Brunswick and Prince Edward Island are in planning stages.
• The three territories – Yukon, Northwest Territories and Nunavut – have no current screening activities.

The screening programme in British Columbia

Lung cancer is the leading cause of cancer-related deaths in British Columbia – six people die of the disease every day.⁴ In 2021, it was estimated that 3,845 people in the province would be newly diagnosed with lung cancer that year, with nearly all being over the age of 40.⁵

In 2022, the first province-wide screening programme for lung cancer was launched.⁶ It is the largest screening programme in Canada by screening locations, with 38 sites (compared with 10 sites in the next-highest programme in Ontario).^{3 7}

Preparing for implementation

The International Lung Screening Trial (ILST) provided evidence for lung cancer screening ahead of province-wide implementation. ILST compared two eligibility criteria: the PLCOm2012 risk model and the US Preventive Services Task Force criteria.⁸ Across eight recruitment sites, including Canada, the study screened 4,500 participants who had a history of smoking using low-dose computed tomography (LDCT) scans at baseline, after two years and with a follow-up at five years.⁸ The trial found that the PLCOm2012 criteria were 15.8% more sensitive than the USPSTF 2013 criteria.⁹ This means that PLCOm2012 are a more efficient criteria to select people to enrol into lung cancer screening and more accurate at identifying those who might go on to be diagnosed with lung cancer.¹⁰

Health inequalities and the screening programme

Before the programme’s implementation, another study investigated the role of driving distance to the screening sites, revealing that residents in rural and remote areas may have to travel over an hour for screening.¹¹

Across Canada, Indigenous communities still experience barriers to equitable healthcare access.¹² To reduce barriers to lung cancer screening, provinces are collaborating with high-risk groups as well as First Nations, Inuit and Métis communities, ensuring that these programmes are culturally relevant and tailored to the specific needs of those at greatest risk.²

Currently, Vancouver Island has one mobile LDCT screening unit, with additional LDCT screening capacity being explored.¹³ A geospatial mapping project is also underway to compare screening participant locations with lung cancer rates in health regions, aiming to improve screening access for underserved populations.¹³

Roll-out of the screening programme

Utilising evidence from trials and pilots, the screening programme started in 2022. It is available to people who meet the following criteria:¹⁴

• age 55 to 74
• history of smoking for at least 20 years
• has a healthcare provider
• no symptoms of lung cancer
• has a 6-year lung cancer risk of 1.5% or higher, based on the PLCOm2012 model.

The programme receives referrals from primary care providers and a telephone assessment, and involves smoking cessation counselling.

Primary care provider referrals

General and nurse practitioners provide initial information to those eligible, which enables people to self-refer via phone to the screening programme for a full eligibility assessment.¹⁴ If the referring healthcare professional believes a person may face challenges (such as language barriers) with self-referral, they can refer them directly.¹⁴

Telephone assessment

This assessment is conducted by a lung screening programme navigator.¹⁴ Smoking cessation services are offered to people who smoke but have been referred to the screening programme.¹⁴

Smoking cessation counselling

Participants receive a brief smoking cessation counselling call and culturally appropriate educational materials.¹⁴ There is an option for people to contact the QuitNow programme for additional telephone counselling support. Nicotine replacement therapy is also provided by the Canadian government free of charge for three months.¹⁴ People who are highly dependent on nicotine, such as those who reported smoking within 30 minutes after waking up, are referred to their primary care physicians for pharmacotherapy options.¹⁴ Additionally, health authorities that already provide smoking cessation services will be listed as alternative support options for people who smoke and would like further help.¹⁴

The impact of the screening programme and lessons learned

The advantages of implementing a province-wide screening programme include ensuring equitable access for all eligible individuals, and providing consistent, high-quality screening and preventive care through a centralised system.³

All provinces with a screening programme, including British Columbia, work with the Canadian Partnership Against Cancer to monitor and evaluate the quality of screening.¹³ Key indicators are participation rates, early detection rates, stage distribution and long-term health improvements across Canada.¹³

From May 2022 to December 2023, British Columbia had a detection rate of 16.3 per 1,000, with 75% of people with screen-detected cancers identified at stage I or II.¹³

Factors that have supported the success of the programme include:¹³

• support from primary care providers to boost screening participation
• smoking cessation integrated into the screening pathway
• centralised intake by trained navigators
• standardised scan reporting supported by artificial intelligence (AI)
• a comprehensive information system that links all aspects of the pathway to enable quality assurance and improvement.

The future of the screening programme

Ongoing evaluation and adaptation are necessary to maintain the programme’s effectiveness. Nearly 30% of lung cancer diagnoses in British Columbia occur in people who have never smoked, highlighting a potential gap in current eligibility criteria.⁶ To address these issues, the programme is:

• conducting an ongoing pilot seeking to provide evidence on whether and how the eligibility criteria could be expanded¹³
• conducting research into AI-powered breath test to identify chemical markers linked to early lung cancer, particularly in people who have never smoked⁶
• developing additional LDCT screening capacity to accommodate the growing demand for lung cancer screening.¹³