Australia doesn’t have to wait for all the answers before starting a lung cancer screening program – it should instead “jump in and do it”.
Speaking to the limbic after the Australian Lung Cancer Conference (ALCC) 2020 in Melbourne, Dr Henry Marshall said it made sense to get started and then tweak the program as new evidence becomes available.
Dr Marshall, a thoracic physician at the Prince Charles Hospital, Brisbane, and an investigator on the International Lung Screen Trial (ILST), said the research community was very hopeful for at least a demonstration project.
“Otherwise we are just going to be endlessly arguing about how to do it and never actually do it. You’ve got to take the plunge. We won’t have all the answers necessarily first up but Australia is pulling together a really good team of multidisciplinary expertise to make sure we get it as right as possible.”
“We are very clear that this is not a set and forget screening program.”
Dr Marshall said issues on the horizon that could radically change lung cancer screening included the possibility of biomarkers for selecting people to screen or how to manage a nodule detected on CT.
Biomarkers may also offer the potential to eventually extend screening – which had to start with the smoking-exposed population – to people who were not smokers.
Dr Marshall said that globally, everyone agrees that lung cancer screening reduces mortality – and the focus should now be on implementation.
“The consensus is that screening is going to be really important to do and we need to do it. This is the world’s largest cancer killer; this is Australia’s largest cancer killer. We don’t have a screening program for it as it has kind of been pushed to the bottom of the pile time and time again.”
He said Cancer Australia has just closed the public consultation phase of its lung cancer screening inquiry and a report is expected to be delivered to the health minister in October.
He added that Dr Vivienne Milch, director of cancer care at Cancer Australia, had highlighted at ALCC the complexities of screening but also the potential.
“One of the things that stuck in my mind was this is going to be the first cancer screening program in a decade maybe. It’s definitely the first screening program in the digital age and we have all this opportunity to harness that technology to make this better, faster, etc.”
For example, nodule detection software offered the opportunity to minimise the variability between radiologists across thousands of scans.
He added that the ILST was also addressing questions such as the value of risk prediction algorithms over standard eligibility criteria for selection of screening participants or multivariate risk prediction algorithms versus nodule size for nodule follow-up.
Data to date suggests the risk model did a better job than the current standard eligibility criteria for selecting people with cancer and not selecting patients without cancer.
Dr Marshall said there were known difficulties in reaching the target population for screening given the association between smoking, socioeconomic status, stigma and other markers of low engagement with screening.
He said screening was hugely underutilised in the US – with only about 2-4% of eligible smokers getting screened there, although it was not yet offered as a national program.
“Another issue for Australia is just the size of the place and the remoteness of some of the communities.”
Dr Marshall said smoking cessation within lung cancer screening was recognised to be a big driver for cost effectiveness.
“If you don’t help people quit smoking, then you are not really going to achieve a cost effective program. It goes hand in hand with screening. Helping people to quit is really important for loads of other conditions that smokers are at risk of, not just lung cancer.”
He said the trial data to date has found fairly minimal intervention results in minimal impact.
“We are looking at hard core smokers now in Australia, particularly in that older age group. They need quite an intensive intervention so lots of pharmacotherapy and lots of behavioural therapy just as we would for any patients we see in the clinic.”
“But the question is how do we achieve that in a screening program or is it left to community services to do it or do we need some sort of hybrid? We don’t know the answer to that at the moment but it is very important and there are trials going on which will hopefully help answer that question.”
Dr Marshall said a national lung cancer screening program could have a massive impact on outcomes.
“A lot of people have had symptoms for ages before they come to a GP. It’s part of the reason why 80% of current lung cancer cases present at an advanced stage which is not curable. Only 20% of cancers are at an early stage which can be surgically resected. Screening is hopefully going to switch that around.”
“I really hope we do get the program going in Australia as I think it would send a really positive new message – basically we really want to help people who have been smokers and we want to help people with lung cancer.”