7.21 Lung cancer screening and biomedical risk assessments

Screening is used to promote the early detection of cancer. Australia currently has three national cancer screening programs: BreastScreen, which recruits and scans women aged 50–74 for early signs of breast cancer; the National Bowel Cancer Screening Program, which offers people over the age of 50 a free screening test that tests for blood in the bowel movement and can be undertaken in their own home; and The National Cervical Screening Program, which recommends regular pap tests for women aged between 18 and 70.¹  

There is considerable interest, both in Australia and internationally, in the potential for population based screening using low-dose CT (LDCT) scans to detect nodules that might be lung cancer early, when it is still treatable. Survival rates are clearly and substantively higher for early diagnosed compared to late stage diagnosed lung cancer,² and research has suggested that screening can detect lung cancer that is curable.³ The largest studies performed to date, the US National Lung Cancer Screening Trial (NLST) and the Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) Trial, both demonstrate the benefits of screening. The NLST showed a 20% reduction in lung cancer mortality after screening high risk individuals (heavy smokers),⁴ and the NELSON trial showed a lung cancer specific mortality reduction of 24% in men and 33% in women.⁵ In Australia, The Queensland Lung Cancer Screening Study (2007–2014) supported the feasibility of lung cancer screening, finding similar rates of benefits and harms to the NLST,⁶ and the ongoing International Lung Screen Trial (ILST) will also provide data from Canada, Australia, Hong Kong, and the UK.⁷ A recent meta-analysis found a significant relative reduction of lung cancer mortality of 12% in the screening group.⁸

While screening of individuals at a substantially elevated risk of lung cancer may be a promising way forward, there are a number of important considerations when implementing such a program on a population level. These include over-diagnosis; false positives leading to unnecessary tests and invasive procedures; increases in distress; radiation exposure; defining the most at-risk population to screen; identifying the ideal frequency and duration of screening; the most appropriate diagnostic work-up of screen detected abnormalities; and implications for public policy.^8-12 Nonetheless, in light of evidence supporting its benefits, the US Preventive Services Task Force recommends annual LDCT lung cancer screening for asymptomatic, high-risk individuals.¹³ The Canadian Task Force on Preventive Health Care similarly recommends LDCT screening for lung cancer among high-risk adults every year up to three consecutive years.¹⁴

In 2019, the Australian Minister for Health requested Cancer Australia conduct an enquiry into a national Lung Cancer Screening Program. Key findings from the enquiry report included:

• There is compelling evidence that the benefits of LDCT screening are significant and any harms are low risk and manageable.
• Lung cancer screening programs appear to be most clinically effective and cost-effective when targeted to high-risk individuals.
• Age and risk assessment tools assist in identifying current and former smokers who may be at high-risk of lung cancer.
• Based on international experience and the balance of benefits and harms a biennial screening program was proposed.
• Targeted screening was proposed to be made available to people aged 55 to 74 years, and for Aboriginal and Torres Strait Islander people aged 50 to 74, with a risk assessment exceeding a defined threshold.
• Screening high-risk individuals with LDCT results in significant reductions in lung cancer mortality and diagnosis of a larger proportion of lung cancers at earlier stages.²

In a 2022 report, Lung Foundation Australia similarly recommended the implementation of a targeted lung cancer screening program that uses LDCT scans in asymptomatic high risk individuals, including those who currently smoke or have previously quit smoking aged 55 to 74 years in the general population and aged 50 to 74 years for Aboriginal and Torres Strait Islander peoples.¹⁵ An Australian cost-effectiveness study recently concluded that lung cancer screening with LDCT could be cost-effective if similar mortality benefits were observed to those found in international trials.¹⁶ Although international research has shown that strategies to increase engagement may be needed, particularly among disadvantaged groups,^{17 , 18} research has shown that there is high willingness for lung cancer screening and surgical treatment among high-risk Australians.¹⁹

The integration of smoking cessation interventions within the context of lung cancer screening programs could also be promising, as participation in a lung screening trial may in itself promote quitting,²⁰ but also represents a teachable moment to quit. Clinical guidelines in the US recommend the provision of advice and support to quit to all smokers who present for lung cancer screening,²¹ with one review noting that within a screening program, the number of patients receiving help to quit smoking could far eclipse the number diagnosed with cancer.²² A longitudinal study conducted in Australia found one third of smokers achieved medium-term smoking abstinence at the three-year follow-up after participating in a screening program which provided brief cessation advice and Quitline materials.²³ A population-based survey in the US found that receiving a lung cancer screening was associated with a higher likelihood of making a recent cessation attempt.²⁴ A 2019 meta-analysis examining the efficacy of different intervention types in lung cancer screenings setting found that in-person counselling and pharmacotherapy interventions were associated with long-term abstinence. Web-based interventions also appeared promising for medium-term abstinence.²⁵ A secondary analysis of the NLST similarly found that the provision of pharmacotherapies alongside screening increases quit attempts.²⁶ A 2021 review concluded that while further research is needed on the optimal types and intensity of cessation interventions to combine with lung screening, studies to date support the use of more intensive, personalised and multi-component interventions delivered by clinicians.²⁷

Several recent studies have examined the effectiveness of integrating telephone counselling interventions in lung cancer screening programs, with mixed results. One trial of intensive telephone cessation support for participants in a lung screening program found that the intervention was associated with greater short-term abstinence compared to brief advice.²⁸ Another trial found that while intensive telephone counselling and NRT was associated with greater odds of short-term abstinence compared to a less intensive intervention, no difference was found in medium or long-term abstinence.²⁹ Several studies have shown no benefit from integrating of telephone counselling with screening in improving cessation rates.^30-32 Research suggests offering the opportunity to enrol in cessation program at multiple time-points through-out the lung cancer screening program may increase enrolment in cessation programs.³³ Further high-quality research is needed to understand the efficacy of smoking cessation interventions in lung screening and the optimal approach to integrating smoking cessation interventions.³⁴ Cessation interventions other than telephone counselling, such as motivational interviewing and pharmacotherapies, may be more effective for screening participants.³¹

Along with lung cancer screening, giving smokers other types of biomedical risk assessments of their smoking has been suggested as a possible strategy for increasing cessation rates.³⁵ This involves providing smokers who have contact with healthcare systems feedback on the biomedical or potential future effects of smoking (e.g. through measurement of lung function, exhaled carbon monoxide, arterial ultrasounds, or genetic susceptibility to lung cancer) to increase their motivation to quit. However, a 2019 Cochrane review did not find evidence that feedback on the physical effects of smoking using physiological measurements aids in long-term quitting. Separate analyses of different biofeedback types (carbon monoxide monitoring, genetic markers for cancer risk, lung function measurement (spirometry) and carotid ultrasound (which can indicate a person’s risk of stroke)) failed to detect a statistically significant benefit. A further analysis removing studies at risk of bias did detect a benefit of spirometry and carotid ultrasound feedback.³⁶ Subsequent studies of spirometry and other lung function tests have also supported the use of spirometry results to increase smoking cessation.^37-39

Relevant news and research

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References

1. Department of Health, Cancer screening. Australian Government; 2015. Available from: http://www.cancerscreening.gov.au/.

2. Cancer Australia. Report on the Lung Cancer Screening Enquiry. Surry Hills, NSW 2020. Available from: https://www.canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/report-lung-cancer-screening-enquiry

3. International Early Lung Cancer Action Program I, Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, et al. Survival of patients with stage I lung cancer detected on CT screening. New England Journal of Medicine, 2006; 355(17):1763–71. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17065637

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19. Flynn AE, Peters MJ, and Morgan LC. Attitudes towards Lung Cancer Screening in an Australian High-Risk Population. Lung Cancer Int, 2013; 2013:789057. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26316943

20. Pistelli F, Aquilini F, Falaschi F, Puliti D, Ocello C, et al. Smoking Cessation in the ITALUNG Lung Cancer Screening: What Does "Teachable Moment" Mean? Nicotine and Tobacco Research, 2020; 22(9):1484–91. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31504798

21. Fucito LM, Czabafy S, Hendricks PS, Kotsen C, Richardson D, et al. Pairing smoking-cessation services with lung cancer screening: A clinical guideline from the Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco. Cancer, 2016; 122(8):1150–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26916412

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39. Clergue-Duval V, Lair R, Lefebvre-Durel C, Barre T, Gautron MA, et al. COPD Positive Screening with Spirometry Increases Motivation to Quit Tobacco Smoking in an Addiction Treatment Center. COPD, 2020; 17(3):240–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32336146