Screening is used to promote the early detection of cancer. Australia currently has the following 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 45 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 HPV tests for women aged between 25 and 74.1 The National Lung Cancer Screening Program will be available to eligible people from July 2025.
7.21.1 Risks and benefits of lung cancer screening
There has been a growing body of research examining 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 Two of 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 (people who smoke heavily),4 and the NELSON trial showed a lung cancer specific mortality reduction of 24% in men and 33% in women.5 A trial in Italy similarly supported the efficacy of LDCT in safely detecting early-stage lung cancer in high-risk people with a negligible risk of false positives,6 and studies in China have concluded that screening improves early lung cancer detection and treatment outcomes.7,8 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.9 Several recent meta-analyses have found a significant relative reduction of lung cancer mortality among high-risk populations.10,11
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; identifying the ideal frequency and duration of screening; the most appropriate diagnostic work-up of screen detected abnormalities; implications for public policy; and defining the most at-risk population to screen.10,12-15 Several approaches for more personalised and targeted identification of people who would most benefit from screening have been proposed;16 for example measurement of particular biomarkers that indicate an increased risk of lung cancer17-19 or using additional predictors of risk; for example, sex, age, education level, body-mass index (BMI), nicotine dependence (i.e., ‘time to first cigarette’), health history, or family history.20-24 There have also been proposals for criteria to better identify people for screening who have never smoked who are at increased risk of lung cancer.7,25-27
7.21.2 Implementation of lung cancer screening programs
In light of evidence showing that the benefits of lung cancer screening outweigh its risks11 and that it is cost-effective,28 screening is now widely supported, though implementation varies across countries.29 The US Preventive Services Task Force recommends annual LDCT lung cancer screening for asymptomatic, high-risk individuals (a 20 pack-year or more smoking history, currently smoke or have quit within the past 15 years, and are between 50 and 80 years old).30 The American Cancer Society recently released updated screening guidelines that recommend removing the years since quitting criterion as lung cancer risk remains elevated for decades after quitting, though eligibility has not yet been expanded.31,32 The Canadian Task Force on Preventive Health Care33 and NHS England34 similarly recommends LDCT screening for lung cancer among high-risk adults.
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.35 Also in 2022, the Australian Government Medical Services Advisory Committee (MSAC) advised that it supported the introduction of a National Lung Cancer Screening Program, including the creation of a new Medicare Benefits Schedule item for LDCT scans. MSAC advised that screening should be on a biennial basis for people aged 50 to 70 years with no symptoms of lung cancer who have a history of smoking of at least 30 pack-years, and, if former smokers, had quit within the previous 10 years. Its support for the program was based on evidence that such a program would reduce deaths from lung cancer and be cost-effective.36 For example, an Australian cost-effectiveness study concluded that lung cancer screening with LDCT could be cost-effective if similar mortality benefits were observed to those found in international trials.37
In May 2023, the Minister for Health and Aged Care announced that the Australian Government would be implementing a National Lung Cancer Screening Program (NLCSP), which will be available to eligible people from July 2025. The Department of Health and Aged Care is working in partnership with Cancer Australia and the National Aboriginal Community Controlled Health Organisation (NACCHO) to design and implement the Program, with the aim of ensuring that populations disproportionately affected by smoking (see InDepth 9A) and lung cancer are reached.38 A modelling study has estimated that in 2025, 930,500 Australians would be eligible for screening.39
7.21.3 Strategies for reaching people eligible for screening
Research has shown that there is high levels of support for lung cancer screening programs among healthcare professionals and high-risk people, both in Australia40,41 and in other countries.42,43 However, reaching people eligible for screening—particularly groups with higher prevalence of smoking and higher rates of lung cancer—has been an important consideration in countries that have implemented screening programs. International research shows that strategies to increase referrals, engagement and willingness to participate in screening are needed,44,45 particularly among under-resourced groups,46-49 as only a small proportion of people eligible are screened.32,50 Lack of knowledge and access, cultural and language differences, cost, and low levels of referrals can serve as barriers to screening.51 Strategies to address these barriers might include tailored and targeted messaging, codesign of programs with groups disproportionately affected by lung cancer, public campaigns, healthcare provider education, addressing stigma and medical mistrust, mobile screening, and patient navigation programs (i.e., where a navigator helps guide the patient through all steps of the screening process).52-63
Training smoking cessation counsellors in screening guidelines may promote screening participation among those receiving cessation support.64 Research in the US showed that training quitline staff in lung cancer screening increased knowledge and was perceived to be acceptable, feasible, and appropriate,65 and a randomised trial found that the provision of educational materials to quitline callers promoted engagement and screening-related appointments.66 There have also been recommendations to change eligibility criteria, as current criteria may inadvertently create or widen disparities.67,68 For example, research in the US shows that fewer Black than White people at risk of lung cancer are eligible for screening, as Black Americans tend to smoke fewer cigarettes per day. Using smoking duration rather than pack-years would largely eliminate this disparity.69
7.21.4 Integrating smoking cessation interventions in lung screening programs
The integration of smoking cessation interventions within the context of lung cancer screening programs shows promise for encouraging cessation70-75 and should be seen as an integral part of care.76,77 Participation in a lung screening trial may in itself promote quitting78,79 but also represents a teachable moment to quit,80 and research has shown that people participating in screening are generally open to receiving cessation advice and interventions.81 Interviews with Australian clinicians, cancer screening managers, policymakers, and researchers reveal strong support for incorporating cessation interventions throughout the lung cancer screening process. Those interviewed recommended adapting existing cessation resources, creating dedicated specialist roles, and delivering broader cessation messaging through mass media and community outreach, as well as the provision of cessation support at no-cost.82 Research in the Netherlands estimated that an intensive smoking cessation program could optimally add another 20% to gains in life expectancy on top of that attributable to screening.83 Clinical guidelines in the US recommend the provision of advice and support to quit to all smokers who present for lung cancer screening,84 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.85 Smoking cessation counselling is not a mandatory part of the screening program in Australia,86 though research in the US suggests mandating cessation interventions in screening settings may improve provision of quitting advice and support.77
A longitudinal study conducted in Australia found one third of people who smoke 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.87 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.88 A secondary analysis of the NLST similarly found that the provision of pharmacotherapies alongside screening increases quit attempts.89 A 2021 review concluded that studies support the use of more intensive, personalised and multi-component interventions delivered by clinicians,90 and a more recent review concluded that there is high quality evidence to support intensive interventions and the use of pharmacotherapies (NRT, varenicline or e-cigarettes) for promoting cessation among screening participants.91 Another recent meta-analysis suggests that e-cigarettes may help promote quitting among people undergoing screening;92 though the long-term cancer risks of vaping are unknown, and research in the US suggests that people who vape may be less likely to participate in screening.93 Other strategies that show promise for promoting quitting include consultations with radiologists following screening to provide results and cessation interventions,94 smartphone apps,95 and educational materials tailored for underserved populations.96 Barriers to quitting in the context of screening appear to be similar to those in other settings; for example low self-efficacy, social norms, comorbid physical and mental health conditions, and beliefs about smoking and cessation.97 Nonetheless, for those who successfully quit, cessation appears to be lasting. Long-term follow up of participants in two trials confirmed increased abstinence among those who received cessation interventions in the screening context.98
Studies have also 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.99 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.100 Several studies have shown no benefit from integrating of telephone counselling with screening in improving cessation rates.101-103 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.104 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.105 Cessation interventions other than telephone counselling, such as motivational interviewing and pharmacotherapies, may be more effective for screening participants.102
7.21.5 Other biomedical risk assessments to promote cessation
Along with lung cancer screening, giving people who smoke other types of biomedical risk assessments of their smoking has been suggested as a possible strategy for increasing cessation rates.106 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.107 Many108-113 but not all114 subsequent studies of spirometry and other lung function tests have also supported the use of spirometry results to increase smoking cessation.
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References
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52. Bilenduke E, Anderson S, Brenner A, Currier J, Eberth JM, et al. Equitable implementation of lung cancer screening: avoiding its potential to mirror existing inequities among people who use tobacco. Cancer Causes and Control, 2023; 34(Suppl 1):209-16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37713024
53. Shusted CS, Barta JA, Lake M, Brawer R, Ruane B, et al. The Case for Patient Navigation in Lung Cancer Screening in Vulnerable Populations: A Systematic Review. Popul Health Manag, 2019; 22(4):347-61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30407102
54. Dignan M, Cina K, Sargent M, O'Connor M, Tobacco R, et al. Increasing Lung Cancer Screening for High-Risk Smokers in a Frontier Population. Journal of Cancer Education, 2024; 39(1):27-32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37688691
55. Ezenwankwo E, Nguyen DT, Akpabio IU, and Eberth JM. Expanding reach, enhancing capacity: embracing the role of primary care in lung cancer screening and smoking cessation in the United States. Lancet Reg Health Am, 2024; 38:100870. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39253709
56. Aspiras O, Hutchings H, Dawadi A, Wang A, Poisson L, et al. Medical mistrust and receptivity to lung cancer screening among African American and white American smokers. Psychology, Health and Medicine, 2024:1-12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39608370
57. Rogova A, Lowenstein LM, Reitzel LR, Casey K, and Volk RJ. Missed Opportunities for Lung Cancer Screening Among Patients With Behavioral Health Disorders With Elevated Cigarette Smoking Rates: Lung Cancer Screening and Behavioral Health. Chest, 2024. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39674344
58. Triplette M, Snidarich M, Heffner JL, Omernik B, Ahmed A, et al. A Community-Engaged Research Study to Inform Tailored Programming for Smoking Cessation and Lung Cancer Screening Among At-Risk LGBTQ+ Elders. Health Promotion Practice, 2024:15248399241296101. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39569838
59. Van Hal G and Diab Garcia P. Lung cancer screening: targeting the hard to reach-a review. Transl Lung Cancer Res, 2021; 10(5):2309-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34164279
60. Toubat O and David EA. A narrative review of lung cancer screening in underserved populations. Curr Chall Thorac Surg, 2023; 5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37064329
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