Future Horizons in Lung Cancer

Lung cancer screening in the UK

Prof John Field - University of Liverpool, Liverpool, UK

I was asked to speak on setting up a lung cancer screening programme and I focussed on what was possible within the UK, knowing that the limitations may be across other countries but I understand the process much better within the UK.

What sort of mortality are we looking at?

There are 1.8 million cases of lung cancer per year worldwide and unfortunately the mortality is extremely high over a five year period. However, the good news is that if individuals are identified with early stage disease, which is considered stage 1, they have around a 75% chance of survival over a five year period. This opens up the whole concept of CT screening and CT screening is, let’s say, a complicated type of X-ray called computer tomography where it takes serial slices through and one can work out the images in the lungs. The advanced methodology now is using volumetric analysis so we can actually look at the size of the tumour on the first occasion and maybe if they come back at other times we can then say if it has grown or if it has stayed the same and if it’s a benign lesion.

So this all started with the American trial, the NLST, and they recruited over 50,000 individuals then they reported in 2011. The main finding from that trial was a 20% advantage in individuals in the CT screen arm. They undertook CT screening against a chest X-ray arm and, in fact, the Americans have taken this forward through the US Preventive Services Taskforce and they’ve recommended that CT screening is implemented. However, in Europe we haven’t actually gone down this particular route because we are really looking for mortality data of CT screen against a non-intervention arm. There are a number of trials in Europe, many of them are pilots. The main trial that we’re awaiting the results is the NELSON. In the UK we had a pilot trial called the UKLS and that was funded by the HTA and we reported this year with a full report in 2016. We’ve demonstrated for 4,000 individuals that were recruited that by using a risk prediction model, and this was developed through the Liverpool Lung Project funded by the Roy Castle Foundation over many years. We recruited individuals with a 5% risk over five years, so they were a very high risk group of individuals, and we had a 1.7% cancer baseline which is much higher than found in the NLST or in NELSON. We found, in fact, about 67% were stage 1 disease and about 85% went through to surgery which is much higher, it’s probably around the 20% surgery for non-small cell lung cancer at the moment in the UK. We are awaiting the mortality data which we will undertake as a pooled analysis with the NELSON in the future.

So the whole trial actually provided evidence not just in bringing in a population, and we went right across all the socioeconomic groups in both Liverpool and in Papworth, we demonstrated by using a risk model we could bring in very high risk, we used volumetric analysis which is the most advanced way of actually looking at CT images and we also brought through, as I said, a large number of people through to surgery. We also undertook a psychological analysis and we demonstrate there was transient impact but in fact this was not clinically significant over the longer period. We also looked at cost effectiveness and the American trial demonstrated $81,000 per QALY which if you bring down to sterling is still a lot. We undertook cost effectiveness on the baseline and were around the sort of £8,500 per QALY. OK, it’s modelling but it does demonstrate it’s well within the NICE guidelines.

So what we’re waiting for is the NELSON data and my argument is that we need to start planning now to implement CT screening. One of the major issues is hard to reach individuals; in fact we’re running a programme in Liverpool called the Liverpool Healthy Lung Project and they are actively going out and identifying the hard to reach community through a whole range of events to bring them into primary care and then they are running through the risk model that we have used and through the same protocol as we used for the UKLS. Their aim is to recruit up to 5,000 individuals going through CT who are high risk over the next three years. In my mind that will give a major contribution of how we engage with the hard to reach and therefore another stepping stone of implementing CT screening.