Introduction
Lung cancer is the leading cause of cancer-related deaths in the world and the second most common cancer overall. It accounts for 18% of all cancer-related deaths (1.8 million a year) and 11.4% of all cancers (2.2 million). It is approximately twice as common in men as women, due to historically higher rates of smoking in men.1 However, while rates are slowly falling in men in high-income countries, they are rising in women.1
Lung cancer has a poor prognosis. Research indicates that the primary reason for the low survival rates is that up to 70% of lung cancers in Europe are diagnosed in the later stages, too late for potentially curative surgery or life-saving treatments.2
If lung cancer were routinely diagnosed in the earlier stages, 57% of patients would be alive in 5-years compared to 3% when the diagnosis is made in the later stages.3 One study found that 88% of patients diagnosed with Stage 1 lung cancer were still alive 1-year later compared to 19% of those diagnosed at Stage 4.4
The Economic Burden
Lung cancer has greater direct healthcare costs and is associated with more lost productivity than breast, colorectal, and prostate cancer combined.5 One estimate assigned 15% of overall cancer costs in Europe to lung cancer.6
A 2009 analysis on the economic burden of cancer across the European Union estimated total annual lung cancer costs of €18.8 billion, of which 23% were due to health care costs, 53% to mortality losses, 20% to informal care costs, and 4% to morbidity losses. These costs are likely to be higher today given the cost of immunotherapies and other targeted agents used to treat the disease.6
Delays to Diagnosis and Treatment
The asymptomatic nature of lung cancer in its early stages is one of the major reasons for delayed diagnosis. However, delays in referrals and treatment initiation also contribute to poor outcomes as well as higher costs.7,8 Patients delaying care for early symptoms remains a significant barrier to timely diagnosis because by the time they’re seen, they may have been symptomatic for months.9
National guidelines recommend that patients with suspected lung cancer see a specialist within 2 weeks.10-12 However, due to the largely non-specific nature of presenting symptoms, at least a third of lung cancer patients have three or more visits with their general practitioner before being referred to a specialist. That compares to just 3% of patients with breast cancer.13 A review of 128 articles on the topic of referral delays found that just 19% reported a time interval adherent to the country’s guidelines for referral and treatment initiation.7
Even after referral it can take many weeks in some European countries before patients undergo the first diagnostic procedure, with 42% of European patients with lung cancer waiting more than 2-months from the first consultation until they receive a definitive diagnosis.14 The significance of this finding should not be underestimated as even a short delay can impact outcomes.4
Workforce Challenges: one of the causes of delay in diagnosis and treatment
A 2018 review of radiology reporting within England’s National Health Service found a large variation in reporting times, due, in part, to shortages of radiologists.15 In the UK, the 2020 workforce census report for clinical radiology found that the country had a 33% workforce shortfall and required nearly 2,000 more consultants to meet safe staffing levels and pre-COVID-19 levels of demand for scans. By 2025, the authors estimated that shortage would hit 44%.15 In the interventional radiology realm, the census found that half of the nation’s trusts and health boards could not provide adequate 24/7 interventional radiology services.16 The UK is not alone leading some to conclude that the field of radiology is struggling with a manpower crisis.17
As the radiologist workforce shortage intensifies, burnout rates increase. One study found that 36% of radiologists reported feeling burned out or depressed.18 For this to be avoided, healthcare systems must consider innovative approaches that help ensure the health of patients and staff are not put at risk. Such innovations include redesigning clinical pathways for diagnosis and treatment and developing new roles and responsibilities for staff which maximise upskilling and enable clinicians to practice at the top of their license.
Screening for Early Diagnosis: one possible solution for delayed diagnosis
Early diagnosis through screening programs for breast, cervical, and prostate cancers demonstrate significant reductions in mortality.19 Several studies demonstrate the same when heavy current or former smokers receive regular screening with Low Dose Computed Tomography (LDCT).20,21 The seminal National Lung Screening Trial (NLST) conducted in the US enrolled 53,454 people at high risk for lung cancer at 33 screening centres between August 2002 and April 2004. Participants were randomized to three annual screenings with either LDCT or single-view posteroanterior chest x-ray and then followed through the end of 2009.20 The LDCT screening group had a 20% relative reduction in mortality from lung cancer compared to the radiographic screening group and a 6.7% lower rate of death from any cause, suggesting that such screening is not, on the whole, deleterious. 20
These results prompted the US Preventive Services Task Force to recommend annual lung cancer screening with LDCT in adults aged 55 to 80 with a 30 pack-year smoking history. The task force amended that recommendation in 2021 to apply to those aged 50 to 80 with a 20 pack-year smoking history.22
In Europe, several randomized lung cancer screening trials have recently been published, the largest being the Dutch Belgian NELSON trial. The NELSON trial randomized 15,822 participants into a screening group and a control group. The 7915 screening group participants underwent four LDCT screening rounds and the control group participants did not undergo screening. All participants were followed for 10 years.21 On average, approximately 70% of the lung cancers detected via screening were found in stage 1 and 9.8% were detected in stages 3 and 4.21 A later analysis showed an overall 24% reduction in lung cancer mortality in those undergoing screening.23
The other European trials also reported a significant reduction in lung cancer mortality along with a reversal of the stage distribution in the LDCT-screened participants.2 In addition, two meta-analytic studies of lung cancer screening have also recently been published, both reporting a significant reduction in lung cancer specific mortality for the screening group compared to the control group.2
Given these findings, authors have suggested it is time to shift the focus from further randomized trials to demonstrate the effectiveness of lung cancer screening in Europe, to the not inconsiderable challenge of effective implementation.2
Screening Program Challenges
Although European expert groups are increasingly converging on the need for programs aimed at identifying lung cancer earlier to reduce mortality rates, many agree that the pace of lung cancer screening implementation in Europe so far has been slow.24 As of May 2021, only Croatia has a national, population-based screening for lung cancer with LDCT, although several countries are running pilot programs.2 Concerns about optimal screening frequency, the potential for over-treatment and over-surveillance, the long-term outcomes, and lack of awareness and understanding of its benefits and effectiveness, particularly among primary care physicians have been cited as significant barriers to uptake.25
The demonstration of cost-effectiveness has also been raised as a concern. Cost and sustainability constraints are top of mind for most health systems in Europe making the prioritization of scarce resources a critical, and yet highly individual task.25 Although screening costs are likely to be offset by cost savings realized through early diagnosis, cost-effectiveness depends on resource use which is country specific.25 Whilst the individual results of cost effectiveness analyses in Europe vary, overall, the incremental cost effectiveness ratio for lung cancer screening is positive25.
To be effective, screening must produce benefits that outweigh the potential risks, including that of radiation-induced cancer. A study published in 2017 concluded that only 1 radiation-induced cancer could be expected for every 108 lung cancers detected in 10 years of annual screening.26 So, the ability of screening to detect more early-stage lung cancers might greatly outweigh this risk. There is widespread agreement that radiologists will need to play a central role in controlling this risk, by working with modern CT scanners capable of producing high-resolution, low noise images at ultra-low doses to implement an effective, high-quality screening service.22
A Turning Point for Lung Cancer Screening in Europe
The screening landscape appears to be shifting with European medical organizations and public health officials committing to improving the rate of earlier diagnosis and supporting screening. These include Lung Cancer Europe; the European Society of Radiology and European Respiratory Society (ERS); the European Union, and the European Lung Cancer Organisation.25,27-28
Although a European positioning paper recommended lung cancer screening in 2017, the authors noted that organisational aspects and cost-effectiveness should be accounted for, and that management of detected nodules above certain sizes should only be carried out in a multidisciplinary setting that has experience in lung imaging and managing suspicious findings. This, they acknowledged, would place more pressure on resources and organisations, but also provide an opportunity to promote lung cancer units.28
In July 2021, the ERS and 27 other organizations wrote an open letter to the members of the Special Committee on Beating Cancer, part of the European Parliament, urging it to recommend lung cancer screening.27 A few months later, ERS and 55 partner organizations issued another letter to the committee pressing policymakers to commit to increasing early lung cancer diagnosis and detection by 20% by 2030 as part of Europe’s Beating Cancer Plan.29 The European commission is awaiting a report they commissioned that includes the latest evidence on screening, raising the expectation that in the EU at least, lung cancer may be added to the list of recommended screening programmes.30
Whilst a welcome shift, experience has demonstrated that even where national screening programmes are supported, full implementation will likely take time. As an example, in 2019 NHS England began a £70m pilot of mobile lung cancer scanning operating from supermarket carparks. The pilot was planned to last four years which means it is not due to conclude (COVID aside) until 2023.31
Addressing the Implementation Challenge
The evidence for screening shows that it represents part of the solution to improving lung cancer outcomes. However, offering screening to people considered high-risk32 still comes with operational, psychological and financial challenges that can prevent the effective implementation of a lung cancer screening programme.2
Transforming the diagnostic workforce
Addressing the chronic lack of a trained workforce necessary to manage the increasing demand for diagnostic imaging,16 will be critical to improving patient outcomes in lung cancer. In this context, clinicians aided by AI tools have demonstrated improved productivity without sacrificing accuracy.33 Practical examples continue to emerge of health systems encouraging providers to train non-radiologist technicians, supported by Artificial Intelligence, to identify abnormal scans for subsequent review by radiologists.34 This approach to enabling clinicians to operate at the top of their licence, which in turn creates capacity, will certainly help in the short-term, however, more ambitious transformations will be needed for long-term success. To start considering the longer-term approach, it is important to have an accurate picture of the current workforce.
A healthcare system in England is already addressing the need for a longer-term approach, through the development of a diagnostic workforce planning tool. The tool enables them to make the best use of their current diagnostic workforce and understand in detail the impact of implementing new staffing models. These new staffing models will then be designed to support the development and optimal use of staff skills and experience. Ultimately, this will lead to the identification of opportunities to develop more sustainable diagnostic service delivery and enable them to plan for future clinical pathway innovations with a higher level of confidence.
One such innovation that this local health system is working to design, and implement is a Rapid Diagnostic Centre. They realise that to be as effective as it can be, it must involve the effective redesign of their clinical pathway.
Redesigning the clinical pathway
A Rapid Diagnostic Centre is an innovative service model that provides a single point of access to a diagnostic pathway for patients. It is designed to help speed up cancer diagnosis and aims to give patients their test results on the same day they attend. The Greater Manchester Rapid Diagnostic Centre Programme in England was designed to improve the time from suspicion of cancer to diagnosis and treatment and reduce patient anxiety, while also diagnosing cancer at an earlier stage. The centre provides a single point of access and a single point of contact from referral onward, with clinical nurse specialists serving as care navigators.35
When rapid diagnostic programmes are coupled with the multidisciplinary care, they can significantly improve reporting times, time to specialist referral and patient assessment in both academic and community hospitals, and lead to cost savings.36-39 The Greater Manchester redesigned pathway enabled radiologists to provide their reports within two hours of completing the scan and patients to receive a CT scan within a day of their referral. In the words of a Greater Manchester health system leader, “The development of a single system-wide radiology picture and archiving system is critical to the development of Rapid Diagnostic Centres.”40 This highlights the need for careful planning and joined up thinking on strategy early in the design phase of an RDC.
The role of imaging technology should also not be underestimated given the central role of modern CT scanners in providing high resolution, low noise images at very low doses41. However, the number of CT scanners per million inhabitant varies significantly between different European countries and has been cited as a potential operational bottleneck for the implementation2. Efficient use of existing technology in combination with strategic investments in new technology will likely be required for the effective implementation of a Rapid Diagnostic Centre enabled lung cancer pathway initiative.
Conclusion
Lung cancer is the leading cause of cancer-related death in the world and the second leading type of cancer. Despite new therapeutic options, the 5-year survival rate remains poor, primarily because the disease is typically diagnosed in the late stages. There is no single reason for such delays. Instead, evidence suggests it is a systemic problem throughout Europe, ranging from patient delaying seeking care to health system related weaknesses that create bottlenecks and difficulties along the diagnostic and treatment pathway.
While the challenges to improving outcomes in lung cancer appear daunting, Europe could be at a turning point in the recommendation and implementation of national lung cancer screening programmes. Effective implementation has challenges, but workforce transformation efforts, increased use of digital and software applications, pathway redesign initiative such as rapid diagnostic centres along with the required investments in diagnostic technology have a part to play in enabling a critical initiative and could help to make a significant difference in improving survival rates.
Improving Lung Cancer Outcomes Through Partnerships
Improving lung cancer outcomes in an uncertain world requires partnerships that are flexible, responsive, and robust in the face of new challenges. In our experience, it takes an ecosystem of expert partners and a new way of thinking to make innovation stick. GE Healthcare can work with you to help change healthcare for the better. Together, we can be a catalyst for change.
References
Attribution of the image: Eraxion
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