Unlike several other cancers, routine screening for lung cancer is not common in Europe. However, lung cancer screening of individuals at risk can improve survival rates. During the 2021 World Conference on Lung Cancer, Dr. Pastorino reviewed the current status of lung cancer screening in Europe and discussed ongoing screening programs at a national or European level.
In Europe, each year 240,000 people die from lung cancer. One potential reason for this high mortality rate is the late diagnosis of the disease. Assuming that lung cancer screening could be applied to 30% of eligible individuals, this could lead to a 30% decrease in lung cancer mortality in screened subjects and thus the saving of 22,000 lives. Individuals between 55-80 years with at least 30 pack years of smoking who quitted smoking maximum 15 years ago are the best candidates for screening. The European screening experience has been based on the standard volumetric assessment of a nodule. In this, European guidelines gradually introduced a higher cut-off for indeterminate nodules, reducing the rate of false positives and overdiagnosis.
There is a clear relation between screening duration and mortality rates. For example, the 2-year NLST program has led to a 20% reduction in mortality while the longer NELSON program (5 years) has led to a reduction of 24%. In the MILD program (6-10 years), this was further improved to a 39% reduction in mortality. Baseline low-dose CT-scan (LDCT) cut-off values for indeterminate pulmonary nodules increased from 50 mm3 in the NELSON study in 2005 to above 100 mm3 now. As a consequence, the vast majority of individuals are negative at baseline LDCT. If the LDCT interval is prolonged, the duration of screening period can be extended or more patients can be screened with the same effort. In this, screening can be performed at fixed time points or on a risk-based interval of annual, biennial or triennial screening of individuals who have negative baseline LDCT.
Currently, there are three prospective clinical trials ongoing in Europe to assess the value of blood biomarkers in combination with LDCT; the BioMILD (microRNAs), ECLS (autoantibodies) and SUMMIT (cfDNA methylation) studies. These studies will provide more solid evidence on the prognostic and predictive value of blood testing in the context of lung cancer screening.
National screening programs
The United Kingdom is the leading country for the implementation of lung cancer screening. With 23 involved centres, the aim is to screen 142,000 individuals. The focus of the program is on the more deprived subjects and lowest socio-economic level and these individuals can be reached with a mobile scanning unit. In Poland, the National LCS Pilot Program recently initiated in six macroregions and aims to screen 14,000 volunteers in three years. By June 2021, 5,522 LDCT have been performed. Also in Italy, a lung screening network has been set up. The RISP (Rete Italiana Screening Polmonare) program was approved by the Parliament in July 2021 with 2-3 years of funding.
On a European level, with funding from the Horizon 2020 grant, a cooperative “4 IN THE LUNG RUN” consortium for the improvement of screening implementation was set up. This program involves six European countries and is coordinated by the Erasmus University in Rotterdam (The Netherlands). The goal is to recruit 24,000 individuals between 60-79 years of age who are heavy smokers (either current or former smokers) to evaluate whether it is safe to have risk-based less intensive screening intervals after a negative baseline CT. Patients with negative baseline CT are randomised to annual versus biennial LDCT. The project is very ambitious and will also implement 3B disease (lung cancer, chronic obstructive pulmonary disease and cardiovascular disease) screening and prevention.
LDCT implementation in Europe is good and real world results on large-scale development will be available soon. In particularly the accrual of higher risk individuals with risk-based LDCT interval, tackling not only lung cancer but also B3 diseases, can lead to an integrated prevention strategy.
Pastorino U. Lung Cancer Screening in Europe: Current Status. Presented at the 2021 World Conference on Lung Cancer; Abstract PL03.01.