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Lung cancer screening in Australia: progress or procrastination?

Fraser Brims, Annette McWilliams and Kwun Fong
Med J Aust 2016; 204 (1): 4-5. || doi: 10.5694/mja15.01109
Published online: 18 January 2016

There is progress internationally with lung cancer screening but far slower headway in Australia

Lung cancer is the fourth leading cause of death and kills more Australians than colon and breast cancer combined.1 It has a 14% 5-year survival rate as most patients present with incurable disease. The number of years of potential life lost to lung cancer in Australia is estimated to be 58 450, similar to that of colorectal and breast cancer combined.1 Primary prevention remains crucial and will reduce future lung cancer deaths, but the majority of lung cancer deaths are now occurring in former smokers who remain at elevated lifetime risk of lung cancer.2

Should Australia adopt lung cancer screening?

Screening with low-dose chest computed tomography (CT) scan has been proven to reduce lung cancer mortality by at least 20%, and screening is now being implemented in the United States. There is no new treatment modality that can reduce lung cancer mortality by this amount. The International Association for the Study of Lung Cancer (IASLC) recommends the implementation of feasibility screening programs in countries without ongoing lung cancer screening studies.3 These programs should incorporate smoking cessation initiatives, standardised algorithms for the selection and management of screening participants, and specialist multidisciplinary teams to manage participants with positive screening results.

In Australia, there are about 2 200 000 current or former smokers between the ages of 55 and 74 years who may be eligible for lung cancer screening.1 Lung cancer screening has been clearly shown to be feasible in specialist centres in many countries.4 It shifts lung cancer stage at diagnosis from advanced to early stage (potentially curative) disease.3,4 The cost of such programs, however, remains an important concern.

The incremental cost-effectiveness ratio per quality-adjusted life-year gained of lung cancer screening in Canada, which has a health care structure similar to Australia’s, is about A$10 000.5 This compares favourably with colorectal screening (A$7000, European data)6 and breast screening (A$45 000, United Kingdom data).7 The costs of treating advanced lung cancer are greater than the costs of treating the early stage disease.8 Further, a consequence of rising pharmaceutical costs of cancer treatment is that early detection becomes more desirable both in direct mortality reduction and reduction of downstream treatment costs.5

Concerns with screening implementation in Australia

Vital information that is currently lacking in the Australian health care setting includes: an economic evaluation to assess health care cost utility; definition of a target population; false-positive rates; and best recruitment and uptake strategies.9 The feasibility of chest CT screening in the Australian setting has already been demonstrated with the Queensland Lung Cancer Screening Study10 (long-term follow-up near completion) and the Western Australia-based Asbestos Review Program.11 However, uncertainties remain over the best recruitment strategies, management of pulmonary nodules and most cost-effective approach. A further evaluation study in WA (LungScreen WA Project) will contribute useful data.

Targeted risk-based approach

The risk of lung cancer is heterogeneous and data from the large US-based National Lung Screening Trial demonstrate that the criteria used to identify at-risk individuals included many who were, in fact, at low risk for developing lung cancer.4 Subsequently, logistic regression-based risk prediction models have demonstrated improved sensitivity with less CT scans required to identify more lung cancers.4 This approach has recently been shown to be more cost-effective.5 A similar, risk-based approach to managing indeterminate nodules (majority are false positive) that require follow-up is also likely to reduce unnecessary repeat CT scans and costs.4 The use of validated risk-prediction models to both select and manage participants is likely the most effective method for screening and such an approach has been recommended by IASLC.3

Future structure

Any future lung cancer screening program in Australia faces a unique challenge. Unlike truly population-based Australian screening programs such as BreastScreen, the National Cervical Screening Program, and National Bowel Cancer Screening Program, which screen people without risk stratification for the disease in question, lung cancer screening would screen participants who have been individually assessed as having a higher than average risk. A national program needs to be community based with shared, informed decision-making between clinicians and potential participants, accredited reporting centres and a central data registry for quality control, monitoring and outcome reporting. Crucially, it must have an integrated smoking cessation intervention, with recent international data supporting the cost-effectiveness,5 additional mortality benefit12 and a high sustained quit rate13 with such an approach. It is a teachable moment that should not be missed.

In the absence of a coordinated approach, ad-hoc screening should be strongly discouraged, with no evidence of benefit and the very real risk of harm. The majority of the outstanding questions for lung cancer screening are likely to be answered in the next few years — Australia needs to generate progress now towards a cohesive national approach and avoid procrastination. The challenge facing Australia is the translation of international results into sustainable, cost-effective clinical practice, ensuring that the desired benefit outweighs the known harms, at the same time as enhancing tobacco control policies.


Provenance: <p>Not commissioned; externally peer reviewed.</p>

  • Fraser Brims1
  • Annette McWilliams2
  • Kwun Fong3

  • 1 Sir Charles Gairdner Hospital, Perth, WA
  • 2 Fiona Stanley Hospital, Perth, WA
  • 3 The Prince Charles Hospital, Brisbane, QLD

Correspondence: fraser.brims@uwa.edu.au

Acknowledgements: 

We wish to thank Drs Henry Marshall and David Manners for their comments and contribution towards the preparation of this manuscript.

Competing interests:

No relevant disclosures.

  • 1. Australian Bureau of Statistics. Statistics section. http://www.abs.gov.au/AUSSTATS/abs@.nsf/webpages/statistics?opendocument (accessed Sep 2015).
  • 2. Peto R, Darby S, Deo H, et al. Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case-control studies. BMJ 2000; 321: 323-329.
  • 3. Field JK, Smith RA, Aberle DR, et al. International Association for the Study of Lung Cancer Computed Tomography Screening Workshop 2011 report. J Thorac Oncol 2012; 7: 10-19.
  • 4. Tammemagi MC, Lam S. Screening for lung cancer using low dose computed tomography. BMJ 2014; 348: g2253.
  • 5. Cressman S, Lam S, Peacock S, et al. Economic evidence for the use of risk-selection and risk-stratification for lung cancer screening programs. J Thorac Oncol 2015; 10 (Suppl 1): ORAL09.07.
  • 6. Sharp L, Tilson L, Whyte S, et al. Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy. Br J Cancer 2012; 106: 805-816.
  • 7. Pharoah PD, Sewell B, Fitzsimmons D, et al. Cost effectiveness of the NHS breast screening programme: life table model. BMJ 2013; 346: f2618.
  • 8. Cressman S, Lam S, Tammemagi MC, et al. Resource utilization and costs during the initial years of lung cancer screening with computed tomography in Canada. J Thorac Oncol 2014; 9: 1449-1458.
  • 9. Standing Committee on Screening, Cancer Australia 2015. Position statement: lung cancer screening using low-dose computed tomography. Canberra: Cancer Australia, 2015. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/EA40B7C67280E5C8CA257CEE00012DA1/$File/Position%20Statement-%20Lung%20Cancer%20Screening%20using%20Low-Dose%20Computed%20Tomography.pdf (accessed Sep 2015).
  • 10. Marshall HM, Bowman RV, Ayres J, et al. Lung cancer screening feasibility in Australia. Eur Respir J 2015; 45: 1734-1737.
  • 11. Brims FJ, Murray CP, de Klerk N, et al. Ultra-low-dose chest computer tomography screening of an asbestos-exposed population in Western Australia. Am J Respir Crit Care Med 2015; 191: 113-116.
  • 12. Pastorino U, Boffi R, Machiano A, et al. Stopping smoking reduces mortality in low-dose computed tomography (LDCT) screening volunteers. J Thorac Oncol 2015; 10 (Suppl 2): PLEN04.07.
  • 13. Tammemagi MC, Berg CD, Riley TL, et al. Impact of lung cancer screening results on smoking cessation. J Natl Cancer Inst 2014; 106: dju084.

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access_time 05:26, 24 January 2016
Claudia Caroline Dobler

In the USA, where Medicare covers the cost for annual Low Dose Computed Tomography (LDCT) lung cancer screening, patients require a written screening order from a healthcare provider obtained during a mandatory “lung cancer screening counseling and shared decision making visit”.(1) This visit covers determination of eligibility, smoking cessation counselling and “shared decision making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure”. Inclusion of shared decision making using a decision aid as a compulsory component of a cancer screening programme is unprecedented, but certainly makes sense in light of increasing evidence that providing patients with information about the benefits and risks of cancer screening through the use of decision aids impacts on their intention to be screened and on actual screening uptake.(2) Studies have reported an increase (mainly for colorectal cancer) as well as a decrease (mainly for prostate cancer) of the intention to be screened and of actual screening uptake after patients used decision aids.(2) An Australian study showed that use of a decision aid including information on overdetection to support informed choice about breast cancer screening resulted in fewer women expressing positive attitudes towards screening, and fewer women intending to be screened.(3)

As LDCT lung cancer screening is associated with a high false positive rate, leading to potentially harmful follow-up investigations, shared decision making and use of decision aids should be emphasised in any future national lung cancer screening programme.

References
1. The Centers for Medicare & Medicaid Services (CMS). Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Last update, February, 5, 2015. Last accessed: January, 24, 2016.

2. Jimbo M, Rana GK, Hawley S, Holmes-Rovner M, Kelly-Blake K, Nease DE, Jr., et al. What is lacking in current decision aids on cancer screening? CA: a cancer journal for clinicians. 2013;63(3):193-214.

3. Hersch J, Barratt A, Jansen J, Irwig L, McGeechan K, Jacklyn G, et al. Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. Lancet. 2015;385(9978):1642-52.

Competing Interests: No relevant disclosures

Dr Claudia Caroline Dobler
Liverpool Hospital, Sydney, NSW, Australia

access_time 06:55, 19 February 2016
Fraser Brims

We note with interest the recent letter by Dr Dobler in response to our earlier editorial(1) regarding the important role of shared-decision making for those considering lung cancer screening. Whilst we welcome the U.S. Medicare mandate for shared-decision making, evidence gaps need acknowledgement. There are independent evaluation standards for patient decision aids (PtDAs) in general (2) and a lung cancer screening PtDA is under development, (3) but to our knowledge no lung cancer screening PtDA has undergone formal evaluation to date. The effect of shared-decision making on other clinically important outcomes such as screening adherence or ameliorating the negative psychological impacts of false positive lung cancer screening results is not known. Despite these limitations, we agree that shared-decision making, with properly developed PtDAs, should be part of future implementation efforts.
As discussed in our editorial, the use of risk prediction tools to select high-risk participants for screening is different to other population-based screening programs. A co-ordinated, targeted, national lung cancer screening program will not offer screening to low-risk people thereby reducing the importance of some aspects of ‘shared-decision making’. Education for ineligible (i.e. low risk) current or former smokers, however, remains important to ensure ad-hoc chest CT scans are not sought outside an established program. If the recruitment and education material provided by a lung cancer screening program does not manage this effectively, there may be unintended consequences such as increased demand for potentially harmful ad hoc screening in those without sufficient risk to benefit from the process.

1. Brims F, McWilliams A, Fong K. Lung cancer screening in Australia: progress or procrastination? The Medical journal of Australia. 2016;204(1):4-5.
2. Joseph-Williams N, Newcombe R, Politi M, Durand MA, Sivell S, Stacey D, et al. Toward Minimum Standards for Certifying Patient Decision Aids: A Modified Delphi Consensus Process. Medical decision making : an international journal of the Society for Medical Decision Making. 2013;34(6):699-710.
3. Lau YK, Caverly TJ, Cherng ST, Cao P, West M, Arenberg D, et al. Development and validation of a personalized, web-based decision aid for lung cancer screening using mixed methods: a study protocol. JMIR research protocols. 2014;3(4):e78.

Competing Interests: No relevant disclosures

Dr Fraser Brims
Sir Charles Gairdner Hospital, Perth, WA

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