#EAPM: Lung-cancer screening - who should take the lead?

During the weekend 14-15 October, Yokohama in Japan hosted a key conference on lung cancer-related issues, writes European Alliance for Personalised Medicine (EAPM) Executive Director Denis Horgan.

The IASLC 18th World Conference on Lung Cancer is the world’s largest meeting dedicated to lung cancer and other thoracic malignancies.

In excess of 7,000 delegates will be present from more than 100 countries, in order to discuss latest developments. Attendees will include surgeons, medical oncologists, radiation oncologists, radiologists, pathologists, epidemiologists, basic research scientists, nurses, patients and more.

Many delegates in all of these categories will head to Japan from Europe.

Certain events seek to provide a forum for in-depth reviews of core issues regarding, for example, lung-cancer screening, featuringinternationally recognised experts in an interactive setting. One of these is a workshop on 'Supporting the Implementation of Quality Assured Global CT Screening'.

Many stakeholders are adamant that the best way to reduce the high incidence of lung cancer is through primary prevention or targeting tobacco consummation. Meanwhile, some advocate secondary prevention as well, and more specifically, actively screening for lung cancer in a population based programme.

It is often stated that the EU and member states need to act on lung cancer screening, and it would certainly be interesting to listen to a conversation between a Commission expert (EU), a member state politician (MS) and a regional representative (RR). So here goes with an imaginary scenario…

EU: As you will know, the European Union does not have competence for healthcare in the current 28 countries. With that backdrop, there is only so much we can do centrally, when it comes to lung-cancer screening programmes and more. These surely need to be part of your own National Cancer Plans (NCPs), in effect.

MS: OK, but even rich countries face an uphill battle to cope with spiralling costs for treatment and care of lung cancer, while lower-income states clearly lack the resources to deal with such high numbers when we’re trying to address screening.

RR: And don’t forget the regions. Even in the richer countries, there are often gaps in resources and connectivity between areas  in a single Member State.

You say there’s not much you can do. But from where we’re standing, in Europe, the battle against cancer needs to be fought at EU level.

EU: Fair enough, to a degree. But improvements and the introduction of comprehensive lung-cancer screening programmes will also require greater collaboration between Member States and across the healthcare sector, given that cancer is a significant (and growing) European healthcare problem.

There also needs to be an agreed approach to tackling it through NCPs. And all collaborations should include patients, caregivers and patient organisations, who have an indispensable contribution to make. We can offer advice and encouragement, of course…

MS: Right, as you know, five cancers account for just over half of the total European cost of treating these diseases and lung is the most expensive at €17 billion. That’s 23% of total cancer costs.

We feel that European regulations in the field of screening need a more coherent infrastructure to allow you guys (and ultimately ourselves at national level and our colleagues in the regions) to maximise strengths and lead the world in cancer prevention. Strong European leadership is vital to tackling the growing cancer burden effectively.

Let me be honest, at the member state level, priorities depend greatly on the circumstances of each country. Some countries have more resources than others, and when these are scarce, policymakers focus on investing in cancer services rather than preventative measures.

RR: Our colleague is correct, member states need support in developing lung-cancer screening best practises and more. The Commission could issue guidelines or make recommendations. These will eventually trickle down to regional level.

As far as I know, the biggest cancer killer of all does not have a solid set of screening guidelines across Europe, despite the need for doctors to improve decision making for the benefit of their patients.

EU: Hold on a minute…Back in December 2003 we produced a Recommendation on cancer screening, which stated that efforts should be taken to encourage citizens to take part in (and have access) to cancer screening programmes.

EU guidelines updated and expanded for breast and cervical cancer screening had already been published by the Commission, while comprehensive European guidelines for quality assurance of colorectal cancer screening were being prepared.

Unfortunately, slightly less-than-half of the population who should be covered by screening (according to the Recommendation itself) actually are. Meanwhile, less-than-half of examinations performed as part of screening programmes actually meet with all the stipulations of that Recommendation.

As I’ve said, there’s only so much we can do if member states don’t play ball.

MS: OK, some member states haven’t been brilliant but, as we know, some are rich, some are poorer. And cost-effectiveness questions arise whenever population-wide screening is considered, especially in relation to frequency and duration.

Guidelines could help to tether costs, by bringing in improvements to the efficiency of screening methodologies and, thus, programmes themselves.

RR: Let me interrupt, here. The potential benefit of low-dose CT lung cancer screening would certainly see an improvement in the lung cancer mortality rate in Europe. I don’t think that is in dispute.

MS: Yes, but screening in cancers also has potential harms. These include radiation risks, unnecessary anxiety in the patient and the patient’s family, and over-diagnosis and possibly subsequent over treatment.

EU: For sure, those are potential issues but, on the other hand, screening can help to ensure that surgery in the case of the early stages of lung cancer can continue to be the most effective treatment for the disease. As it stands, most patients are diagnosed at an advanced stage - usually non-curable.

RR: I’ve read that among recommendations currently being discussed in European forums are the setting of minimum requirements, which should include standardised operating procedures for low-dose imaging, criteria for inclusion (or exclusion) for screening.

MS: That’s true, and many member states have been and are planning, piloting or implementing population-based screening programmes for other cancers, such as breast, cervical and colorectal.

But barriers often exist in areas such as access to screening and quality assurance. Other issues include the need for well-controlled introduction of any recommended programmes and updating those tests that are already running. It’s all time and money.

RR: That aside, governance in all screening programmes needs political as well as stakeholder commitment to agreed screening policies. At regional level we are looking up and watching, waiting and hoping, but we’re not seeing it.

Europe needs common targets, coupled with legal, fiscal and organisational frameworks to place and update programmes. The EU and Member States should be taking a lead, here, as we cannot do it from the bottom up.

From a preventative point of view, new, up-to-date guidelines (on screening and more) would be a great leap forward - devised and agreed within strict standards of safety and ethics, of course.

MS: I agree. Doctors have told me that without screening and early detection of lung cancer (and other diseases), much of the incredible medical science being developed will struggle to fulfil all of its potential when it comes to saving lives and improving the quality of lives.

EU: But as I pointed out, we’ve essentially been here before, as shown by the progress - or a certain lack thereof - between the Recommendation of late 2003 and today.

It is vital to ensure that any and all recommended and eventually agreed standards can be met down the line, and we’ll never get there if Member States don’t also step up to the plate.

Agreed, there is a need for more guidelines across the arena of healthcare, especially in screening for lung cancer. But, there is also a need for agreement and coordination across the Member States on various screening programmes covering other disease areas. 

If we recommend and encourage but the member states don’t get around to implementing the work we can all theoretically do together, then what’s the solution?

RR: Well, you both need to find one. Because, guess what? The patients are here on the ground at regional and local level. ‘Down here’ they and we are virtually powerless. You need to sort it out, and quickly, because citizens are suffering unnecessarily.

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