Parking Lot Lung Cancer Screening Pays Dividends

Liam Davenport

March 24, 2017

A pilot program in a supermarket parking lot offering lung cancer screening to individuals at high risk has quadrupled detection rates of early disease, allowing almost all patients to be offered potentially curative treatment, British researchers have announced.

The United Kingdom has not introduced lung cancer screening, despite good results from a UK trial, with arguments cited such as the upfront costs and the lack of clarity over whether it could save lives.

Now this pilot project is described as "an enormous success" by Ashley Woodcock, MD, PhD, OBE, professor of respiratory medicine at the University of Manchester. "The important next steps are to learn the lessons in order to scale up effectively, and therefore ensure transferability to larger populations and to other regions," he said.

Dr Woodcock suggested that this "is a unique 'teachable moment,' an opportunity to link into stop-smoking services and to improve long-term health."

Cancer Detected Every Day

The Lung Health Check Pilot, which was funded by the UK charity Macmillan Cancer Support via the Macmillan Cancer Improvement Partnership in Manchester (MCIP), used low-dose computed tomography (CT) to screen current and former smokers identified from general practices.

The result was that 80% of lung cancers were detected at stage I or II, with the rate of cancers detected at stage IV plummeting from almost half to just over 1 in 10. Moreover, the clinicians detected a case of cancer for almost every scanning day of the project.

Phil Barber, MD, consultant respiratory physician at the University Hospital of South Manchester and the Christie Hospital, and MCIP clinical lung lead, described the results as a "landmark day for the respiratory health of Manchester people."

"It is often assumed that people living in more deprived areas, like those chosen for this pilot, do not usually take up screening opportunities, but we have demonstrated that this is not the case, and that many people are keen to attend," he said in a statement.

"We have hard evidence now that CT scanning high-risk patients helps us to identify cancers early enough to cure them, and we have also picked up many patients with other lung conditions at a much earlier stage than would otherwise have been possible," he added.

Lynda Thomas, chief executive of Macmillan Cancer Support, commented: "Our Manchester pilot has achieved extraordinary success in diagnosing lung cancer at an early curative stage."

Janet Tonge, MCIP program director, added, "When cancers were found in the first few days of scanning, it was an emotional moment for the MCIP team knowing we had enabled this ground-breaking service to happen and lives to be saved."

Area of High Smoking Rates

Manchester has some of the highest smoking rates in the United Kingdom, and, as a result, lung cancer is the most common cause of death in Manchester among people younger than age 75 years. The number of deaths from lung cancer is greater than for all other cancers combined.

The screening pilot (devised and implemented by the University Hospital of South Manchester National Health Service Foundation Trust and the MCIP in collaboration with general practitioners, Manchester City Council, Macmillan, and the three Clinical Commissioning Groups in Manchester) was based on the results of the US National Lung Screening Trial.

That trial  involved 53,454 people at high risk for lung cancer at 33 US medical centers. The results, which were published in 2011, showed that annual screening with low-dose CT led to a 20% reduction in lung cancer deaths and a 6.7% reduction in deaths from any cause. They led to a recommendation from the US Preventive Services Task Force that high-risk individuals aged 55 to 80 years be screened for lung cancer. Such screening has been adopted in major cancer centers in the United States.

The United Kingdom, however, has not done so, despite results from the UK Lung Screening Trial of over 4000 individuals showing that 85.7% of detected cancers were stage I or II and 83.3% were able to undergo resection.

Pilot Project

To conduct a real-world pilot of targeted lung cancer screening in the United Kingdom, the researchers sent a letter all individuals aged 55 to 74 years in the 14 participating general practices in Manchester, inviting them to a lung health check if they were a smoker or ex-smoker. This was accompanied by a leaflet to help them decide whether to take part.

The health checks were based in supermarket parking lot and designed as a one-stop shop, with a lung specialist nurse leading a discussion about symptoms, performing spirometry, and calculating an individual's lung cancer risk.

Those at high lung cancer risk were invited to have low-dose CT right away in a mobile scanner in the same parking lot. Those at low risk did not undergo CT, although people with abnormal symptoms and/or abnormal spirometry results were asked to contact their general practitioners.

Although most CT scans were negative, around 1 in 10 revealed a nodule, which was followed up by a scan 3 months later. If these scans indicated lung cancer, they were reviewed and the individuals asked to attend the chest clinic.

More than 2500 people attended the screening, of whom approximately 50% were women. One third were current smokers, and the majority were from very deprived areas of Manchester. Around half of participants were offered immediate CT, leading to the discovery of 42 cancers, or 1 for every 33 CT scans.

The results showed that 80% of detected lung cancers were diagnosed as stage I or II disease, compared with a rate of less than 20% that is seen historically when patients are diagnosed after reporting symptoms.

Moreover, just over 10% cancers were advanced stage IV disease, compared with almost 50% diagnosed through standard care.

Of the patients diagnosed at the lung health checks, approximately 90% were offered curative treatment, which represents a marked increase over the figures achieved outside of screening, the researchers comment.

The researchers also found that 20% of the people who attended screening were diagnosed with chronic obstructive pulmonary disease.

Seeding Crystallization

Discussing the pilot project, Dr Barber pointed out that Macmillan's core activity is more in palliative care but that the early discussions concerned whether "we could bring forward the stage at diagnosis and move into screening but with high-risk patients."

Speaking to Medscape Medical News, he said that "as the focus sharpened onto this project, everybody realized that it was long overdue." However, the money that Macmillan brought to the project meant that "we weren't quite in the usual commissioning minefield of having to compete with all sorts of other priorities."

"In fact," he added, "it was slightly off-piste in comparison with most health funding projects…. We had the organizational set-up with commissioning buy-in, but we didn't have to put it to commissioners as a project competing with all the other pressing needs of the health service. So it was protected money, in a sense."

As soon as it became clear that the pilot project was paying dividends in terms of cancer detection, Dr Barber said that "the response regionally and nationally was really extraordinary, and all the more extraordinary because we hadn't really made any results available."

He continued: "I think it has acted as a sort of seed on which a crystal has formed.… We seemed to touch something in the collective consciousness, or collective subconsciousness perhaps, that this is an important area of public health and clinical activity, but it's as if it needed that catalyst."

There is now interest in both the north and greater Manchester areas to implement a similar project, and MCIP is sharing information on the pilot nationally. Dr Barber expects that the findings will be replicable elsewhere and that it will become a priority for conventional funding bodies to implement targeted lung cancer screening.

The service was funded by Macmillan Cancer Support and commissioned by Manchester Clinical Commissioning Groups. The authors have disclosed no relevant financial relationships.

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