Part of:

South Tyneside and

Sunderland Healthcare Group

Lung cancer case finding in COPD using low-dose CT

The South Tyneside Model

Ross T., Fuller E.

Lung cancer

• Largest cause of cancer-related death in the UK

• Late diagnosis is associated with poor outcomes

• Around 50% diagnosed at stage IV1

• 1 year survival for stage IV just 17%1

Our region

• South Tyneside has the highest rate of smoking in the North East2

• Also has one of the highest incidences of lung cancer in the UK3

• 1/3 patients present as emergency admission

Lung cancer incidence across the North East

Slide courtesy of Linda Wintersgill, Northern Cancer Alliance

Lung cancer screening

• Trial in US comparing low-dose CT with chest x-ray in heavy smokers

• 20% mortality reduction in low-dose CT group4

• Further studies showing around 85% of cancers detected with low-dose CT screening are stage I or II5

NELSON screening study

• Over 15,000 patients randomised to receive either LDCT or no screening

• LDCTs performed at baseline, 1 year, 3 years and 5.5 years

• Results presented September 2018 suggest 26% relative mortality reduction in male LDCT group at 10 years

Evidence clearly shows that Europe must start planning for implementation [of low-dose CT screening] within

the next 18 months

Oudkerk, M., et al. (2017). "European position statement on lung cancer screening." The Lancet Oncology 18(12):

e754-e766

COPD and lung cancer

• COPD and emphysema are both independent risk factors for lung cancer, even when controlled for smoking exposure

• Focusing on smoking alone may miss cancers in COPD patients who have other risks, such as asbestos exposure

Both [airflow obstruction and emphysema] have

been neglected by current guidelines identifying the

target population that should undergo screening

Sanchez-Salcedo P., et al. (2015). “Improving selection criteria for lung cancer screening. The potential role of

emphysema.” Am J Respir Crit Care Med 2015 Apr 15;191(8):924-31

Aims and objectives

• Develop a lung cancer case-finding model within routine NHS practice

• Target an appropriate patient group

• Encourage smoking cessation

• Detect cancers early enough to offer curative treatment

• Cost-effective

The South Tyneside Model

• Suitable asymptomatic patients identified by practice nurses at COPD annual review

• Practice nurses received written guidance and face-to-face training

• Offered low-dose CT and counselled by practice nurses

• Smoking cessation emphasised

The South Tyneside Model

• Project underwent three month trial phase at 6 voluntary GP practices to assess feasibility

• Then rolled out to all GP practices within the CCG

• CCG business case successful with support from Trust with cost agreed for low-dose CT and report from radiologist for GPs

• Both low-dose CTs and reporting by radiologist performed out-of-hours

The South Tyneside Model

• If radiologist suspects lung cancer then respiratory physician informed and appointment made in one-stop clinic

• Any other results are responsibility of GPs and they follow-up

• If nodule detected then GP arranges follow-up scan

Results

• 560 low-dose CTs performed

• 94 nodules detected

• 16.8% of low-dose CTs revealed a nodule

• All confirmed lung cancers offered curative treatment in the form of surgery or radical chemo/radiotherapy

• Example of lung cancer detected (patient underwent surgery)

• Many findings of bronchiectasis, ILD, and other cancers

• Patient below referred to respiratory consultant due to new finding of bronchiectasis

Successes

• GPs and practice nurses have embraced the project and all nodules detected are under follow-up

• Model has established lung cancer case finding within routine NHS practice

• Lung cancers being detected early enough to offer curative treatment

• Many other significant findings including other cancers, ILD, bronchiectasis

Challenges

• Ensuring all GPs are made aware of inclusion criteria

• How do we reach patients who are not attending their COPD annual review

Future work

• Project is ongoing and patients will be offered annual scans

• Cost-effectiveness and health economics

• Patient experience of project

References

1. Office for National Statistics, Cancer survival by stage at diagnosis for England, 2016.

2. Integrated Household Survey, ONS (experimental statistics) via London Health Observatory: (www.lho.org.uk/viewResource.aspx?id=16678)

3. Public Health England Cancer Data (https://www.cancerdata.nhs.uk/dashboard/lung.html#?tab=Overview&ccg=00N)

4. The National Lung Screening Trial Research Team. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. The New England journal of medicine. 2011;365(5):395-409.

5. Field JK, Duffy SW, Baldwin DR, Brain KE, Devaraj A, Eisen T, et al. The UK Lung Cancer Screening Trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer. Health TechnolAssess 2016;20(40)

6. Oudkerk, M., et al. (2017). "European position statement on lung cancer screening." The Lancet Oncology 18(12): e754-e766

Photography courtesy of Sally Ann Norman Photography (https://www.sallyannnorman.com)

Thank you

Any questions?

Ross T., Fuller E.

thomas.ross@stft.nhs.uk

Thanks to Dr Sally Athey

and Dr Jennifer Hunter