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.
Thanks to Dr Sally Athey
and Dr Jennifer Hunter