Lung cancer screening in Switzerland

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1 SAMO Interdisciplinary Workshop on Chest Tumors 27 th and 28 th January 2017 Hotel Hermitage, Lucerne Lung cancer screening in Switzerland Walter Weder, MD, Professor of Surgery University Hospital Zurich, Switzerland

2 Lung Cancer Screening Benefits Lung cancer mortality reduction Reduction advanced disease Life years gained Harms False-positives Over diagnosis Over treatment Radiation exposure Cost Quality of life / smoking behaviour

3 Why should we want to screen? Stage shift! Localised Regional spread Distant spread When diagnosis is based on symptoms When diagnosis is based on screening

4 National lung screening trial (NLST) subjects randomised to one of two groups: - Low dose CT - Chest X-ray 3 screening rounds at annual intervals Non-calcified nodules 4mm in CT or any size in X-ray were referred for diagnostic work-up Primary outcome: lung cancer related mortality Aberle et al. N Engl J Med 2011

5 National lung screening trial (NLST) Inclusion criteria - Age years - Smoking history 30PY, active or stopped less than 15 years ago Exclusion criteria - History of lung cancer - Other prior cancer in past 5 years - Chest CT less than 18 months ago - Unexplained weight loss (>15lb in past year) - Metallic implants or devices in chest or back - Home oxygen supplementation - Pneumonia treated with antibiotics in past 12 weeks Aberle et al. N Engl J Med 2011

6 National lung screening trial (NLST) 24%/year positive (96% false positive) Lung cancer incidence LDCT: 65 per PY CXR: 57 per PY Harm from diagnostic work up LDCT: 1.4% (16 patients died within 60 days) CXR: 1.6% (10 patients died within 60 days) Relative reduction in lung cancer mortality rate 0.80 (95% ) Number needed to Screen: 320 NLST Research Team NEJM 2011;365:

7 National lung screening trial (NLST) Aberle et al. N Engl J Med 2011

8 In other words JAMA Patient Page; JAMA 2013;309;18:1948

9 A Comparative Modeling Study for the USPSTF Advantageous scenario (harms-benefits ratio): Annual CT-screening Aged 55 through 80 minimum 30 pack-years; maximum quit smoking 15 years: 19% eligible 287,000 screens LC deaths prevented (ratio 1:575) 14% (range %) lung cancer mortality reduction 5,250 life-years gained per 100,000 persons 190 overdiagnosed cases (10% of screen-detected cases)

10 A Comparative Modeling Study for the USPSTF The 9 most advantageous scenario de Koning et al., Annals of Internal Medicine 2014

11 Results from (ongoing) trials Trial Lung cancer mortality in % Relative Risk LDCT screening beneficial LDCT Control NLST 1.3% 1.7% 0.80 Yes DANTE 1.6% 1.7% 0.94 (Yes) DLCST 0.7% 0.5% 1.35 (No) MILD 0.04% 0.07% 1.64 (No) NELSON Coming in 2016 ITALUNG LUSI UKLS

12 A Systematic Review to Update the USPSTF Recommendation Humphrey et al., Annals of Internals Medicine 2013

13 Ongoing European trials will offer explanations Heuvelmans et al. J Thorac Imag 2015

14 Sample size of ongoing European trials Heuvelmans et al. J Thorac Imag 2015

15 Age, sex and smoking history diverse across trials & volume based Heuvelmans et al. J Thorac Imag 2015

16 Technology and work-up diverse across trials & volume based Heuvelmans et al. J Thorac Imag 2015

17 Swiss experts and NPOs work together to carefully deal with lung cancer screening Experts from all 5 university hospitals and the cantonal hospitals of Lucerne, Lugano, St. Gallen and Baden

18 LDCT screening in Switzerland Before 2011 Hirslanden Zurich perfoms LDCT screening, ELCAP member 2011 Publication of NLST in NEJM 2012 Formation of Expert group of Pulmonologists, Radiologists, Thoracic Surgeons and Epidemiologists from 5 medical faculties Symposium in Zurich and draft of Statement paper 2013 First discussions with BAG 2014 Publication of Statement paper (Frauenfelder et. al Respiration) Consortium broadened (Lungenliga CH, SUVA) 2015 FAQs and Fact Sheet Application to BAG for reimbursement of LDCT + consultation Negative answer from BAG; wait for Nelson 2016 Development and introduction of LDCT screening

19 Experts are against «free market» and argue for standardized quality-controlled screening (if at all) «Free market» High quality possible but risk of: Few SOP for entire screening sequence Inequality of access Follow up paid through health care insurance (!) Lack of systematic quality control little room for continued improvement Through health care insurance Well defined (SOPs) screening sequence including smoking cessation Certified centres Registry a must (like CMS in USA) Patient selection & access Quality control and improvement within and across centres Outcomes (benefits and harms) Cost effectiveness Adapted from Prof. Dr. Milo Puhan

20 Conclusions CT lung cancer screening reduces overall and lung cancer mortality in selected patients Benefits, harms and cost-effectiveness have been assessed on the basis of one large RCT The population at risk will remain high for a long time period Risk prediction models optimize the selection of those who could benefit most from CT lung cancer screening Possible unintended side-effects should be carefully monitored CT screening is likely to become an important element in reducing lung cancer mortality