Lung cancer case finding in COPD using low-dose CT The South Tyneside Model Part of: South Tyneside and Sunderland Healthcare Group 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 IV 1 1 year survival for stage IV just 17% 1
Our region South Tyneside has the highest rate of smoking in the North East 2 Also has one of the highest incidences of lung cancer in the UK 3 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 group 4 Further studies showing around 85% of cancers detected with low-dose CT screening are stage I or II 5
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 lowdose 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 followup 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 Technol Assess 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