How lung cancer can be detected and diagnosed earlier in Sweden
Lung cancer is today the leading cause of death in Sweden. The earlier that lung cancer is detected, the greater are the chances of survival. A national screening programme has been brought to attention, but much needs to be resolved before we are there. Around 70 participants met digitally during a workshop on early detection and diagnosis of lung cancer hosted by Vision Zero cancer. The realization of a national implementation study for a screening program combined with smoking cessation, health informants, lung health checks, biomarkers, advanced imaging, apps and risk assessment tools based on AI in primary care, were some of the ideas that came up.
Lung cancer causes symptoms that come up late in the course of the disease and assessments are complicated. This means that half of the patients have a spread disease at diagnosis. At the same time, the general public and primary care can become better at paying attention to early symptoms, which can easily be confused with other conditions. With new systems and knowledge, we can pick up on symptoms earlier and more quickly come to treatment. And get a better chance of reaching the ‘vision zero’ – that zero people will die as a result of cancer and that more people will live longer and better.
Detecting the cancer in stage 1 gives a two-year survival rate of 80 percent. In stage 4, the two-year survival rate is 10 percent.
The workshop began with insights on why early detection of lung cancer is important, what other countries do on the subject and which needs are prominent in primary care. We were also updated on the expected results of Region Stockholm's planned pilot study on lung cancer screening in connection with mammography, research on how biomarkers can improve early detection of lung cancer and an exchange of knowledge with the UK. Moderator Lisa Kirsebom interviewed a panel of representatives from health care, government and politics about what is left to solve before a national screening program can become a reality in Sweden.
The participants were then divided into groups to discuss two questions. The first about what data and knowledge we need to foster moving forward. Among other things, the difficulties in finding the right people to screen were highlighted – in the Stockholm region pilot study there are only women, how do we reach men who smoke? And how do we reach newcomers from countries where smoking is more common than in Sweden and where authorities are viewed with scepticism?
– The group that smokes the most can be the hardest to get to participate in screening programs" says one workshop participant. We also need to reach out with information on quitting smoking. Health informants can build trust and find new ways to reach out. Here we can also collect the knowledge generated during this year with covid-19 – how we can overcome the barriers of language and culture.
The group that smokes the most can be the hardest to get to participate in screening programs" says one workshop participant. We also need to reach out with information on quitting smoking.
At the same time, about 15 percent of those who get lung cancer have never smoked. To find them, the health care system, especially within primary care, needs new tools and more support.
The second question regarded in which areas there are needs for strategic and targeted cooperation to detect lung cancer earlier. The discussions led to concrete proposals. An app that combines the patient's self-perceived symptoms with the geographic presence of radon. The continued strengthened research on radiology and biomarkers were some proposals that came up. Several participants expressed the need and interest to cooperate in the realization of a national implementation study. Allow a number of demonstrative projects where strategies can be tested, some of the workshop participants highlighted e.g. screening, mobile screening, biomarker testing, ways to attract people to screening, collaboration with primary care, digital health surveys, health informants and more general lung health checks.
About 15 percent of those who get lung cancer have never smoked. To find them, the health care system, especially within primary care, needs new tools and more support.
Examples of other ideas highlighted were collaboration with schools/universities/employers both around prevention and early detection, cancer-certified health centres with special expertise on early detection and collaboration between primary care and the country's diagnostic centre in case of diffuse symptoms.
We are all very aware that something must happen now. I believe a lot in modern technology, algorithms and so forth. And to get information to further this process – that we patients are allowed to record and document symptoms.
The issue of including patients in the development of models, not only via data but also via experience, also came up. The workshop ended with Karin Liljelund, patient representative and vice chairman of the Lung Cancer Association, pointing out that patients would like to share their data.
– I appreciate that we patients are invited. We are all very aware that something must happen now. I believe a lot in modern technology, algorithms and so forth. And to get information to further this process – that we patients are allowed to record and document symptoms.
Are you curious about the introductory insights?
The importance of early detection and diagnosis
Mikael Johansson, Associate Professor and Senior Physician Oncology at Norrland University Hospital, talked about the importance of early detection and diagnosis. Over half of all lung cancer cases are diagnosed at stage 4, when the disease is metastatic and incurable. Approximately 25 percent is diagnosed in stages 1 and 2, when it can be treated with surgery or precision radiation therapy.
– Detecting the cancer in stage 1 gives a two-year survival rate of 80 percent. In stage 4, the two-year survival rate is 10 percent. Lung cancer screening increases survival, Mikael says. Sweden urgently needs to implement screening of risk groups. But how do we reach them, how do we organize ourselves, how do we choose better audiences?
What does the rest of the world do?
Ebba Hallersjö Hult, Head of the innovation milieu Vision Zero Cancer, gave an outlook on the world. The United States and South Korea have introduced targeted screening programs. Canada and China also carry out studies and plans towards this. The UK has conducted several studies and tested strategies to find and reach the right people. In Norway, an implementation study will start in 2021 in which approximately 1,000 high-risk people will be screened. The focus is to build knowledge about cost-effectiveness of lung cancer screening. Denmark is considering launching a small-scale screening program to map the impact on capacity needs in subsequent diagnostics. There too is a big ongoing discussion about how best to reach the risk group. In the EU, Croatia, a high-incidence country, has begun implementation. Also underway are a lot of exiting steps taken in the EU within the study 4-IN-THE-LUNG-RUN. The Study, within the Horizon 2020 programme, evaluates different strategies for lung cancer screening in 2020-2024. The study involves medical research institutions from Holland, Germany, England, France, Spain and Italy.
– Sweden is timely with discussions, research and studies. Now is the time to take it further, Ebba concludes.
Decision support in primary care to detect lung cancer earlier
It is a challenge to find patients who have cancer among all those who seek medical treatment within primary care, says Elinor Nemlander, General Practitioner at Sophiahemmet Primary Care Center and PhD student at Karolinska Institutet. In primary care, symptoms that may exist due to cancer are common. Coughing is the fourth most common cause for visiting. Elinor Nemlander believes in risk assessment tools, which can help primary care detect the right patients. For this, primary care-based clinical research is needed on the predictive value of symptoms, which is exactly the research that Elinor is undertaking.
Pilot study and cost-effectiveness of lung cancer screening in conjunction with mammography
Screening can require significant resources if the precision in the selection of people to screen is not accurate. The Stockholm-Gotland region has investigated the interest in and cost-effectiveness of lung cancer screening. In the pilot project, 1,727 women were asked questions about smoking habits and health at their mammography screening. 90% said they were also interested in lung cancer screening. Based on this, IHE calculated that lung cancer screening is cost-effective and lowers the mortality rate of patients 55-74 years of age. Telling us about this was Gunnar Wagenius, Senior Physician at Karolinska University Hospital and Chairman of the National Lung Cancer Registry, and Katarina Steen Carlsson, Associate Professor of Health Economics at Lund University and IHE.
Conclusions from expert meeting with England on lung cancer screening
Suzanne Håkansson, Senior Director Government Affairs, AstraZeneca AB and a member of Vision Zero Cancer's core team shared words on a meeting and knowledge exchange held with British experts which Vision Zero cancer arranged earlier this autumn. Last year, the UK launched its Long-Term Cancer Plan, with a couple of quantitative targets. The NHS has encouraged development projects to contribute to the objectives. Here you will find more about the UK's success factors for lung cancer screening.
Biomarkers to improve early detection of lung cancer
Mattias Johansson, PhD, Scientist, Genetic Epidemiology Group at the International Agency for Research on Cancer (IARC), talked about his research on how biomarkers can improve CT lung cancer screening. After a long study including 1 200 proteins, he and the research team have scaled down the work to seven biomarkers. These can significantly improve prediction, compared to a standard risk model based on smoking data. The study is ongoing.
– Next year we will try to validate the panel. In a year and a half, we hope that we will have a usable tool to really improve the inclusion criteria and follow-up process.
Panel discussions on issues left to solve and what obstacles to overcome
After the introductory talks, the moderator Lisa Kirsebom, science journalist and natural scientist, interviewed a panel consisting of Jan Nyman, Associate Professor andSenior physician Oncology at Sahlgrenska University Hospital and Chairman of the National Working Group for Lung Cancer, Mattias Fredriksson, Head of Unit responsible for national guidelines and screening at the National Board of Health and Welfare from the National Board of Health and Welfare, Jan Adolfsson, Associate Professor and Physician, Member of the National Screening Council and Camilla Waltersson Grönvall, Member of Parliament, Ordinary member of the Committee on Health and Welfare and spokesperson for the party Moderaterna.
Jan Nyman opens the discussion with stating that the screening population is set – 55-74-year-olds who are or have been heavy smokers. The question is now rather how to get them to come to screening. Mattias points out that other screening programs are often aimed at people who can be found using social security numbers. But now it is a group with a risk behaviour we need to find, they are not a given part of the population. In addition, about 15 percent of patients with lung cancer have never smoked. To find them, there must be other ways than screening.
Another aspect of establishing a screening program is how long it takes. Jan Adolfsson points out that the road to a national screening program is long. He compares it to mammography screening, which took 7-8 years to set up, and colorectal cancer screening, where the recommendation came in 2012 but implementation has not yet happened in many regions. From a political point of view, Camilla Waltersson Grönvall wants to see solutions move faster. For example, through more pilot studies, which Mattias Fredriksson welcomes. All initiatives are valuable and teach us more which moves us further towards making a final decision, he says.
Jan Adolfsson emphasizes that it is possible to start with efforts aimed at quitting smoking right away. And that it is the most cost-effective solution. At the same time, efforts are not mutually exclusive and can with advantage take place in parallel.
The panel agrees that the national perspective is important. Both for pilot studies, tools in primary care an