Lung-cancer screening

On 28 March the EAPM (European Alliance for Personalised Medicine) organised its 5th annual conference which focused on lung-cancer screening and some issues that currently affect personalised medicine.

More than 130 participants attended the conference, including EU officials and the Belgian Health Minister, Maggie De Bloc. The event concluded with the following:

• An increase in cancer incidence by 30{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} between 1995 and 2012 – the effect of growing ageing population and chronic diseases associated with living longer. This trend is likely to continue in the future causing budget pressure on healthcare systems. In the same period fewer people died of cancer due to advances in screening, diagnosis and treatment. The WHO (World Health Organisation) has predicted that cancer will rapidly increase over the coming decades and new cases of cancer globally are expected to increase by 70{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} over the next 20 years, from around 14 million to 25 million.
• Lung cancer is the deadliest cancer (no early symptoms) that accounts for 20{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of all cancer deaths (1,6 million annually). Early diagnosis results in 80{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} surviving rate (it varies across Europe; detection should be at stage 1 or 2 out of 4) and together multidisciplinary care, organ-specific tumour board/team that includes healthcare providers able to manage the patient through the disease taking not only the tumour but specific patient’s needs and high output centers contribute to better outcomes. In addition, high number of various guidelines exist but there are often out of date or the implementation is very poor.  There is a need for:

– effective screening programs – advanced imaging technology and biomarkers (breath, blood, tissue sampling, staging), prompt access to diagnostic facilities, full molecular characterisation;

– harmonised focus on the lung and the effects of the disease and its treatments on breathing; effective medication with break through survival benefits and no-side effects; holistic care, team work with the patient at the centre. Lung cancer screening can be only effective within the framework of a cancer plan with primary prevention and health care measures included. However, there are disparities in healthcare across Europe.

– smoking cessation programmes-no link to fear, tobacco ban, strict advertising measures, standardised packaging, raise tax and use it for screening – 80-90{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of lung cancer patients are smokers

– accurate algorithms for diagnosis and management of findings

– financial support for research/investigator – initiated important/big studies

–  to develop the technology, the required infrastructure and the legal, regulatory environment for a fully sustainable healthcare systems that will offer truly personalised medicine (currently very low awareness within the society), prevention and wellness for EU citizens, providing completely new Quality-of-life

– to develop and integrate novel-omics, imaging and multi-level advanced smart sensor technologies and big data/deep data analytics. However, the challenge is that patients are reluctant to share with their data due to the lack of trust.

– better dialog and cooperation between health and finance ministries as the cost of lung cancer is very high and greater involvement of economists. To establish cost of illness to use as evidence for governments

• Due to the lack of lung cancer CT screening recommendations at EU level, guidelines need to be developed urgently and also to assess how the service delivery will be undertaken in the differing health care systems throughout the EU. It is needed for the EU to provide support and collaborative structure. Final results from the ongoing NELSON trial will become available soon which should serve as evidence to develop such recommendations and guidelines. The NELSON trial aims to determine: screening for lung cancer with low-dose multi-slice CT in a high risk group leads to a decrease in lung cancer mortality of 25{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} or more; the effects on quality of life and smoking cessation; and what is the cost-effectiveness of cancer screening.
• The following recommendations for future EU guidelines have been mentioned:

– Identification of high risk patients – use of risk prediction models

– Focus groups – encourage participation of the ‘hard to reach population’

– Volume of the nodules for biopsy

– Integrate smoking cessation into cancer screening

– Centers of excellence to run CT screening programmes

– Radiology reporting CT screening protocols  – NELSON or UKLS (UK Lung Cancer Screening trial aims to evaluate low-dose computed tomography (LDCT) lung cancer population screening in the UK)

– Training and accreditation of radiologists/radiographers – set up European imaging registry to include previous CT trials for training /research collaboration

– Quality assurances – set up national-European CT screening registry once implementation has been provided

– Actions for incidental findings

– Guidelines need to be developed by various actors, including politicians, clinicians, patients. Dialogue is critical to support and drive the rapidly advancing science and deliver access to innovative medicines across Europe.

– Building collaboration with a continued process and regularly update guidelines taking into consideration new findings/developments

– Build on three components 1. effectiveness, 2. harm-benefit ratio, 3. economic evaluation: cost-effectiveness, cost-benefit and cost-utility

– European Society of Radiology referred to theESR/ERS white paper on lung cancer screening

• A representative from the EC (European Commission) referred to the 2003 Council Recommendation on cancer screening that covers only 3 types of cancer – breast, cervical and colorectal cancer – and advised that the EC has re-opened a discussion with the EU Council to obtain a mandate to include lung cancer at EU level. He added that ERN (European Reference Network), launched on 1 March 2017, virtual networks involving healthcare providers across Europe) includes 4 networks on cancer – Genetic Tumour Risk Syndromes; Solid Adult Cancers; Onco-Hematological Diseases; Paediatric Cancer. He added that the CANCON EU Joint Action has recently concluded its findings on reducing the cancer burden in the EU helping raise cancer survival and reduce cancer mortality. Currently, the EC is preparing a new EU Joint Action on innovative aspects of cancer, including personalised medicine and genetic screening. Member states have now time until 11 May 2017 to apply and get involved in the upcoming Joint Action.
• A representative from Siemens advised that currently the company is looking at minimalising radiation exposure and costs and collaboration of various actors is vital. Currently new technologies with low radiation levels are ready to be brought to patients.

A general remark has been made against possible over-treatment (which come with the territory in screening programmes – breast and prostate, for instance) with many arguing that over-testing can very easily lead to this over-treatment, including unnecessary invasive surgery.

During the coming months, EAPM will be developing the policy asks that will be presented at the Annual European Personalised Medicine Congress taking place on 27-30 November in Belfast, Northern Ireland.