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INSIDE STORY

DREAMSTIME.COM

NEW FOCUS
ON SCREENING

Population screening
of older people at risk
of lung cancer is yet
to be proven cost
effective but there’s
growing interest.
JANE LYONS

12 FEBRUARY 2016

IN 2010, Geoff Tapping returned
home from a few years as a grey
nomad traveller with his wife.
The
62-year-old
ex-army
officer was restless and looking for something to do when he
spied a newspaper advertisement
looking for over-60s with a history of smoking for a lung cancer
screening study at the University

of Queensland Thoracic Research
Centre in Brisbane.
Deciding to do his bit for science, he signed up for the study.
His first low-dose computed
tomography (CT) scan was uneventful, but 12 months later his
second scan identified a small
lump, which a long-needle biopsy
confirmed as cancer.

“I was back at my Army
Reserve when I got the word that
I had cancer.
“It was so strange because I
didn’t have that ‘OMG I’ve got
cancer moment’. It was almost a
non-moment: ‘Okay, so what do I
do next?’,” Mr Tapping says.
In late 2011, surgeons performed a lung lobectomy. More

than four years later, he’s still
cancer-free and is not only passing his Reserve fitness tests but is
also showing better lung function
than when he started the study.
Mr Tapping’s tale is the kind of
good news story about screening
of high-risk individuals that lung
cancer researchers and advocacy
groups want to see more of.
Dr Fraser Brims, a consultant
physician at the Sir Charles Gairdner Hospital, Perth, co-authored
an editorial in the MJA 1 recently,
arguing that Australia needs to
lift its game on research into lung
cancer screening.
“If you compare Australia
to the UK, many of the European countries, Canada and US,
we have been lagging behind
because all of them have established quite mature research programs,” Dr Brims says.
But the lack of focus in Australia is about to change. Since
Dr Brims submitted his article
to the journal, the NHMRC has
announced a $3 million grant
supporting a large study into the
effectiveness of screening with
low-dose CT.
Lung cancer doesn’t spark
many good news stories. It has a
14% five-year survival rate, and
kills more people in Australia
than breast and colon cancer combined, with an estimated 58,450
years of potential life lost to the
disease annually. 1
By the time most people are
diagnosed with lung cancer, they
have reached the stage where
there are few curative options.
This makes early detection critical to improving these odds, yet
screening remains controversial.
Costs loom large in these
debates.
According to Dr Brims, the rising cost of lung cancer treatment
is making early detection tools
more desirable.
The potential cost of implementing
screening
remains
unclear, with US studies estimating the cost benefit ratio at around
$81,000 per life year gained, while
Canadian studies estimate it at
closer to $10,000.
A previous MJA editorial 2 in
2013 questioned the utility of lung
cancer screening. Its co-authors
argued that smoking cessation
was more effective — and cost
effective — for combating lung
cancer in Australia, and therefore deserved more emphasis and
funding.
Three years on, and with further studies under the belts of
lung cancer screening proponents, these authors nevertheless
still support greater emphasis on
primary prevention.
“Smoking cessation remains
the mainstay of preventing lung
cancer,” says Michael Abramson,
professor of clinical epidemiology

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INSIDE STORY
at Monash University and one of
the 2013 editorialists.
“There is now an accumulating body of evidence in favour
of targeted risk-based screening
of current and former smokers,”
he says.
“However, the challenges of
offering state-of-the-art diagnostic testing and proven therapies
for lung cancer in a country the
size of Australia, with a dispersed
population, remain substantial.”
Dr Brims says that with the
majority of lung cancers now
occurring in ex-smokers, screening needs to be looked at as well.
“Yes, smoking cessation is
massively important, but you
can’t say they’ve stopped smoking so it’s not a problem anymore,” he says.
In 2011, the US National Lung
Screening Trial (NLST), which
targeted 53,454 current or former
heavy smokers aged 55–74, found
that screening with low-dose chest
CT scans decreased mortality from
lung cancer by at least 20%. 3
Although the NLST supported
the introduction of a screening
program in the US, creating ripples
of excitement among researchers,
the study was not directly applicable to Australia.
According to Dr Brims, the deve­
lopment of a national Australian

screening program is still stymied
by a lack of vital local information, which includes “an economic
evaluation to assess healthcare
cost utility, definition of a target
population, false positive rates,
and best recruitment and uptake
strategies”.
The
federal
government
agrees. Last year, the Standing
Committee on Screening, which
advises the Australian Health
Ministers
Advisory
Council,
released a position statement on
lung cancer screening.
“On the basis of the current
evidence and in line with the Population Based Screening Framework, the Standing Committee
on Screening does not support an
Australian lung cancer screening
program, either for the general
population or for high-risk populations,” it says.
“The Standing Committee on
Screening will continue to evaluate and advise on emerging evidence for lung cancer screening.”
Peak cancer advocacy bodies endorsed this position but are
also keeping an eye on gathering
research momentum.
“It’s true that we lack enough
evidence in the Australian population in a number of key areas,
but it is also true that lung cancer
screening is very much something

on the horizon,” says Professor Karen Canfell, the chair of
the Cancer Council NSW’s cancer screening and immunisation
committee.
The Lung Foundation Australia is also keen to see the key
issues resolved and is happy to
finally see some serious funding
dedicated to screening research.
“Lung cancer has been very

“Lung cancer
screening is very
much something
on the horizon”
PROFESSOR KAREN CANFELL

poorly funded and that includes
screening
programs,”
says
Heather Allan, the foundation’s
chief executive officer.
She says one of the reasons for
low funding is because the issue
loses its advocates.
“The survival rate for lung
cancer is 14%. If you compare that
to breast cancer, there is a huge
army of very articulate [breast
cancer survivor] advocates who
are pushing government all the
time,” Ms Allan says.
“The Lung Foundation continues to advocate for lung cancer

screening to be very high on the
government agenda so that when
the evidence is resolved we can
move really quickly to introduce
an effective lung cancer screening
program that will save lives.”
Funding frustrations in the
lung cancer screening research
field have now turned into high
hopes with the release of results
from the Queensland Lung Cancer Screening Study (QLCSS) 4
demonstrating chest CT screening feasibility, and the upcoming
NHMRC study.
Professor Kwun Fong, a thoracic physician from the University of Queensland Thoracic
Research Centre at the Prince
Charles Hospital who secured
the NHMRC grant, was one of the
QLCSS leads.
The study assessing the feasibility of a NLST-style protocol in
Australia has nearly completed
long-term follow-up.
“We have demonstrated that
it can benefit people and that the
harms are generally low.
“We’re just in the process of
trying to prove that it is a costeffective intervention,” Professor
Fong says.
“We’re working with a team
of very good health economists
and we’re getting some good
health utilisation data to look at

the costs of finding these cancers and treating these cancers to
convince the funders that it is a
worthwhile effort.”
This economic evaluation will
be available by the end of the
financial year.
But with 250 people enrolled
in the QLCSS, it has been a trailer
for the upcoming main attraction: the NHMRC study due to
start mid-year in collaboration
with researchers from Canada
and Europe.
“The new study will look at
two things: benefits of risk prediction for improving the efficiency of screening and optimal
nodule management,” Professor
Fong says.
In particular, researchers
will examine the use of a risk
prediction model, PLCOM2012,
which uses 10 variables to calculate a patient’s lung cancer risk,
and which has already proven
to increase the accuracy of lung
cancer risk predictions and the
efficiency of identifying people
for screening.
“We are going to see if we can
make [lung cancer screening]
cheaper, better and produce
fewer false positives,” Professor
Fong says.
References at medicalobserver.com.au