Proposed lung cancer screening program ‘a complex arrangement’

The RACGP is ‘cautiously’ supportive of a lung cancer screening program for high-risk populations, according to its latest submission to the Medical Services Advisory Committee (MSAC).
 
Aimed at supporting earlier detection of lung cancer, it has been proposed that a National Lung Cancer Screening Program (NLCSP) use low-dose tomography (LDCT) to assess high-risk individuals, such as smokers and ex-smokers.
 
Screening will be every two years for participants in the program, or until a lesion requiring management is identified. All entrants will also require a referral form for LDCT completed by a GP or other eligible practitioner.
 
In response to the proposal, the college has called for a carefully considered and staged approach to implementation, with general practice being the ‘principal route of entry’ into the program.
 
‘The benefits of screening are highly contingent on identifying the appropriate high-risk target populations and the specificity of screening tools,’ RACGP President Dr Karen Price wrote.
 
‘Embedding risk assessment tools in the general practice setting enables systematic identification of the at-risk population.’
However, while broadly supportive of the program, the RACGP is concerned that the proposal is unclear about who will conduct the risk calculation, consent, and referral process for LDCT, and how the costs of providing these services will be covered.
 
Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care, told newsGP while he is supportive of the NLCSP, it is a ‘hugely complex task’ to introduce a new screening program.
 
‘The NLCSP has looked at different components of implementation [and] this one has added complications,’ he said.
 
‘Lung cancer screening is complicated by the need to make the program accessible to people living in urban, rural and remote areas. It needs to be accessible to groups of people with higher smoking prevalence which includes those with mental illness, Aboriginal and Torres Strait Islander peoples and CALD [culturally and linguistically diverse] groups.
 
‘The second step of the screening process is a LDCT scan for which patients will need shared decision-making, informed consent and a referral.
 
‘This makes it a much more complex arrangement than receiving bowel cancer screening kit in the post.’
 
Professor Morgan also says the proposed model of using an individualised risk calculator to judge patient suitability means it would ideally need to be incorporated in general practice software to ensure it can be used seamlessly within normal workflows.
 
‘To identify potential participants, conduct the risk assessment and then engage in shared decision making to refer for a scan takes time,’ he said.
 
‘It is much better to set expectations at this stage that the scan is likely to show some abnormalities. The same people who are at risk of lung cancer are at risk of COPD, cardiovascular disease and other cancers.’
 
Overdiagnosis concerns
The college’s submission states that in addition to providing information on the benefits of the program, patient consent and information should ‘clearly outline the possible harms from engaging in screening’, such as the potential for overdiagnosis.
 
The LDCT step of the proposed screening pathway is, according to Professor Morgan, ‘perhaps the most challenging’ and echoes the RACGP submission in calling for further clarification about the pathways for managing incidental findings.
 
‘All incidental findings will need clear management pathways − there is a great risk that some of these findings will lead to a cascade of further investigations,’ he said.
 
‘Most LDCT scans will show some abnormalities – this might be a thyroid nodule, adrenal nodule, coronary calcification or some lung pathology.
 
‘In about 11% of scans there will be a nodule that will need earlier follow-up scans and some will need biopsy. All of this will be very disruptive and anxiety-provoking for people waiting on results.
 
‘Some people will discover a cancer in the thyroid that would never have caused any harm in their lifetime. This sort of overdiagnosis has been disastrous and wasteful overseas.’
 
The RACGP submission says continuous evaluation of the NLCSP should be employed to monitor for overdiagnosis, by prospectively comparing mortality rates between screened and unscreened populations.
 
‘Reducing overall mortality and diagnosing lung cancer at an earlier stage when treatments are more successful are laudable aims,’ Professor Morgan said.
 
‘There is a need to have the educational resources and public information campaigns designed and ready to go. There is also a need to have the physical infrastructure in place to not only offer CT scans but also to manage the results of those scans.
 
‘This is why the RACGP has recommended a staged rollout of any screening program.’
 
Meanwhile, should the NLCSP be implemented, Professor Morgan would also like to see an extension of Medicare-funded health assessments – currently for people aged over 75 – to younger patients for regular comprehensive preventive health checks.
 
He said such an extension would ensure all national screening programs and recommendations within the Red Book can be implemented using ‘a planned, proactive and team-based approach’.
 
In addition, Professor Morgan says the implementation of an NLCSP will lead to an increasing number of people undergoing cancer treatment, as well as cancer survivors who will need help.
 
‘We know how important it can be to support people in this situation,’ he said.
 
‘It will be important to build capacity to support survivors from all types of cancer.’
 
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cancer screening LDCT lung cancer overdiagnosis preventive health