Lung cancer screening

Lung cancer is the 3rd most common cancer diagnosed in the UK, accounting for approximately 13% of all new cancer cases annually. It is the second most common cancer in both males and females.  Incidence of lung cancer is strongly related to age, with over 4 in 10 (44%) of new cases of lung cancer diagnosed in people aged 75 and over. In North Tyneside, the prevalence of lung cancer is 177 per 100,000 people. Latest data suggests approximately 216 new cases are diagnosed each year in North Tyneside[ii].

Both modifiable and non-modifiable risk factors for lung cancer are well known. Smoking, exposure to radon gas, exposure to chemicals such as asbestos, silica or diesel engine exhaust fumes, air pollution, family history and age are all associated with an increased risk of lung cancer. In England, approximately 30% of lung cancer cases are diagnosed at an early stage (stage 1 & 2), with 70% of cases diagnosed at later stages (stage 3 & 4). As is the case with other cancers, early diagnosis results in better survival rates. 1 year survival rates for those diagnosed at Stage 1 are between 85-81%. In contrast, 1 year survival rates among individuals with stage 4 lung cancer at diagnosis is between 15-19%.

Until recently, there was no national screening programme for lung cancer. In December 2020, a Lung Cancer Case Finding pilot intervention was initiated in North Tyneside. Under this pilot scheme, people with a recorded history of COPD who were registered with GP practices in Wallsend and North Shields were invited for screening. Of 420 patients that accepted the offer of early screening, 18 cancers were found, of which 17 were in the early stages able to receive curative treatment.

In 2022, the UK National Screening Committee recommended that targeted lung cancer screening becomes available nationally[vii]. In 2023, the national Targeted Lung Health Check scheme was rolled out. Under this scheme, people aged 55 to 74 with a GP record including a history of smoking are invited for an initial assessment. During this assessment, a questionnaire is used to determine whether a person is at a high risk of lung cancer. If they are deemed to be at a high risk, they are offered a low dose CT scan of the lungs and smoking cessation advice where required.

Adapting a new National Screening Programme for Local Implementation

All National Screening Programmes are overseen by the National Screening Committee and commissioned through NHSE to ensure a universal offer to those eligible. In December 2020 North Tyneside began a pilot intervention of lung cancer case finding, focusing on targeting high risk individuals. Experience and learning from this pilot intervention as well as other cancer screening initiatives will help guide the roll out of the Lung Health Check Programme locally, with first scans expected in Spring of 2024.

Prioritising equality in screening uptake

Given the novelty of this screening programme, no data is currently available to describe patterns and discrepancies in screening uptake. However, based on our experience from other screening programmes such as breast and bowel screening, it is likely that inequalities in uptake will follow similar patterns. Experience from the pilot lung cancer case finding programme in Northumberland local authority highlighted that uptake was lowest in younger people, men and those living in the most deprived areas. This is in keeping with the UKHSA inequalities in screening report which highlights that individuals from socioeconomically deprived areas, people belonging to ethnic minorities and people with learning disabilities are less likely to take part in screening. Additionally, evidence from colon cancer screening nationally suggests that men are less likely than women to take up screening offers.

Increasing awareness of screening programme

The Lung Health Check Programme is a new screening programme and as such raising awareness is a key priority. Communications are being developed with local populations and tailored according to local needs. Information is available in a range of commonly spoken languages and appointments can be adapted according to participant’s needs. The Northern Cancer Alliance is disseminating a range of other promotional materials including posters, leaflets and videos.

Experience from the North Tyneside Lung Cancer Case Finding Pilot demonstrated that uptake improved after direct engagement with eligible patients via GP practices. However, given the novelty of the Lung Health Screening Programme, efforts will also need to be made to increase awareness among healthcare professionals to help improve screening uptake.

Prioritising accurate coding of smoking status

Invitations to participate in the Lung Health Check screening programme will be based on accurate coding of current or previous smoking status in individual’s GP records. It is therefore important to review the consistency of smoking status coding across GP practices to try ensure that this does not become a source of inequality in screening offers.

Removing barriers to screening

Known barriers to screening based on evidence from other screening programmes such as bowel and breast cancer screening include:

• Fear and denial around the test outcome
• A misconception that the test is not applicable if you don’t have any apparent symptoms
• Individual perceived risk being low or lack of consideration of future consequences
• Low health literacy and numeracy
• Gender – on the whole males are less likely to take up screening than females
• People from lower socioeconomic groups
• People from ethnic minority groups
• People with learning disability or severe mental illness
• Travel barrier associated with attending CT scan appointment

The Northern Cancer Alliance has begun work to address some of these barriers to screening. People living in the most socio-economically deprived areas will receive their invites first, with invites issued on a practice-by-practice basis. Participant information booklets have been translated into 11 languages and an easy read version has been created. Those who do not speak English as a first language will be able to arrange an appointment with an interpreter present, and individuals with a learning disability are able to have additional support such as bringing a friend or carer or have access to longer appointments.

Risk factors for lung cancer include:

• Smoking
• Air pollution
• Occupational exposure to chemicals
• Age
• Family history

Given this risk factor profile, it is estimated that up to 80% of all lung cancer cases are preventable. The National Lung Health Check Screening programme will only be available to those who are deemed to be at risk due to a history of smoking. However, we also know that people with the highest socio-economic deprivation are the most likely to develop lung cancer, and the least likely to survive. In England, the incidence of lung cancer is 174% higher in women and 168% higher in men in the most deprived quintile compared with the least. Additionally, when looking at other cancer screening programmes, we know that lower socio-economic status is associated with lower screening uptake. Therefore, those living in some of our more deprived communities are at higher risk of developing lung cancer, but also at a higher risk of not taking up screening offers.

The national goal for the Lung Health Check Programme is to reach 40% of the eligible population by 2025 and plans to reach 100% coverage by 2030. Based on the office for National Statistics, 12.9% of people in the UK smoke, this is slightly lower at approximately 11% in the age group eligible for screening. In North Tyneside, the estimated prevalence of smoking is 11.2%. If we assume that the prevalence of smokers in the eligible age group is slightly lower at 10%, then the number of people who would be eligible for screening based on current smoking status is at least 5,290. However, taking into account all individuals who have smoked at some point in their life, the maximum estimated number of people eligible for screening via the Lung Health Check Programme in North Tyneside could be as high as 21,691 people.

Given the recency of the National Lung Health Check scheme, there is a large unmet need, currently encompassing all individuals eligible for the screening programme. Based on national targets of reaching 40% of the eligible population, the medium-term unmet need across North Tyneside is likely to be in the range of 2116 to 8676 people by 2025. First scans are expected to be offered in Spring of 2024.

To guide future planning of services, Lung Health Check providers will collect data around engagement, to help understand why some people may not take up the offer of a Lung Health Check or decline a CT scan.

The number of new lung cancer cases on average each year is projected to rise from around 55,400 cases in 2023-2025 to around 66,200 cases in 2038-2040. However, overall the rates of new lung cancer diagnoses are projected to fall by 2% by 2040.  For females, lung cancer rates are projected to rise by 3% in this time period, while rates are project to fall by 7% in males. Historically, rates of lung cancer have been higher in males compared to females, but these are predicted to become similar by 2040. This is thought to be largely due to historical smoking patterns, with smoking rates among males reaching a peak earlier than in females [i].  

Predictions of smoking prevalence suggest that overall, smoking prevalence is projected to reduce to 6.0% by 2040 [ii]. Currently, the prevalence of smoking in North Tyneside is 11.2%, which is lower than the average across England at 12.7%.

As of February 2024 there were 1,991 people on the waiting list for a CT scan at Northumbria Healthcare NHS Foundation Trust. Current waiting lists should be considered in light of any new screening programmes which may increase demand.

As part of the National Lung Health Check Screening Programme, individuals will be offered referral to smoking cessation services where appropriate. The possibility of increased demand for our local smoking cessation services therefore needs to be taken into account.

The North Tyneside Cancer Prevention Network (CPN) brings together professional partners such as the ICB, PCN cancer leads and coordinators and voluntary and community organisations. Key stakeholders will include primary care networks, Healthwatch North Tyneside, LDNE, Coping with Cancer, patient engagement groups and VODA.

There are numerous cancer patient engagement and support groups/networks in North Tyneside. Some operate on regional footprints as well:

• Northern Cancer Voices
• North Tyneside CCG Cancer Plan Patient Engagement Task & Finish Group
• North of Tyne and Gateshead Patient and Professional Group
• North Tyneside CCG Patient Forum

The NHS Long Term Plan outlines the aim to save thousands of lives each year by improving how we diagnose and treat cancer, including extending screening services. The key ambitions as outlined by the NHS Long Term Plan are: by 2028, 55,000 more people each year will survive their cancer for five years or more, and 75% of people with cancer will be diagnosed at an early stage (stage one or two). By improving our rates of diagnosing lung cancer in the earlier stages, the screening programme will help achieve these national targets.

The Targeted Lung Health Checks are based on the findings of a recent study (NELSON Lung Cancer Trial) which showed that scanning people at higher risk of developing lung cancer reduced mortality from the diseases by 26% in men and between 39 – 61% in women. Locally, our Lung Cancer Case Finding Pilot demonstrated the feasibility and effectiveness of screening, with 420 patients that accepting the screening offer. Among these patients, 18 cancers were found, of which 17 were in the early stages able to receive curative treatment.

Although there is currently little data available to comment on variation in Lung Health Check uptake, experience from other cancer screening programmes can help guide best practice intervention to increase screening uptake. These include:

• Primary care pre-endorsement to tell patients that they are about to be invited for screening
• Primary care endorsement on invitation letter
• Timed appointments and reminders (instead of open invitations)
• Remind patients about appointment via text message
• Electronically informing GP Practices of DNAs
• Non attenders: Telephone for conversation about screening
• Non attenders: GP reminder letter (very large effects)
• Returning to fixed appointment letters

Extensive work has been previously undertaken in relation to general cancer risk factor awareness. The Cancer Awareness Measure (CAM) is a validated survey developed by Kings University, UCL and Cancer Research UK. The CAM was carried out in North Tyneside in winter 2021 with over 400 individuals surveyed, making up a representative sample of the borough population. While not specifically focused on lung cancer, the CAM covers awareness of signs and symptoms of cancer, factors affecting making an appointment, risk factors for cancers and awareness of the cancer screening programmes. This data showed that awareness was lowest amongst the routine manual and non-working population.

Based on evidence from other cancer screening programmes such as breast cancer screening and bowel cancer screening, it is likely that there will be differences in screening uptake between our most and least deprived communities. Given recent roll out of the national lung cancer screening programme, a future needs assessment outlining issues with or variations in uptake of the screening programme would be of benefit to guide future interventions.

Key contact:Chris Woodcock

Job Title: Deputy Director of Public Health

E-mail: Chris.Woodcock@northtyneside.gov.uk

Telephone: (0191) 643 2120