Lung cancer screening implementation: Complexities and priorities

Psychosocial impacts of, and barriers to, lung cancer screening: An international qualitative study of multidisciplinary health professionals' perspectives

OBJECTIVES

Many lung cancer screening (LCS) programs are in development following landmark trials demonstrating the effectiveness of screening for reducing lung cancer mortality. Psychosocial aspects are important considerations for LCS services, both for harms to participants and as barriers to appropriate uptake. This study investigated the psychosocial impacts and determinants of LCS for screening participants from the perspective of an international, multidisciplinary sample of healthcare professionals.

METHODS

Semi-structured interviews were conducted with health professionals involved in LCS delivery or design, or with LCS-eligible populations (including primary care practitioners, respiratory physicians, nurses, trial assistants/coordinators, and researchers). Participants were sampled to include perspectives across different countries, trials/programs, and policy landscapes. Data was analysed thematically.

RESULTS

Twenty-seven participants were interviewed. Most were from England (n = 11) and Australia (n = 10), with representation across seven established LCS trials/programs. Themes generated were: (a) anxiety and fear are central to screening experiences; (b) positive psychological responses to LCS are common; (c) ingrained lung cancer fatalism underpins anxiety; (d) smoking stigma is pervasive and interacts with LCS invitation; (e) influence of family and community; (f) issues specific to LCS-eligible populations; and (g) psychosocial impacts are diverse and moderated by certain factors. Themes each included psychosocial barriers to engagement (e.g., fear of cancer, nihilism, lack of social support). Key service design recommendations were developed from findings (e.g., public awareness campaigns to reduce fatalistic perceptions).

CONCLUSION

Psychosocial responses to LCS are diverse, complex and uniquely influenced by smoking-based eligibility criteria and lung cancer fatalism. Similarities in perspectives across an international sample of multidisciplinary healthcare professionals suggest the potential for best-practice guidelines for optimising psychosocial outcomes and determinants of LCS.

PRACTICE IMPLICATIONS

Findings include key recommendations to inform LCS practice and service design. Further research investigating and testing communication strategies targeting (a) stigma and fatalism, and (b) risk and ineligibility, is needed.

'Every Touch Point Is an Opportunity': Tobacco Control Experts' Views on How to Implement Smoking Cessation Interventions Within an Australian Lung Cancer Screening Program

BACKGROUND

Targeted lung cancer screening (LCS) presents unique opportunities for smoking cessation among high-risk individuals. Implementation requires consideration of context-specific determinants. We sought perspectives from tobacco control/smoking cessation experts on optimally implementing smoking cessation interventions in an Australian LCS program.

METHODS

Recruitment was via maximum variation and snowball sampling in 2022. Individual/pair interviews explored factors that may influence acceptability and feasibility, potential delivery models, and implementation strategies. We interpreted interview data using codebook thematic analysis, then mapped key topics against the Consolidated Framework for Implementation Research and previous LCS expert-identified determinants.

RESULTS

Expert participants' (N = 30) roles included program/policy managers, researchers and clinicians, working in academia, not-for-profits/peak bodies and health departments. They emphasised the benefits of integrating smoking cessation interventions into routine LCS encounters. Key barriers included perceived professional and LCS participant reluctance, stigma, and rural access. Experts discouraged duplicating current cessation resources, and suggested prioritising implementation efforts. Flexible delivery models, addressing needs of priority populations (e.g., rural/remote, culturally and linguistically diverse), were recommended. Experts generally favoured a 'hybrid' intervention pathway, combining internal and external cessation services, to maximise feasibility and uptake. Training program staff on cessation intervention delivery and leadership buy-in were emphasised as essential requirements.

DISCUSSION

In this Australian tobacco control expert sample, there was near-unanimous support for embedding cessation interventions within routine LCS delivery and capitalising on opportunities to overcome current service delivery barriers. In conjunction with LCS participant perspectives, findings are relevant to planning and implementing cessation interventions in LCS contexts.

Future risk projection to engage 'near-miss' individuals in lung cancer screening eligibility: an analysis of ILST data

INTRODUCTION

Lung cancer risk increases with time, and participants who are initially ineligible for lung cancer screening (LCS) could become eligible later. The aim of this study was to determine the proportion of people (initially ineligible) who may become eligible in a risk model-based LCS programme and the impact smoking cessation could have on this cohort.

METHODS

All potential participants for the International Lung Screening Trial aged 55-80 years, ineligible for Low-dose CT screening at baseline (PLCOm2012<1.5% 6-year risk), were included. Assuming annual increments of change in age, smoking duration and quit time, and under the assumption of other risk variables being constant, projections of risk were made using the PLCOm2012 model from evaluation to the upper age limit of 80 years.

RESULTS

4451 subjects with a median age of 61 (IQR: 57-66) years were included. Assuming no change in smoking status post evaluation, 2239 participants (50.3%) became eligible (PLCOm2012≥1.51%) by age 80, with 26.9% and 38.7% of the cohort reaching eligibility by age 70 and 75 years, respectively. Among participants with a baseline risk≥0.6%, 1518 (34.1%) reached eligibility within 10 years of initial evaluation. Smoking cessation after first evaluation can reduce the proportion of individuals who may become eligible for LCS by age 70 from 68.7% to 24.9%.

CONCLUSIONS

Future risk projection of eligibility could provide a time window for reassessment of risk on an individual level. It is important to provide smoking cessation services to individuals who are ineligible for LCS at the initial programme contact.

Racism, discrimination, medical mistrust, stigma, and lung cancer screening: a scoping review

OBJECTIVE

Lung cancer screening can reduce lung cancer-specific mortality, but it is widely underutilized, especially among minoritized populations that bear a disproportionate burden of lung cancer, such as Black Americans. Racism, discrimination, medical mistrust, and stigma contribute to lower uptake of preventive screenings in general, but the role these factors play in lung cancer screening is unclear. We therefore conducted a scoping review to synthesize the literature regarding how racism, discrimination, medical mistrust, and stigma relate to lung cancer screening.

DESIGN

Informed by PRISMA-ScR guidelines, we searched five databases for relevant literature, and two trained researchers independently reviewed articles for relevance. We conducted a narrative, descriptive analysis of included articles.

RESULTS

A total of 45 studies met our inclusion criteria. Most articles reported on medical mistrust or one of its cognates (e.g. trust and distrust, n = 37) and/or stigma (n = 25), with several articles focusing on multiple constructs. Few articles reported on racism (n = 3), and n = 1 article reported on discrimination. Results from empirical studies suggest that medical mistrust, distrust, and stigma may be barriers to lung cancer screening, whereas trust in health care providers may facilitate screening. The articles reporting on racism were commentaries calling attention to the impact of racism on lung cancer screening in Black populations.

CONCLUSIONS

Overall, novel interventions are needed to promote trust and reduce mistrust, distrust, and stigma in lung cancer screening initiatives. Dedicated efforts are especially needed to understand and address the roles that racism and discrimination may play in lung cancer screening.

Identifying the population to be targeted in a lung cancer screening programme in Denmark

INTRODUCTION

We assessed the impact of recruitment criteria on lung cancer detection in a future Danish screening programme with low-dose CT.

METHODS

We combined data from two Danish population-based health examination surveys with eligibility criteria from seven randomised controlled trials on lung cancer screening. Incident lung cancers were identified by linkage with the National Pathology Data Bank (Patobank). For an average of 4.4 years of follow-up, we calculated sensitivity, specificity, efficient frontier and number needed to screen (NNS) for lung cancer detection.

RESULTS

When applying the different eligibility criteria to the 48 171 persons invited to the two surveys, the number of lung cancer cases identified in the target groups varied from 46 to 68. The National Lung Screening Trial (NLST) criteria had the highest sensitivity of 62.6% (95% CI 52.7 to 71.8) and the Dutch-Belgian NEderlands-Leuvens Screening ONderzoek (NELSON) criteria had the highest specificity 81.6% (95% CI 81.0 to 82.1). Sensitivity was higher for men than for women (NLST criteria 71.7% (95% CI 57.7 to 83.2) and 53.7% (95% CI 39.6 to 67.4), respectively). The NLST criteria identified the target population obtaining the lowest NNS with 46.3. The application of the NLST criteria showed that the higher the sensitivity, the lower the number of false-negative cases and, thus, the lower the NNS.

CONCLUSIONS

This study highlights the impact of the definition of the at-risk population on lung cancer screening efficacy. We found lower sensitivity among women regardless of screening criteria used. This should be carefully addressed in a possible screening programme.

Software-assisted structured reporting and semi-automated TNM classification for NSCLC staging in a multicenter proof of concept study

OBJECTIVES

In this multi-center study, we proposed a structured reporting (SR) framework for non-small cell lung cancer (NSCLC) and developed a software-assisted tool to automatically translate image-based findings and annotations into TNM classifications. The aim of this study was to validate the software-assisted SR tool for NSCLC, assess its potential clinical impact in a proof-of-concept study, and evaluate current reporting standards in participating institutions.

METHODS

A framework for SR and staging of NSCLC was developed in a multi-center collaboration. SR annotations and descriptions were used to generate semi-automated TNM classification. The SR and TNM classification tools were evaluated by nine radiologists on n = 20 representative [18F]FDG PET/CT studies and compared to the free text reporting (FTR) strategy. Results were compared to a multidisciplinary team reference using a generalized linear mixed model (GLMM). Additionally, participants were surveyed on their experience with SR and TNM classification.

RESULTS

Overall, GLMM analysis revealed that readers using SR were 1.707 (CI: 1.137-2.585) times more likely to correctly classify TNM status compared to FTR strategy (p = 0.01) resulting in increased overall TNM correctness in 71.9% (128/178) of cases compared to 62.8% (113/180) FTR. The primary source of variation in classification accuracy was explained by case complexity. Participants rated the potential impact of SR and semi-automated TNM classification as positive across all categories with improved scores after template validation.

CONCLUSION

This multi-center study yielded an effective software-assisted SR framework for NSCLC. The SR and semi-automated classification tool improved TNM classification and were perceived as valuable.

CRITICAL RELEVANCE STATEMENT

Software-assisted SR provides robust input for semi-automated rule-based TNM classification in non-small-cell lung carcinoma (NSCLC), improves TNM correctness compared to FTR, and was perceived as valuable by radiology physicians.

KEY POINTS

SR and TNM classification are underutilized across participating centers for NSCLC staging. Software-assisted SR has emerged as a promising strategy for oncologic assessment. Software-assisted SR facilitates semi-automated TNM classification with improved staging accuracy compared to free-text reports in NSCLC.

Lung cancer screening - Time for an update?

Lung cancer screening can reduce the mortality of lung cancer, the leading cause of cancer death worldwide. Real world screening experience highlights areas for improvement in a complex and changing world, particularly ethnic disparity, and the potential for new and emerging risk factors, in addition to well known risk of smoking and asbestos exposure. Biomarkers offer the promise of objective risk assessment but are not yet ready for clinical practice. This review discusses some of the major issues faced by lung cancer screening and the potential role for biomarkers.

Empowering minoritized Alabamians screened for lung cancer-The Alabama Lung Cancer Awareness Screening and Education (ALCASE) project

BACKGROUND

In Alabama only 4% of those eligible have been screened for lung cancer. The ALCASE project focused on navigating eligible individuals to lung cancer screening.

METHODS

Trained local staff enrolled screen eligible individuals from seven rural counties and one urban county. Demographics and knowledge of and barriers to lung cancer screening were collected using questionnaires. Education was provided and individuals were navigated to undergo screening. Descriptive statistics for enrolled and screened participants were computed using SAS 9.4. Debriefing interviews were conducted with the ALCASE staff regarding facilitators/barriers to implementing this project and lessons learned. Using NVivo, themes were identified through a combined deductive and inductive process.

RESULTS

In total, 447 people were contacted of which 257 were enrolled. Participants were predominantly African American (86.8%), female (56.8%), and 86.4% had health insurance. Study participants acknowledged the need for more education of lung cancer/screening procedures; help navigating clinics for screening services and having healthcare facilities close to home. The top five barriers to getting screened were transportation, financial issues, emotional concerns, healthcare insurance, and COVID-19. Of the 257, 106 participants (41%) completed a primary care referral and were screened for lung cancer. Debriefing interviews revealed: (i) Overall impressions of implementing ALCASE were positive. (ii) Barriers in implementing ALCASE were identified predominantly at the physician and institutional level. (iii) Facilitators in implementing ALCASE were identified at multiple levels. (iv) Suggestions on improving lung cancer screening leaned toward mitigating barriers at the institutional and structural level.

CONCLUSION

Ability to get screened is severely challenged by both personal and structural barriers.

Enhancing Lung Cancer Care in Portugal: Bridging Gaps for Improved Patient Outcomes

Lung cancer has the highest incidence and cancer-related mortality worldwide. In Portugal, it ranks as the fourth most common cancer, with nearly 6000 new cases being diagnosed every year. Lung cancer is the main cause of cancer-related death among males and the third cause of cancer-related death in females. Despite the globally accepted guidelines and recommendations for what would be the ideal path for a lung cancer patient, several challenges occur in real clinical management across the world. The recommendations emphasize the importance of adequate screening of high-risk individuals, a precise tumour biopsy, and an accurate final diagnosis to confirm the neoplastic nature of the nodule. A detailed histological classification of the lung tumour type and a comprehensive molecular characterization are of utmost importance for the selection of an efficacious and patient-directed therapeutic approach. However, in the context of the Portuguese clinical organization and the national healthcare system, there are still several gaps in the ideal pathway for a lung cancer patient, involving aspects ranging from the absence of a national lung cancer screening programme through difficulties in histological diagnosis and molecular characterization to challenges in therapeutic approaches. In this manuscript, we address the most relevant weaknesses, presenting several proposals for potential solutions to improve the management of lung cancer patients, helping to decisively improve their overall survival and quality of life.

Implementation considerations for risk-tailored cancer screening in the population: A scoping review

BACKGROUND

Risk-tailored screening has emerged as a promising approach to optimise the balance of benefits and harms of existing population cancer screening programs. It tailors screening (e.g., eligibility, frequency, interval, test type) to individual risk rather than the current one-size-fits-all approach of most organised population screening programs. However, the implementation of risk-tailored cancer screening in the population is challenging as it requires a change of practice at multiple levels i.e., individual, provider, health system levels. This scoping review aims to synthesise current implementation considerations for risk-tailored cancer screening in the population, identifying barriers, facilitators, and associated implementation outcomes.

METHODS

Relevant studies were identified via database searches up to February 2023. Results were synthesised using Tierney et al. (2020) guidance for evidence synthesis of implementation outcomes and a multilevel framework.

RESULTS

Of 4138 titles identified, 74 studies met the inclusion criteria. Most studies in this review focused on the implementation outcomes of acceptability, feasibility, and appropriateness, reflecting the pre-implementation stage of most research to date. Only six studies included an implementation framework. The review identified consistent evidence that risk-tailored screening is largely acceptable across population groups, however reluctance to accept a reduction in screening frequency for low-risk informed by cultural norms, presents a major barrier. Limited studies were identified for cancer types other than breast cancer.

CONCLUSIONS

Implementation strategies will need to address alternate models of delivery, education of health professionals, communication with the public, screening options for people at low risk of cancer, and inequity in outcomes across cancer types.

AI co-pilot bronchoscope robot

The unequal distribution of medical resources and scarcity of experienced practitioners confine access to bronchoscopy primarily to well-equipped hospitals in developed regions, contributing to the unavailability of bronchoscopic services in underdeveloped areas. Here, we present an artificial intelligence (AI) co-pilot bronchoscope robot that empowers novice doctors to conduct lung examinations as safely and adeptly as experienced colleagues. The system features a user-friendly, plug-and-play catheter, devised for robot-assisted steering, facilitating access to bronchi beyond the fifth generation in average adult patients. Drawing upon historical bronchoscopic videos and expert imitation, our AI-human shared control algorithm enables novice doctors to achieve safe steering in the lung, mitigating misoperations. Both in vitro and in vivo results underscore that our system equips novice doctors with the skills to perform lung examinations as expertly as seasoned practitioners. This study offers innovative strategies to address the pressing issue of medical resource disparities through AI assistance.

Co-designing a recruitment strategy for lung cancer screening in high-risk individuals: protocol for a mixed-methods study

Background

Lung cancer is a significant cause of cancer-related mortality globally, with early detection through screening critical to improving patient outcomes. However, recruiting high-risk individuals, particularly in deprived populations, for screening remains a considerable challenge. This study aims to co-design a targeted recruitment strategy for lung cancer screening, tailored to the specific needs and experiences of high-risk individuals, in collaboration with a Patient and Public Involvement (PPI) panel and expert stakeholders in Ireland.

Methods

We will employ a mixed-methods design guided by the Medical Research Council (MRC) framework for developing complex interventions. Our approach will integrate systematic review findings on screening participation interventions, evaluation of the recruitment strategy's feasibility in an Irish context, and the application of behavioural science frameworks. The target population includes individuals over 55 years, either current smokers or those who quit within the last year, who reside in highly deprived areas.

Conclusion

This co-designed recruitment strategy will combine evidence-based research, local context understanding, and stakeholder input to develop a solution that is both scientifically robust and tailored to the target population's needs. This patient-centred approach aims to increase the potential for successful implementation of lung cancer screening programs, thereby improving early detection and patient outcomes.

The roles of FHL2 in cancer

LIM domain protein 2, also known as LIM protein FHL2, is a member of the LIM-only family. Due to its LIM domain protein characteristics, FHL2 is capable of interacting with various proteins and plays a crucial role in regulating gene expression, cell growth, and signal transduction in muscle and cardiac tissue. In recent years, mounting evidence has indicated that the FHLs protein family is closely associated with the development and occurrence of human tumors. On the one hand, FHL2 acts as a tumor suppressor by down-regulating in tumor tissue and effectively inhibiting tumor development by limiting cell proliferation. On the other hand, FHL2 serves as an oncoprotein by up-regulating in tumor tissue and binding to multiple transcription factors to suppress cell apoptosis, stimulate cell proliferation and migration, and promote tumor progression. Therefore, FHL2 is considered a double-edged sword in tumors with independent and complex functions. This article reviews the role of FHL2 in tumor occurrence and development, discusses FHL2 interaction with other proteins and transcription factors, and its involvement in multiple cell signaling pathways. Finally, the clinical significance of FHL2 as a potential target in tumor therapy is examined.

Addressing Inequity in Spatial Access to Lung Cancer Screening

BACKGROUND

The successful implementation of an equitable lung cancer screening program requires consideration of factors that influence accessibility to screening services.

METHODS

Using lung cancer cases in British Columbia (BC), Canada, as a proxy for a screen-eligible population, spatial access to 36 screening sites was examined using geospatial mapping and vehicle travel time from residential postal code at diagnosis to the nearest site. The impact of urbanization and Statistics Canada's Canadian Index of Multiple Deprivation were examined.

RESULTS

Median travel time to the nearest screening site was 11.7 min (interquartile range 6.2-23.2 min). Urbanization was significantly associated with shorter drive time (p < 0.001). Ninety-nine percent of patients with ≥60 min drive times lived in rural areas. Drive times were associated with sex, ethnocultural composition, situational vulnerability, economic dependency, and residential instability. For example, the percentage of cases with drive times ≥60 min among the least deprived situational vulnerability group was 4.7% versus 44.4% in the most deprived group.

CONCLUSIONS

Populations at risk in rural and remote regions may face more challenges accessing screening services due to increased travel times. Drive times increased with increasing sociodemographic and economic deprivations highlighting groups that may require support to ensure equitable access to lung cancer screening.

National lung cancer screening program feasibility study in Estonia

OBJECTIVES

The main aim of the lung cancer screening (LCS) feasibility study was to investigate the plausibility of and bottlenecks to systematic enrolment in family physician practices by evaluating all their patients.

METHODS

In 3 family physician practices, for each individual born in 1947-1966 (target age group 55-74 years), information on ever smoking was gathered by a family physician/nurse. All current and ex-smokers were invited to an 'LCS visit'. In parallel, 2 inclusion criteria were used: (1) current smoker (≥20 pack-years) or ex-smoker (quit <15 years ago and smoking history ≥20 pack-years) and (2) PLCOm2012noRace risk score >1.5. All individuals with elevated lung cancer risk were assigned low-dose computed tomography.

RESULTS

Among the total 7035 individuals in the 3 family physician practices, the LCS target age group comprised 1208 individuals, including 649 (46.3-57.1%) males and 559 (42.9-53.7%) females. Of the 1208 applicable age group individuals, 395 (all current or ex-smokers) were invited to the 'LCS visit'. According to either 1 or both the LCS inclusion criteria, 206 individuals were referred to low-dose computed tomography, and 201 (97.6% of those referred) ended up taking it. The estimated participation rate in LCS, based on data from our feasibility study, would have been 87.4%.

CONCLUSIONS

In LCS, systematic enrolment of individuals by family physicians results in high uptake, and thus, effectiveness of the LCS in the setting of a well-functioning family physician system like in Estonia. Also, the feasibility study provided excellent input to the currently ongoing regional LCS pilot study in Estonia.

Developing a pan-European technical standard for a comprehensive high-quality lung cancer computed tomography screening programme: an ERS technical standard

BACKGROUND

Screening for lung cancer with low radiation dose computed tomography (LDCT) has a strong evidence base. The European Council adopted a recommendation in November 2022 that lung cancer screening (LCS) be implemented using a stepwise approach. The imperative now is to ensure that implementation follows an evidence-based process that delivers clinical and cost-effectiveness. This European Respiratory Society (ERS) Task Force was formed to provide a technical standard for a high-quality LCS programme.

METHOD

A collaborative group was convened to include members of multiple European societies. Topics were identified during a scoping review and a systematic review of the literature was conducted. Full text was provided to members of the group for each topic. The final document was approved by all members and the ERS Scientific Advisory Committee.

RESULTS

Topics were identified representing key components of a screening programme. The actions on findings from the LDCT were not included as they are addressed by separate international guidelines (nodule management and clinical management of lung cancer) and by a linked ERS Task Force (incidental findings). Other than smoking cessation, other interventions that are not part of the core screening process were not included (e.g. pulmonary function measurement). 56 statements were produced and areas for further research identified.

CONCLUSIONS

This European collaborative group has produced a technical standard that is a timely contribution to implementation of LCS. It will serve as a standard that can be used, as recommended by the European Council, to ensure a high-quality and effective programme.

Pulmonary Nodules, Lung Cancer Screening, and Lung Cancer in the Medicare Population

BACKGROUND

Early detection of lung cancer through management of pulmonary nodules (PNs) may reduce lung cancer mortality. We assessed the relationship between PNs and lung cancer.

RESEARCH QUESTION

How common are PNs in the Medicare population? What is the rate of lung cancer after detection of PNs? What is the relative proportion of early-stage lung cancer diagnosed after reporting of PNs vs through low-dose CT (LDCT) scan screening?

STUDY DESIGN AND METHODS

Using the Surveillance Epidemiology and End Results Program-Medicare database, we defined two cohorts: those in the 5% sample with ≥ 12 months of Medicare Parts A and B coverage from 2014 through 2019 (5% sample cohort) and those with a diagnosis of lung cancer from 2015 through 2017 with coverage for the prior 18-month period (lung cancer cohort). We defined PNs as chest CT scans with accompanying codes of 793.11 (International Classification of Diseases [ICD], Ninth Revision) or R91.1 (ICD, Tenth Revision) denoting a solitary PN. Patients in the lung cancer cohort were classified by whether they had undergone LDCT scan screening and whether they had a diagnosis of PN or neither (reference) within 18 months before diagnosis. We compared cancer stage and survival across groups.

RESULTS

Of 627,547 patients in the 5% sample cohort, 5.0% demonstrated PNs over median of 5.0 years of follow-up. Cumulative 1- and 2-year lung cancer rates after initial PN diagnosis were 3.2% and 4.7%, respectively. Of 44,194 patients in the lung cancer cohort, 15.7%, 2.9%, and 81.4% were in the PN, LDCT scan, and reference groups, respectively. Of patients in the PN, LDCT scan, and reference groups, 58.1%, 50.3%, and 24.4% respectively, had disease of a localized stage. Among all patients with localized disease, 30.0% and 4.9% were in the PN and LDCT scan and groups, respectively. Three-year lung cancer-specific survival rates were 75.0%, 75.6%, and 49.4% for the PN, LDCT scan, and reference groups.

INTERPRETATION

Patients with lung cancer who received a diagnosis after identification of PNs tended to have localized disease. Of all patients with localized disease, almost one-third had PNs that were diagnosed previously, compared with 5% of patients who had undergone LDCT scan screening. PNs represent a relatively common presentation of potentially curable lung cancer.

Education messages and strategies to inform the public, potential screening candidates and healthcare providers about lung cancer screening: A systematic review

International lung cancer screening (LCS) trials, using low-dose computed tomography, have demonstrated clinical effectiveness in reducing mortality from lung cancer. This systematic review aims to synthesise the key messages and strategies that could be successful in increasing awareness and knowledge of LCS, and ultimately increase uptake of screening. Studies were identified via relevant database searches up to January 2022. Two authors evaluated eligible studies, extracted and crosschecked data, and assessed quality. Results were synthesised narratively. Of 3205 titles identified, 116 full text articles were reviewed and 22 studies met the inclusion criteria. Twenty studies were conducted in the United States. While the study findings were heterogenous, key messages mentioned across multiple studies were about: provision of information on LCS and the recommendations for LCS (n = 8); benefits and harms of LCS (n = 6); cost of LCS and insurance coverage for participants (n = 6) and eligibility criteria (n = 5). To increase knowledge and awareness, evidence from awareness campaigns suggests that presenting information about eligibility and the benefits and harms of screening, may increase screening intention and uptake. Evidence from behavioural studies suggests that campaigns supporting engagement with platforms such as educational videos and digital awareness campaigns might be most effective. Group based learning appears to be most suited to increasing health professionals' knowledge. This systematic review found a lack of consistent evidence to demonstrate which strategies are most effective for increasing participant healthcare professional and community awareness and education about LCS.

Effective voltammetric tool for simultaneous detection of MMP-1, MMP-2, and MMP-9; important non-small cell lung cancer biomarkers

Simultaneous detection of multiple biomarkers can allow to reduce the costs of medical diagnostics, and thus improve the accuracy and effectiveness of disease diagnosis and prognosis. Here, for the first time, we present a low-cost, simple, and rapid method for simultaneous detection of three matrix metalloproteinases (MMP-1, MMP-2, and MMP-9) that play important roles in the progression of lung cancer. The sensor matrix was constructed using a G2 polyamidoamine dendrimer (PAMAM) containing amino, carboxyl, and sulfhydryl groups. The recognition process was based on specific enzymatic cleavage of the Gly-Ile peptide bond by MMP-1, Gly-Leu bond by MMP-2, and Gly-Met bond by MMP-9, and monitoring was done by square wave voltammetry. The activity of metalloproteinases was detected based on the change of current signals of redox receptors (dipeptides labeled with electroactive compounds) covalently anchored onto the electrode surface. The conditions of the biosensor construction, including the concentration of receptors on the sensor surface and the time of interaction of the receptor with the analyte, were carefully optimized. Under optimal conditions, the linear response of the developed method ranged from 1.0⋅10^-8 to 1.0 mg⋅L^-1, and the limit of detection for MMP-1, MMP-2, and MMP-9 was 0.35, 0.62, and 1.10 fg⋅mL^-1, respectively. The constructed biosensor enabled us to efficiently profile the levels of active forms of MMP-1, MMP-2, and MMP-9 in tissue samples (plasma and lung and tumor extracts). Thus, the developed biosensor can aid in the early detection and diagnosis of lung cancer.

Updated cost-effectiveness analysis of lung cancer screening for Australia, capturing differences in the health economic impact of NELSON and NLST outcomes

BACKGROUND

A national, lung cancer screening programme is under consideration in Australia, and we assessed cost-effectiveness using updated data and assumptions.

METHODS

We estimated the cost-effectiveness of lung screening by applying screening parameters and outcomes from either the National Lung Screening Trial (NLST) or the NEderlands-Leuvens Longkanker Screenings ONderzoek (NELSON) to Australian data on lung cancer risk, mortality, health-system costs, and smoking trends using a deterministic, multi-cohort model. Incremental cost-effectiveness ratios (ICERs) were calculated for a lifetime horizon.

RESULTS

The ICER for lung screening compared to usual care in the NELSON-based scenario was AU$39,250 (95% CI $18,150-108,300) per quality-adjusted life year (QALY); lower than the NLST-based estimate (ICER = $76,300, 95% CI $41,750-236,500). In probabilistic sensitivity analyses, lung screening was cost-effective in 15%/60% of NELSON-like simulations, assuming a willingness-to-pay threshold of $30,000/$50,000 per QALY, respectively, compared to 0.5%/6.7% for the NLST. ICERs were most sensitive to assumptions regarding the screening-related lung cancer mortality benefit and duration of benefit over time. The cost of screening had a larger impact on ICERs than the cost of treatment, even after quadrupling the 2006-2016 healthcare costs of stage IV lung cancer.

DISCUSSION

Lung screening could be cost-effective in Australia, contingent on translating trial-like lung cancer mortality benefits to the clinic.

Real-World Patterns and Decision Drivers of Radiotherapy for Lung Cancer Patients in Romania: RADIO-NET Study Results

Radiotherapy (RT) plays a crucial role in all stages of lung cancer. Data on recent real-world RT patterns and main drivers of RT decisions in lung cancer in Romania is scarce; we aimed to address these knowledge gaps through this physician-led medical chart review in 16 RT centers across the country. Consecutive patients with lung cancer receiving RT as part of their disease management between May-October 2019 (pre-COVID-19 pandemic) were included. Descriptive statistics were generated for all variables. This cohort included 422 patients: median age 63 years, males 76%, stages I-II 6%, III 43%, IV 50%, mostly adeno- and squamous cell carcinoma (76%), ECOG 0-1 50% at the time of RT. Curative intent RT was used in 36% of cases, palliative RT in 64%. Delays were reported in 13% of patients, mostly due to machine breakdown (67%). Most acute reported RT toxicity was esophagitis (19%). Multiple disease-, patient-, physician- and context-related drivers counted in the decision-making process. This is the first detailed analysis of RT use in lung cancer in Romania. Palliative RT still dominates the landscape. Earlier diagnosis, coordinated multidisciplinary strategies, and the true impact of the multimodal treatments on survival are strongly needed to improve lung cancer outcomes.

Optimizing the implementation of lung cancer screening in Scotland: Focus group participant perspectives in the LUNGSCOT study

INTRODUCTION

Targeted lung cancer screening is effective in reducing lung cancer and all-cause mortality according to major trials in the United Kingdom and Europe. However, the best ways of implementing screening in local communities requires an understanding of the population the programme will serve. We undertook a study to explore the views of those potentially eligible for, and to identify potential barriers and facilitators to taking part in, lung screening, to inform the development of a feasibility study.

METHODS

Men and women aged 45-70, living in urban and rural Scotland, and either self-reported people who smoke or who recently quit, were invited to take part in the study via research agency Taylor McKenzie. Eleven men and 14 women took part in three virtual focus groups exploring their views on lung screening. Focus group transcripts were transcribed and analysed using thematic analysis, assisted by QSR NVivo.

FINDINGS

Three overarching themes were identified: (1) Knowledge, awareness and acceptability of lung screening, (2) Barriers and facilitators to screening and (3) Promoting screening and implementation ideas. Participants were largely supportive of lung screening in principle and described the importance of the early detection of cancer. Emotional and psychological concerns as well as system-level and practical issues were discussed as posing barriers and facilitators to lung screening.

CONCLUSIONS

Understanding the views of people potentially eligible for a lung health check can usefully inform the development of a further study to test the feasibility and acceptability of lung screening in Scotland.

PATIENT OR PUBLIC CONTRIBUTION

The LUNGSCOT study has convened a patient advisory group to advise on all aspects of study development and implementation. Patient representatives commented on the focus group study design, study materials and ethics application, and two representatives read the focus group transcripts.

Lung Cancer Screening in Greece: A Modelling Study to Estimate the Impact on Lung Cancer Life Years

(1) Background: Lung cancer causes a substantial epidemiological burden in Greece. Yet, no formal national lung cancer screening program has been introduced to date. This study modeled the impact on lung cancer life years (LCLY) of a hypothetical scenario of comprehensive screening for lung cancer with low-dose computed tomography (LDCT) of the high-risk population in Greece, as defined by the US Preventive Services Taskforce, would be screened and linked to care (SLTC) for lung cancer versus the current scenario of background (opportunistic) screening only; (2) Methods: A stochastic model was built to monitor a hypothetical cohort of 100,000 high-risk men and women as they transitioned between health states (without cancer, with cancer, alive, dead) over 5 years. Transition probabilities were based on clinical expert opinion. Cancer cases, cancer-related deaths, and LCLYs lost were modeled in current and hypothetical scenarios. The difference in outcomes between the two scenarios was calculated. 150 iterations of simulation scenarios were conducted for 100,000 persons; (3) Results: Increasing SLTC to a hypothetical 100% of eligible high-risk people in Greece leads to a statistically significant reduction in deaths and in total years lost due to lung cancer, when compared with the current SLTC paradigm. Over 5 years, the model predicted a difference of 339 deaths and 944 lost years between the hypothetical and current scenario. More specifically, the hypothetical scenario led to fewer deaths (−24.56%, p < 0.001) and fewer life years lost (−31.01%, p < 0.001). It also led to a shift to lower-stage cancers at the time of diagnosis; (4) Conclusions: Our study suggests that applying a 100% screening strategy amongst high-risk adults aged 50−80, would result in additional averted deaths and LCLYs gained over 5 years in Greece.

Emotions and lung cancer screening: Prioritising a humanistic approach to care

Low-dose computed tomography lung cancer screening has mortality benefits. Yet, uptake has been low. To inform strategies to better deliver and promote screening, in 2018, we interviewed 27 long-term smokers immediately following lung cancer screening in Australia, prior to receiving scan results. Existing lung screening studies employ the Health Belief Model. Reflecting growing acknowledgement of the centrality of emotions to screening uptake, we draw on psychological and sociological theories on emotions to thematically and abductively analyse the emotional dimensions of lung cancer screening, with implications for screening promotion and delivery. As smokers, interviewees described feeling stigmatised, with female participants internalising and male participants resisting stigma. Guilt and fear related to lung cancer were described as screening motivators. The screening itself elicited mild positive emotions. Notably, interviewees expressed gratitude for the care implicitly shown through lung screening to smokers. More than individual risk assessment, findings suggest lung screening campaigns should prioritise emotions. Peer workers have been found to increase cancer screening uptake in marginalised communities, however the risk to confidentiality-especially for female smokers-limits its feasibility in lung cancer screening. Instead, we suggest involving peer consultants in developing targeted screening strategies that foreground emotions. Furthermore, findings suggest prioritising humanistic care in lung screening delivery. Such an approach may be especially important for smokers from low socioeconomic backgrounds, who perceive lung cancer screening and smoking as sources of stigma and face a higher risk of dying from lung cancer and lower engagement with screening.

High FHL2 mRNA expression and its prognostic value in lung cancer

BACKGROUND

Lung cancer is the most frequent cancer globally with a high number of cancer-related deaths. The 4-and-a-half LIM domain protein 2 (FHL2) is an oncogenic gene, which promotes the proliferation, invasion, and metastasis of cancer cells. In this study, we aimed to demonstrate that lung cancer patients with high FHL2 expression have worse overall survival (OS) and relapse-free survival (RFS).

METHODS

TCGA was used to study FHL2 mRNA expression. Nomograms were used to predict the relationship between FHL2 expression levels and survival. The qRT-PCR was used to detect the FHL2 expression in lung cancer cells. In vitro experiments including CCK-8 assay, wound healing, and Transwell assay were performed.

RESULTS

This study comprised RNA-Seq gene expression data and clinical features for 1018 lung cancer patients. FHL2 was found to be overexpressed in lung cancer tissues. FHL2 demonstrated moderate diagnostic ability for lung cancer (AUC = 0.857). Kaplan-Meier curves and Cox regression analysis revealed the higher FHL2 expression with the poorer OS and RFS (P < 0.001). The nomogram results indicated that FHL2 could be used to predict the survival of lung cancer patients. GSEA analysis results show that high expression of FHL2 is related to glycolysis and unfolded protein reflection. FHL2 was highly expressed in lung cancer cells and related to their proliferation, migration, and invasion ability.

CONCLUSIONS

The high expression level of FHL2 in lung cancer can be used as an independent predictor of prognosis in clinical practice.

Motivation is not enough: A qualitative study of lung cancer screening uptake in Australia to inform future implementation

Introduction

Participation in lung cancer screening (LCS) trials and real-world programs is low, with many people at high-risk for lung cancer opting out of baseline screening after registering interest. We aimed to identify the potential drivers of participation in LCS in the Australian setting, to inform future implementation.

Methods

Semi-structured telephone interviews were conducted with individuals at high-risk of lung cancer who were eligible for screening and who had either participated (‘screeners’) or declined to participate (‘decliners’) in the International Lung Screening Trial from two Australian sites. Interview guide development was informed by the Precaution Adoption Process Model. Interviews were audio-recorded, transcribed and analysed using the COM-B model of behaviour to explore capability, opportunity and motivation related to screening behaviour.

Results

Thirty-nine participants were interviewed (25 screeners; 14 decliners). Motivation to participate in screening was high in both groups driven by the lived experience of lung cancer and a belief that screening is valuable, however decliners unlike their screening counterparts reported low self-efficacy. Decliners in our study reported challenges in capability including ability to attend and in knowledge and understanding. Decliners also reported challenges related to physical and social opportunity, in particular location as a barrier and lack of family support to attend screening.

Conclusion

Our findings suggest that motivation alone may not be sufficient to change behaviour related to screening participation, unless capability and opportunity are also considered. Focusing strategies on barriers related to capability and opportunity such as online/telephone support, mobile screening programs and financial assistance for screeners may better enhance screening participation. Providing funding for clinicians to support individuals in decision-making and belief in self-efficacy may foster motivation. Targeting interventions that connect eligible individuals with the LCS program will be crucial for successful implementation.

Use and Outcomes of Low-Dose CT Scan Lung Cancer Screening in the Medicare Population

BACKGROUND

Relatively little is known about various aspects of low-dose CT (LDCT) scan lung cancer screening in US clinical practice, including characteristics of cases diagnosed after screening. We assessed this using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

RESEARCH QUESTION

What were the characteristics of patients with lung cancer, including stage and survival, whose disease was diagnosed after LDCT scan screenings?

STUDY DESIGN AND METHODS

We created an LDCT scan use cohort consisting of everyone in the 5% SEER-Medicare sample with ≥ 12 months of non-health maintenance organization (HMO) Part A and B coverage while 65 to 77 years of age from 2015 through 2019. LDCT scan use and lung cancer diagnosis rates were assessed in this cohort. Additionally, we created a lung cancer cohort consisting of patients who received a diagnosis between 2015 and 2017 at 65 to 78 years of age with complete (non-HMO Part A and B) coverage the year before diagnosis. The cases cohort comprised those screened or unscreened based on undergoing screening during that period; lung cancer characteristics and survival were compared between these groups.

RESULTS

In the LDCT scan use cohort (n = 414,358), use rates increased from 0.10 (per 100 person-years) in 2015 to 1.3 in 2019. Among those with first screenings, 39.2% underwent a subsequent screen within 18 months. The 1-year cumulative lung cancer diagnosis rate after initial screenings was 2.4%. Claims for prescreen counseling were infrequent (about 10%). Of 48,891 patients in the lung cancer cohort, 1,150 (2.4%) underwent screening. Among screened patients, 52.3%, 11.0%, 20.7%, and 16.0% received diagnoses of stages I, II, III, and IV disease, respectively. Lung cancer-specific survival through 3 years was significantly greater in screened versus unscreened patients overall and for all stages except stage II; 3-year lung cancer-specific survival was 89.0% in screened patients with stage I disease.

INTERPRETATION

LDCT scan use was low but increased over time. The lung cancer yield was substantial; cases among those who underwent screening primarily were in the early stage with high survival rates. Although screening rates were unacceptably low, screening outcomes in those Medicare recipients undergoing screening were favorable.

Hsa_circ_0006692 Promotes Lung Cancer Progression via miR-205-5p/CDK19 Axis

Circular RNA (CircRNA) is related to tumor development. Nevertheless, the regulation and function of hsa_circ_0006692 and its interactions with miR-205-5p and CDK19 in the development of non-small-cell lung cancer (NSCLC) were un-explored. The correlations of expression levels of hsa_circ_0006692 in NSCLC specimens and cells with pathological characteristics were studied. The interactions of hsa_circ_0006692 with miR-205-5p and CDK19 were assessed with real-time PCR, RNA-binding protein immunoprecipitation (RIP), luciferase reporter, RNA pull-down, and fluorescence in situ hybridization (FISH). The roles of hsa_circ_0006692 on cell growth, invasion, and migration in vitro and metastasis in vivo were evaluated. Hsa_circ_0006692 was over-expressed in 60 cases of NSCLC specimens and cells, which was positively correlated with TNM stage, tumor size, and invasion of the lung basal layer. The results of the in vitro and in vivo studies revealed that the over-expression of hsa_circ_0006692 facilitated NSCLC cell growth, migration, and invasion, cell cycle arrest at the S phase, and the activation of BCL-2, CCND1, and PCNA. The results of the dual-luciferase reporter assay, RNA immunoprecipitation, and pull-down assays indicated that hsa_circ_0006692 sponged miR-205-5p, which targeted CDK19 and facilitated the malignant behaviors of lung cancer cells. Hsa_circ_0006692 modulated EMT of lung cancer cells via the stimulation of CDH1, CDH2, VIMENTIN, and MMP7. This study revealed that hsa_circ_0006692 promoted NSCLC progression via enhancing cell growth, invasion, and metastasis through sponging mir-205-5p, up-regulating the downstream oncogene CDK19 and modulating EMT of lung cancer cells. The circ-0006692/mir-205-5p/CDK19 axis might serve as a prognosis biomarker and target for drugs aimed against NSCLC.

Earlier diagnosis of lung cancer

The purpose of this article is to review options for more rapid diagnosis of lung cancer at an earlier stage, thereby improving survival. These options include screening, allowing general practitioners to refer patients directly to low-dose computed tomography scan instead of a chest X-ray and the abolition of the "visitation filter", i.e. hospital doctors' ability to reject referrals from general practitioners without prior discussion with the referring doctor.

Implementing lung cancer screening in Europe: taking a systems approach

Lung cancer is the leading cause of cancer death in Europe. Screening by means of low-dose computed tomography (LDCT) can shift detection to an earlier stage and reduce lung cancer mortality in high-risk individuals. However, to date, Poland, Croatia, Italy, and Romania are the only European countries to commit to large-scale implementation of targeted LDCT screening. Using a health systems approach, this article evaluates key factors needed to enable the successful implementation of screening programs across Europe. Recent literature on LDCT screening was reviewed for 10 countries (Belgium, Croatia, France, Germany, Italy, the Netherlands, Poland, Spain, Sweden, and United Kingdom) and complemented by 17 semistructured interviews with local experts. Research findings were mapped against a health systems framework adapted for lung cancer screening. The European policy landscape is highly variable, but potential barriers to implementation are similar across countries and consistent with those reported for other cancer screening programs. While consistent quality and safety of screening must be ensured across all screening centers, system factors are also important. These include appropriate data infrastructure, targeted recruitment methods that ensure equity in participation, sufficient capacity and workforce training, full integration of screening with multidisciplinary care pathways, and smoking cessation programs. Stigma and underlying perceptions of lung cancer as a self-inflicted condition are also important considerations. Building on decades of implementation research, governments now have a unique opportunity to establish effective, efficient, and equitable lung cancer screening programs adapted to their health systems, curbing the impact of lung cancer on their populations.

Using Electronic Medical Records to Identify Potentially Eligible Study Subjects for Lung Cancer Screening with Biomarkers

Lung cancer screening trials using low-dose computed tomography (LDCT) show reduced late-stage diagnosis and mortality rates. These trials have identified high-risk groups that would benefit from screening. However, these sub-populations can be difficult to access and retain in trials. Implementation of national screening programmes further suggests that there is poor uptake in eligible populations. A new approach to participant selection may be more effective. Electronic medical records (EMRs) are a viable alternative to population-based or health registries, as they contain detailed clinical and demographic information. Trials have identified that e-screening using EMRs has improved trial retention and eligible subject identification. As such, this paper argues for greater use of EMRs in trial recruitment and screening programmes. Moreover, this opinion paper explores the current issues in and approaches to lung cancer screening, whether records can be used to identify eligible subjects for screening and the challenges that researchers face when using EMR data.

CKAP4 Antibody-Conjugated Si Quantum Dot Micelles for Targeted Imaging of Lung Cancer

At present, various fluorescent nanomaterials have been designed and synthesized as optical contrast agents for surgical navigation. However, there have been no reports on the preparation of fluorescent contrast agents for lung cancer surgery navigation using silicon quantum dots (Si QDs). This study improved and modified the water-dispersible Si QD micelles reported by Pi et al. to prepare Si QD micelles-CKAP4. The data showed that the Si QD micelles-CKAP4 were spherical particles with a mean hydrodiameter of approximately 78.8 nm. UV-visible absorption of the Si QD micelles-CKAP4 ranged from 200 to 500 nm. With an excitation wavelength of 330 nm, strong fluorescence at 640 nm was observed in the fluorescence emission spectra. Laser confocal microscopy and fluorescence microscopy assay showed that the Si QD micelles-CKAP4 exhibited good targeting ability to lung cancer cells and lung cancer tissues in vitro. The in vivo fluorescence-imaging assay showed that the Si QD micelles-CKAP4 was metabolized by the liver and excreted by the kidney. In addition, Si QD micelles-CKAP4 specifically targeted lung cancer tissue in vivo compared with healthy lung tissue. Cytotoxicity and hematoxylin and eosin staining assays showed that the Si QD micelles-CKAP4 exhibited high biosafety in vitro and in vivo. Si QD micelles-CKAP4 is a specifically targeted imaging agent for lung cancer and is expected to be a fluorescent contrast agent for lung cancer surgical navigation in the future.