The time is ripe for lung cancer screening. This is supported by the most up-to-date scientific evidence, the same on which the European Union will issue a directive in the coming months to recommend the launch of dedicated programs. “Not a mere bureaucratic act”, he specifies to Salute Giorgio Vittorio Scagliotti, Director of the Division of Medical Oncology of the University of Turin. “National health systems will be called upon to actively participate in the launch of lung cancer screening programs in populations at risk”.
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Lung cancer
In Italy, over 49,000 cases of lung cancer are diagnosed every year. More than half of the patients at the time of diagnosis are metastatic, a stage in which there is no other therapeutic path than the systemic one and in which the mortality in the first year is between 70 and 80%. Lowering these numbers is possible, indeed it must. With primary prevention, of course, that is, with programs to raise awareness especially among the younger sections of the population on the dangers of smoking, one of the main causes of lung cancer. But today – finally – we can also speak concretely about early diagnosis.
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Breaking down mortality with screening
“It took a few years for the data to mature”, explains Giorgio Scagliotti. “But now we have the results of three important randomized studies that show how, through the use of a low-dose spiral CT scan, it is possible to reduce mortality by about 20% five years after diagnosis of lung cancer in a high-risk population “. A real annual screening for heavy smokers, i.e. people between 55 and 80 who smoke more than one pack of cigarettes a day or who have quit for less than 15 years. “In the trials, during 3-5 years of screening, lung cancers were identified in about 1% of the population, but most of the cancers detected were still in an early stage, when intervening means having between 70 and 78% probability of being alive five years after diagnosis “. The European recommendation should be the beginning of a new phase in the fight against lung cancer, one in which discretion is abandoned, in which everything was left to the initiative and goodwill of the individual investigator, in favor of the definition of programs. structured screening, such as for breast, prostate, cervical and colorectal cancer.
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Sustainable screening
The benefits of screening on the health plan of citizens at risk are undeniable. Arriving at the diagnosis when the tumor is still in stage 1-2 allows excellent results to be achieved in terms of both patient survival and indirect parameters such as the person’s ability to reintegrate into society and the world of work. At the organizational level, there is no doubt to consider the impact of the future screening program on the use of human and technological resources. First, we need to define the population at risk to target screening. At the moment the main criterion is the consumption of tobacco, but over time and with new scientific discoveries it will be necessary to revise the setting. “We will need to have solid evidence on the use of biomarkers,” comments Scagliotti. “With the pace at which molecular biology is proceeding, however, it is possible that in the next few years we will be able to interrogate molecular indicators in the breath or in the blood that will allow us to predict more precisely the population at high risk”. The involvement of the population at risk in the screening program is likely to be an incremental process. “It will not go from 0 to 100, but people will have to be invited and sent to the program,” adds the doctor. “This is why a process of amplification of the message and awareness of the role of spiral CT must be initiated, involving all stakeholders, from general practitioners to pharmacists and advocacy organizations”.
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As for the additional workload for machinery and personnel required by the screening program, the application of artificial intelligence algorithms will play a crucial role in the future, according to the expert. We are not yet at this point (artificial intelligence in radiological diagnostics is still in its infancy), but it is possible to imagine that in an automated system artificial intelligence acts as the first radiologist in reading x-rays and scanners and that the human radiologist intervenes in cases where the response of the machine is not unique. More immediately, “there is evidence that if no nodules are present at the first spiral CT scan, patients could be referred for a check-up every 2-3 years instead of once a year, reducing the workload”, adds Scagliotti. . “This protocol is being examined by four major European studies, one of which is Italian. And again in Italy, the role of two microRNAs is being evaluated in a prospective study, which in two previous studies proved to be able to better predict high-risk individuals ”. Finally, a lung cancer screening program cannot fail to be complemented by smoking cessation programs. “Counseling must be integrated into the screening program”, concludes Scagliotti. “A pathway must be offered to the smoker that includes the support of psychologists and anti-smoking centers and possibly provide drug treatments that have been shown to be effective in helping people to quit smoking.”