Professor Charles Swanton with one of his team in the lab Professor Charles Swanton chief clinician Cancer Research UK Professor Charles Swanton, Cancer Research UK’s chief clinician.
Following today’s announcement of the roll-out of NHS lung health checks across England, our chief clinician, Professor Charles Swanton, writes how this must form part of a wider, ongoing focus on lung cancer.
A decade ago, I decided to devote my career to tackling what many saw as one of medicine’s biggest challenges: lung cancer, a ‘smokers disease’ shrouded in unfair stigma, prevalent among the most disadvantaged. Patients would frequently arrive at clinic with advanced disease, with few options beyond harsh radiotherapy and chemotherapy to buy a few extra months. Curative surgery was only effective for a small, fortunate proportion diagnosed early.
Ten years on, much of this is still true. The disease still claims 35,000 lives prematurely every year, many from the more deprived sectors of society. Late diagnosis is still a huge issue, with two-thirds diagnosed at an advanced, incurable stage. In survival terms, we’re still doing worse than many comparable countries.
And yet, in terms of our mindset, things have changed almost beyond recognition. Sophisticated new drugs provide more options, which can be profoundly effective for some. Funders are prioritising lung cancer research as never before, leading to new insights into how and why this disease develops, evolves and spreads. As smoking rates fall, lung cancer’s stigma is slowly – perhaps too slowly, but still – lifting.
‘It will spot many lung cancers early enough to save lives’
Today’s NHS England announcement, of a multimillion pound programme of targeted lung health checks, rolling out in ten of the most deprived regions in the country, is yet another reason to be optimistic. At-risk individuals – smokers and ex-smokers – will be invited for a lung ‘MOT’: a questionnaire, stop-smoking advice and, if appropriate, a chest scan that, in many instances, can be carried out on the spot in specialised trucks. This laudable initiative will undoubtedly spot many lung cancers early enough to save lives.
The programme will also yield important insights about how a full nationwide lung screening programme could be introduced, should data and cost-effectiveness analysis eventually point that way. Last year’s initial findings from a large European lung screening trial have suggested substantial benefits. Do they outweigh the harms? We urgently need to see the full findings – not least since not everyone will have access to this programme; ensuring equality of access for all, avoiding post-code lotteries, will be essential.
But there’s more to do beyond early detection.
‘Workforce shortages remain a serious worry’
Lung cancer can advance rapidly, and treatment delays can be lethal. While the NHS is taking welcome steps here too, continued reports of workforce shortages and missed waiting time targets remain a serious worry. The new lung screening programme needs to be accompanied by parallel plans to properly resource and sustain it.
We also need to develop ways to spot the disease early when it occurs in non-smokers – a group of thousands who often feel additionally marginalised by the disease’s tragic stigma.
And there’s a further complexity: even with early diagnosis and swift treatment, close scrutiny of NHS data reveals another uncomfortable fact. Too many people with early, curable lung cancer seem to be missing out on curative treatment – particularly surgery. And this is especially true among older people in certain areas.
For example, in the best hospitals, 80% of patients with early-stage lung cancer receive surgery. In others, just 20% do. This unwarranted variation in treatment is as much of a root cause of the nation’s poor lung cancer statistics as are late and slow diagnosis, and deserves creative solutions. For example, when different clinical teams have time to meet, and share data, experiences and solutions, it lifts everyone towards the same high standard. This needs to become the norm, not the exception – but creating time for reflection in a busy NHS is harder than ever.
And we mustn’t forget the elephant in the room. Around 15% of the UK population still smokes, and around 8 in 10 lung cancers are tobacco-linked. Most people who smoke want to quit, but cuts to local authority budgets have restricted the help available to them. This is tragically myopic – for every £1 invested in Stop Smoking Services, £2.37 is saved by preventing smoking-related illnesses.
And yet, despite these challenges, not for one minute do I regret my decision to specialise in lung cancer. There’s hope on the horizon. As today’s announcement shows, the disease is finally stepping out of the shadows. We owe it to our patients to make sure it stays in the spotlight.
Professor Charles Swanton, Cancer Research UK’s chief clinician
This article originally appeared in The Guardian
David Baldwn February 10, 2019
It is worth noting that the NHSE Clinical expert Group for Lung cancer have written advise to commissioners on how to tackle the huge variation as mentioned in this excellent summary. This is available on the Roy Castle website for download but I cannot find it on the CRUK website. There is a whole section on evidence for variation and a potential solution. All this links with the National Optimal Lung cancer pathway.