Screenings of Lung Cancer and COPD are Significant. What Do the Latest Data from Czechia Say?

When and for Whom to Indicate CT?

Chronic preventable and/or treatable lung diseases, including COPD and cancer, are related to age and smoking. CT is one of the basic tools of differential diagnosis in pneumology. Targeted searches often reveal two or three respiratory diseases in the same patient simultaneously. Besides smoking, there are many harmful civilizational factors—large fires, ongoing war, traffic pollution, workplace pollution, climate change. Most of Europe is struggling with massive pollution. Current research, however, suggests that the key is not where a person lives, but where they are physically active.

Most patients with lung cancer also suffer from other lung diseases, and most of the serious ones manifest very late or in very nonspecific ways. The expert journal Chest issued recommendations in 2021 for when to perform low-dose CT for lung cancer. It is confirmed that lung cancer screening unequivocally prolongs life and dramatically increases the number of operable tumors, which can significantly change the prognosis.

This year, updated GOLD recommendations for COPD (COPD GOLD 2023) were released, which now include information on COPD screening and the use of CT. For example, for asymptomatic patients who smoke and are around 50 years old, COPD screening is not indicated, as it has not been proven to have any benefit. Screening should be undertaken by individuals who show symptoms and have smoked more than 20 pack-years. Early data on COPD screening suggests that it allows for earlier treatment initiation and earlier targeting of smoking cessation. It is also recommended for COPD patients to consider CT screening for lung cancer detection.

Currently, two programs are underway in Czechia aimed at the early detection of lung diseases: “Lung Cancer—Early Detection Program” and “NSC—Early Detection of Chronic Obstructive Pulmonary Disease.”

Lung Cancer Screening—Current Outcomes

Bronchogenic cancer screening has been ongoing since 2022, is designed for at least five years, and targets a high-risk (asymptomatic) population, specifically smokers (≥ 20 pack-years) aged 55–74 years. A high-risk individual undergoes low-dose CT, with radiologists playing a crucial role in categorizing patients into three groups (negative/uncertain/positive findings). The number of radiologists involved in the program is thus increasing.

In the first quarter of 2022, patients were referred by general practitioners, later they could go directly to pulmonologists. According to delayed data from health insurance companies, patients recruit essentially from every region and most districts, with better results in Prague and northern Czechia. However, 48.5% (1690) of those identified by GPs refused the procedure after instruction, and only 51.5% (1796) of the 3486 identified individuals were referred to pulmonologists.

Initial data from health insurers from early December 2022 indicate that in the first and second quarters of 2022, 703 individuals were examined, of which 3.7% were definitively positive, thus indicated for endoscopy for targeted investigation of emerging lesions, 73.3% were negative findings, and 23% had uncertain findings. Data from radiology departments, which are ahead of health insurers, showed that by December 9, 2022, 2260 individuals were examined: 3.5% were positive findings, 72.3% were negative, and 24.2% were uncertain.

COPD Detection Program

As part of the pilot project for early COPD detection, new patients were sought in a high-risk and symptomatic population from 2018 to 2022, with data evaluation expected this year. The target group was smokers (≥ 10 pack-years) aged 40–69. A significant portion were recommended by general practitioners, and some went directly to pulmonologists.

According to data from the end of last year, 942 people were examined, of which 35.8% had clear signs of previously undiagnosed COPD, all in mild stages (GOLD 1–2). Non-specific lung impairment was found in 28.1% (265), and of those who returned for a follow-up after 3-6 months (38), 26.3% (10 individuals) were confirmed to have COPD. Overall, COPD was newly diagnosed in 347 of the 942 project participants. Of the patients coming from general practitioners, 26% had positive findings, whereas the proportion was 40% among those who sought out pulmonologists themselves. Generally, when a person is forced to seek a specialist due to symptoms, their motivation is higher.

Considering the Merger of Both Projects

Patients often meet the criteria for both mentioned programs, so it is worth considering merging them in the future, i.e., combining functional and imaging tests to examine high-risk individuals. The lecturer's workplace already has preliminary data from a set of 29 patients for whom lung cancer was not detected during the screening, but new respiratory pathology was found in 60% of these ostensibly pulmonologically healthy individuals. In 35% (10) of cases, it was COPD or asthma bronchiale, and in 7% (2) it was suspected lung tumors.

The lecturer further highlighted a study published in Respiratory Research, the authors of which found a special way to increase screening sensitivity based on the cytological examination of ordinary sputum from participants. This approach can increase the yield of screening, especially for patients in the inconclusive grey zone.

According to Associate Professor Koblížek, there is ample evidence (with more continuously emerging) that lung cancer screening in high-risk patients is highly beneficial and can favorably change the fate of the screened individuals. He also pointed out that after the COVID-19 pandemic, middle-aged patients with stage III/IV lung cancer unnecessarily die because they reach pulmonologists too late.

Eva Srbová
editor for proLékaře.cz

Source: Koblížek V. Screening of Serious Lung Diseases (Lung Cancer and COPD). Expert Seminar: Updates in the Treatment of Respiratory Diseases, January 25, 2023.