Lung Cancer Screening Guidelines Across Canada

Environmental Scan

July 2015

July 20152

• Biannually, the Canadian Partnership Against Cancer collects information from the provinces/territories and international organizations on the status of population-based lung cancer screening strategies.

• This information compares current guidelines and evidence-based recommendations in order to identify leading practices.

Background

July 20153

Presentation Outline

Canadian Task Force on Preventive Health Care Guidelines

Current Evidence in Lung Cancer Screening Status of Lung Cancer Screening in the U.S.Strategies for Lung Cancer Screening in CanadaSummary of Key Activities for Lung Cancer

Screening Across CanadaUse of LDCT for lung cancer screeningSynoptic reporting for lung cancer pathology

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Canadian Task Force on Preventive Health Care Guidelines

• There is fair evidence to recommend against lung cancer screening for asymptomatic people using chest radiographic examination (D recommendation).

• There is insufficient evidence (in quantity and/or quality) for the Task Force to make a recommendation for using computed tomography (CT) scanning when screening asymptomatic people for lung cancer. However, there may be other factors which may influence decision-making (I recommendation).

• The Canadian Task Force on Preventive Health Care is currently reviewing this guideline. The published recommendation statement is expected in 2016.

• For more information please visit: http://canadiantaskforce.ca/

The Canadian Task Force on Preventive Health Care (2003) recommends the following for lung cancer screening:

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Status of Lung Cancer Screening in the U.S.

• Findings from the National Lung Screening Trial stated the following:o 20% reduction in mortality after 3 annual screens using low-dose spiral computed tomography in the high

risk* group versus the control group.o For summary of scientific evidence and related references with regards to lung cancer screening please visit:

Anticipatory Science*high risk is considered those persons ages 55-74 who have a smoking history of 30+ pack years or have quit smoking within the past 15 years.

• The U.S. Preventive Services Task Force has issued a final recommendation statement on screening for lung cancer. o Annual screening for lung cancer with low-dose computed tomography (LDCT) is recommended for persons

aged 55-80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years.

o For more information please visit: U.S. Preventive Services Task Force

• The Centers for Medicare and Medicaid Services issued its final decision in favour of providing LDCT lung cancer screening coverage for high risk Medicare beneficiaries** as of February 6, 2015.o A physician’s order is required and may only be issued after a counseling and shared decision-making visit

with the patient.o Requirements for the radiologists and the facilities providing LDCT screening were also outlined.

**high risk refers to those meeting the NLST criteria outlined above

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Current Strategies for Lung Cancer Screening in Canada

Type of Strategy in Place Agency Responsible for Strategy Implementation

Yukon No program in place. Government of Yukon

Northwest Territories

No program in place ; tobacco prevention and cessation programs are available.

Department of Health & Social Services

Nunavut* No program in place; however, there is a robust tobacco reduction program.

Department of Health

British Columbia

No program in place. BC Cancer Agency has reviewed scientific evidence for high risk screening and is preparing business case for implementation.

BC Cancer Agency

Alberta No formal program in place. Health Technology Assessment completed 2015. Decision is to not fund a formal screening program at this time. May be revisited in 2017.Alberta Cancer Foundation Grant received for pilot project.

Alberta Health Services

Saskatchewan A committee has been formed to monitor national progress. Saskatchewan Cancer Agency

Manitoba No program in place. Manitoba Health and CancerCare Manitoba

*No response received from Nunavut for the July 2015 scan.

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Current Strategies for Lung Cancer Screening in Canada

Type of Strategy in Place Agency Responsible for Strategy Implementation

Ontario No program in place. Program in Evidence-Based Care (PEBC) – Evidence-based Series #15-10: Screening High-Risk Populations for Lung Cancer report is available online. These guidelines recommend screening high risk individuals through an organized screening program, but opportunistic screening is not recommended due to the considerable risks posed to patients outside of an organized program.

Cancer Care Ontario

Quebec

No program in place; An expert committee is mandated to make recommendations to the Direction québécoise de cancérologie (DQC) for priorities and issues to ensure care and services are offered for lung cancer based on current evidence throughout the lung cancer pathway. The Institut national d’excellence en santé et en services sociaux (INESSS) was mandated by the DQC to produce a report on the use of low-dose helical CT for the purposes of lung cancer screening, but work is suspended temporarily due to other priorities.

Direction québécoise de cancérologie, Ministère de la Santé et des Services sociaux du Québec

New Brunswick

No program in place; Pan Canadian Lung Cancer Screening Guidelines are currently being monitored

New Brunswick Cancer Network (NB Department of Health)

Nova Scotia No program in place. Participating in the Pan-Canadian Early Lung Cancer Detection Study. Working group reviewed evidence for screening high risk population in Nova Scotia and submitted a recommendation to the Minister of Health.

Cancer Care Nova Scotia

Prince Edward Island

No program in place. A committee is evaluating provincial cancer rates and national evidence for screening.

Department of Health and Wellness

Newfoundland and Labrador

No Program in Place. A lung Screening committee is being established in Fall of 2016. There is an active lung cancer diagnostic committee.

Eastern Health, Cancer Care Program

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Yukon• Due to limited resources, the territory does not have a program in place.

Northwest Territories• There is no formal lung cancer screening program or specified directed activities.

Northwest Territories does however actively promote tobacco prevention and cessation program.

Nunavut*• Due to limited resources, the territory does not have a program in place; however,

there is a robust tobacco reduction program.

Summary of Key Activities Across Canada

*No response received from Nunavut for the July 2015 scan.

July 20159

British Columbia• BC Cancer Agency has reviewed scientific evidence for high risk screening and is

preparing a business case for provincial program development and implementation.

Alberta• AHS requested a Health Technology Assessment is completed. Alberta Health will

not publicly fund a lung cancer screening program at this time and hold the policy decision on a program until 2017.

• Alberta Cancer Foundation Grant received for pilot project to develop screening framework.

Summary of Key Activities Across Canada

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Saskatchewan• A committee has been formed although the province prefers to wait until a

national consensus has been reached before taking action in this field.

Manitoba• A working group will be established as needed to continue monitoring the

evidence and practice of screening in other jurisdictions. Manitoba will also participate in CPAC initiatives to support development of national guidelines and consensus on screening for lung cancer.

Summary of Key Activities Across Canada

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Ontario• Cancer Care Ontario (CCO) Program in Evidence-based Care (PEBC) Evidence-based Series #15-10: Screening High-

Risk Populations for Lung Cancer is published on the CCO website at: https://www.cancercare.on.ca/toolbox/qualityguidelines/clin-program/screening-ebs/

• The guidelines, developed by CCO’s PEBC and a clinical expert panel, recommend the use of low-dose computed tomography as a screening modality for lung cancer in high risk populations (those 55 to 74 years with a smoking history of ≥ 30 pack years who currently smoke or have quit within the past 15 years) who are disease-free at the time of screening “through an organized screening program and administered by specialized centres with multi-disciplinary care teams”.

• Opportunistic screening of asymptomatic individuals is not recommended due to the considerable risks posed to patients outside of an organized program.

• CCO commissioned Sunnybrook Research Institute to evaluate the cost-effectiveness of high risk lung cancer screening in Ontario. The results of this work are currently being taken under consideration in determining the next steps for designing and implementing an organized High Risk Lung Cancer Screening Program in Ontario.

• CCO is currently in the process of hiring a Clinical Lead to guide activities related in high risk lung cancer screening in Ontario.

Summary of Key Activities Across Canada

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Quebec• Currently, there is no program in place for lung cancer screening. • An expert committee is mandated to make recommendations to the Direction québécoise de

cancérologie (DQC) for priorities and issues to ensure care and services are offered for lung cancer based on current evidence throughout the lung cancer pathway.

• The Institut national d’excellence en santé et en services sociaux (INESSS) has been mandated by the DQC to produce a report on the use of low-dose helical CT for the purposes of lung cancer screening. This work is suspended temporarily due to other priorities.

New Brunswick• Pan Canadian Lung Cancer Screening Guidelines are currently being monitored.• There may potentially be some work in the area similar to Alberta for example, determining the

proximity of CT scanners to the population in New Brunswick. • There is interest in identifying how to define the high risk population (New Brunswick is not involved in

the Pan Canadian Early Lung Cancer Detection Study).

Nova Scotia• Nova Scotia is currently participating in the Pan-Canadian Early Lung Cancer Detection Study. Working

group formed reviewed evidence for high risk screening, analyzed evidence within the Nova Scotia context, and submitted a recommendation/business case to Government re: next steps.

Summary of Key Activities Across Canada

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Prince Edward Island• Currently, there is no program in place. A committee is evaluating provincial cancer rates and national evidence for

screening.

Newfoundland/Labrador• No program in place.• There is an active “Lung cancer diagnostic pathway committee”. The committee has reviewed the current practices

for work-up of abnormal chest imaging for lung cancer diagnosis in Newfoundland. It was decided to implement a triage process, with the goal of streamlining this diagnostic pathway, and at the same time to triage patients very early to treatment.

• Anecdotal evidence suggest that opportunistic LDCT testing is occurring. There is currently no mechanism to track or capture the amount of LDCT testing.

• A lung cancer screening working group is being established:1. to review the current literature, statistics and demographics pertaining to lung cancer and lung cancer

screening;2. to review the structures and experiences of lung cancer screening programs that may exist in other

jurisdictions in Canada and beyond; and 3. to recommend directions and initiatives that should be taken regarding lung cancer screening in Newfoundland

and Labrador.

Summary of Key Activities Across Canada

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Are LDCT lung scans being ordered for lung cancer screening (as opposed to for other purposes such as lung cancer diagnosis in individuals with

prior x-ray abnormality, follow-up, etc.) in your province/territory?Province/Territory Yes/No/Don’t know If yes, where is this taking place?

Yukon No

Northwest Territories No

Nunavut* No response

British Columbia Under research protocol and ad hoc screening for COPD patients, smokers with chronic cough

BCCA (research protocol) and outside of BCCA (ad hoc screening)

Alberta Yes Private CT providers

Saskatchewan No

Manitoba Don’t know

Ontario Yes, however the extent to which opportunistic screening is occurring is unknown.

Screening is occurring through hospital-based initiatives. The locations and extent of other opportunistic screening is unknown.

Quebec No

New Brunswick Don’t know

Nova Scotia Yes On an ad-hoc basis

Prince Edward Island No response

Newfoundland and Labrador

Anecdotal evidence suggest that opportunistic LDCT testing is occurring.

There is currently no mechanism to track or capture the amount of LDCT testing.

*No response received from Nunavut for the July 2015 scan.

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Does your province/territory use synoptic reporting for lung cancer pathology?

Province/Territory

Does your province/territory use synoptic reporting for lung cancer pathology?

Yukon No response

Northwest Territories Yes, same as Alberta

Nunavut* We have an agreement with Cancer Care Ontario whereby our cancer reports are sent to CCO wo does the cancer registry etc. for us

British Columbia Yes, in some hospitals

Alberta Yes

Saskatchewan No

Manitoba We have “synoptic-like” reporting, not discrete data fields but synoptic format

Ontario Yes – the 2013 CAP Protocol is used for lung resections.

Québec The implementation is ongoing. The content is based on CAP reports which have been translated.

New Brunswick Yes - CAP lung resection checklist for pathology

Nova Scotia A modified CAP recommended synoptic report for lung cancer has been prepared and it is in the final stage of reviewing. An approved synoptic report is expected to be put in place for clinical practice in the fall or early winter this year.

Prince Edward Island Yes

Newfoundland and Labrador

Yes - synoptic template from Canadian Association of Pathologists

* No response received from Nunavut for the July 2015 scan.

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Reference Slide

Please use the following reference when citing information from this presentation:

Cancerview.ca. Lung Cancer Screening Guidelines Across Canada: Environmental Scan. Toronto: Canadian Partnership Against Cancer; [enter date]. Available from: [enter URL link]