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SESSION OVERVIEW

The theme for this fifth EAPM conference, under the auspices of the Maltese Presidency of the European Union, is lung cancer screening.

Figures show that lung cancer causes almost 1.4 million deaths each year worldwide, representing almost one-fifth of all cancer deaths.

Within the EU, meanwhile, lung cancer is also the biggest killer of all cancers, responsible for almost 270,000 annual deaths (some 21%).

From a preventative point of view it is, at the very least, surprising that the biggest cancer killer of all does not have a solid set of screening guidelines across Europe.

There is therefore a need for more guidelines in screening for lung cancer. There is also a need for agreement and coordination across the European Union’s 28 Member States.

As long ago as December 2003, EU health ministers unanimously adopted a Recommendation on cancer screening, which acknowledged both the significance of the burden of cancer and the evidence for effectiveness of breast, cervical and colorectal cancer screening in reducing the burden of disease.

At that point, EU guidelines updated and expanded for breast and cervical cancer screening had already been published by the Commission, while comprehensive European guidelines for quality assurance of colorectal cancer screening were being prepared.

Thirteen years on and incidence and mortality rates of cancers still vary widely across the EU, reflecting a major health burden in various Member States, often splitting large and smaller countries along with richer and poorer nations. Therefore, there needs to be concrete action at the EU and Member State levels.

Despite the EU’s substantial efforts, overall the bloc is still only around half-way towards implementing the Recommendation. Not only that, but slightly less-than-half of the population who should be covered by screening (according to the Recommendation itself) actually are.

 

- Session I - Generating alignment in the area of diagnosis: Development of guidelines

Despite the now-ageing Recommendation mentioned in the overview, less-than-half of examinations performed as part of screening programmes actually meet with its stipulations. This cannot be allowed to happen with lung cancer.

There is a need for greater efforts, supported by collaboration between elected representatives in the European Parliament, Member States and professional, organisational and scientific support for those countries seeking to implement or improve population-based screening programmes.

In the end, when it comes to the biggest cause of lung cancer - smoking - not enough people are kicking the habit, although governments everywhere are constantly telling us of the dangers of smoking and the costs of treatment.

Of course knowledge of health risk, escalating costs and peer pressure all help but it is still not enough. Lung cancer prevention is just one example of how society can work as a whole to improve Europe’s health.

This session will seek to raise awareness of the need for guidelines in lung-cancer screening, to be agreed internationally, and implemented nationally, while improving the knowledge of policymakers and world health agencies so that effective guidelines and policies can be formulated.

The above will need to work across national borders to ensure cooperation and collaboration in respect of much-needed guidelines in the fast-developing field of personalised medicine.

Currently, certainly in Europe, evidence-based best-practice recommendations are not disseminated effectively. Clearly, when knowledge is not actively transferred variations in clinical practice will continue.

This means that not only are patients failing to receive the best care, there is potential to cause them preventable harm. Where variations in practice occur, healthcare is unequal within individual countries and across EU member states, and health systems are likely to be inefficient.

Therefore, active implementation strategies are required, to be agreed by consensus.

- Session II - Securing patient access to better care through screening guideline

Assessing the impact of lung-cancer screening guidelines and effectively implementing them should lower the levels of unnecessary costly diagnostic and therapeutic approaches, optimise health resources and harmonise patient management.

The general result will inevitably be improved access for patients to better care and, by extension, improved patient health outcomes.

Treatments and medicine is moving from health professional-led decision making to evidence-based shared decision making. Already, a number of European guidelines have been developed in specific disease areas, such as in the areas of urology, respiratory medicine, gastroenterology and cardiology. Yet lung cancer remains a key area not yet adequately covered.

It will be important to address the major gap in engagement between the scientific community and key stakeholders as users/beneficiaries of guidelines. Not to mention legislators.

Well-informed healthcare professionals and unified guidelines will play a key role in harmonising care and ensuring better care for patients and their families. This requires awareness building and training.

In this session, Members of the European Parliament will explore how to implement consensus-based guidelines on lung-cancer screening at the pan-European level.

There is a need for greater efforts, supported by collaboration between our elected representatives in the European Parliament, Member States and professional, organisational and scientific support for those countries seeking to implement or improve population-based screening programmes.

In the end, when it comes to the biggest cause of lung cancer - smoking - not enough people are kicking the habit, although governments everywhere are constantly telling us of the dangers of smoking and the costs of treatment.

But the key here is that we need to stop viewing patients and potential patients as the theoretical ‘man on the Clapham omnibus’, or Everyman, and begin to realise that the right treatment for the right patient at the right time will improve quality of life for many and save the lives of countless others, now and long into the future.

Parliament and other legislative bodies have a key role to play in this regard.

- Session III - Screening and mapping from other disease areas: Learning and sharing

In the United States, certain kinds of annual screening have been associated with a 15%-20% decrease in lung cancer mortality (compared with chest radiography screening) and, roughly, a 7% reduction in overall mortality.

Overall, findings in both Europe and the US strongly suggest that lung-cancer screening works. There is hard evidence, although debate continues about the best way to implement screening of this kind.

Guidelines could help to tether costs, by bringing in improvements to the efficiency of screening methodologies and, thus, programmes themselves.

Key to such a situation would be making the best use of efficient risk-assessment methods, top-of-the-range imaging technology, and guidelines that encourage the minimisation of invasive procedures and risk to the patient.

The EU should put guidelines in place that will allow Member States to set-up quality assured early detection programmes for lung cancer, possibly through increased public-private partnerships.

Granted, the largest European trial (known as NELSON), has yet to make results available. However, there are clearly potential harms to population-based screening, which include false-positive results, complications from invasive follow-up, plus over-diagnosis and connected over-treatment. The above potential harms are yet one more reason why lung-cancer screening needs to come with consensus-agreed guidelines.

Learning from other screening programmes, it seems clear that designated national screening bodies should be responsible for advice on policies and decision-making.

These should work to ensure that any lung-cancer screening programme finds the best balance between benefit, harm and cost. Clearly, agreement at EU level on screening guidelines will aid co-ordination, as will an adequate legal framework. Sharing experiences from other screening programmes is clearly necessary, as we have learned, among other things, that population-based cancer screening has infrastructure requirements that need to be verified or developed before starting to screen. Gathering together results from relevant trials to aid evidence assessments is necessary and makes complete sense.

The benefits of the use of Big Data cannot be over-estimated (within strict ethical and legal guidelines, of course) and such sharing and, thus, learning will prove the benefits of improved coordination and cooperation on a pan-European level.

- Conclusion: Enabling quality through screening: Next steps

It is the aim of this conference on lung-cancer screening to emerge with concrete proposals. When it comes to lung cancer, Europe is already looking at risk prediction models to identify patients for screening, plus a determination of how many annual screening rounds is enough.

Yet it is clear than any further delay to the implementation of the best form of lung cancer screening will mean many more unnecessary lives lost.

The European Respiratory Society (ERS) and the European Society of Radiology (ESR) have both recommended screening for lung cancer under the following circumstances: “In comprehensive, quality-assured, longitudinal programmes within a clinical trial or in routine clinical practice at certified multidisciplinary medical centres.”

Meanwhile, the International Association for the Study of Lung Cancer (IASLC) has developed a consensus statement of issues needing more research. These include effective risk assessment, and integrating screening with anti-smoking information. Some experts have said that, while we wait, there is a good case for “immediate implementation of carefully designed and well targeted demonstration programmes”.

Screening can help to ensure that surgery in lung cancer’s early stages can continue to be the most effective treatment for the disease.

Modern medicine is advancing swiftly and there are many areas trying to play catch up. Much can be achieved with consensus-based guidelines to ensure that effective screening can take place.

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