Lung Cancer Screening in Alberta

Lung cancer remains the leading cause of cancer-related deaths, claiming more lives than breast, colon, and prostate cancers combined. In Alberta alone, more than 1,500 people die from lung cancer each year with only a 28% overall five-year survival rate.

The stigma surrounding lung cancer, often linked to smoking, poses significant challenges in addressing the disease and improving patient outcomes. This negative perception creates barriers to securing funding and donations, as many potential contributors hesitate to support initiatives related to lung cancer due to its association with smoking.

Despite the substantial revenue generated from tobacco taxes, none of these funds are directly allocated to support lung cancer patients. The disease is extremely lethal and severely underfunded

Despite the substantial revenue generated from tobacco taxes, none of these funds are directly allocated to support lung cancer patients. The disease is extremely lethal and severely underfunded, disproportionately impacting individuals from lower socioeconomic groups and rural Albertans, making it a tough issue to tackle.

 While screening programs for other cancers like colon, breast, and cervical are well-established, the adoption of lung cancer screening has faced considerable delays despite significant research evidence supporting its benefits.

The National Lung Screening Trial (NLST), a large study conducted in the U.S. in 2011 with 50,000 participants, demonstrated that lung cancer screening reduced mortality (a finding later confirmed in the European NELSON trial). Remarkably, it remains the only cancer screening intervention to demonstrate an all-cause mortality reduction in a randomized trial. However, 13 years later, outside of British Colombia, Canadian provinces have yet to implement full scale lung cancer screening programs.

In 2016, the Canadian Task Force on Preventive Health Care recommended adopting lung cancer screening programs, but it remains the only recommendation from the task force that has not been put into practice.

Despite this, research into lung cancer screening has been ongoing in Alberta since 2007. The first significant project saw Calgary participate in the PAN-CAN study which screened 2,500 individuals across the country and generated critical evidence-based Risk Prediction Model for patient management for lung nodules. Findings from this study, published in the New England Journal of Medicine (2013), have been used globally to risk-stratify patient results from lung cancer screening programs.

Building on this foundation, the Alberta Cancer Foundation funded the Alberta Lung Cancer Screening Study (ALCSS), which screened 800 Albertans (2014-2020). This was the first prospective study to assess the efficiency of risk prediction models in selecting individuals for screening, demonstrating their superior effectiveness over pack-year based “NLST-like” criteria.

Clinical Implementation and Pilots in Canada

Ontario led the way in Canada with a pilot lung cancer screening project in 2016/2017, followed by British Columbia, which implemented a full-scale program in 2021. Other provinces have taken a more gradual approach, using pilot processes before committing to long-term programs. In Alberta, funding from the Canadian Partnership Against Cancer (CPAC) has supported a pilot project with a $1.6 million grant. This pilot began in 2021, started enrolling participants in 2022, and will conclude in fall 2024 once 3,800 individuals have been enrolled. The results are being submitted to Alberta Health with the goal of establishing a full-scale lung cancer screening program in 2025.

Alberta Pilot Program Spotlight

The Alberta pilot project was a joint partnership between CPAC and AHS, with CPAC providing funding and AHS contributing resources and infrastructure. Dr. Alain Tremblay, a respirologist in the Department of Medicine, was appointed as the Medical Lead of the program. The goal was to enroll and screen 3,000 individuals at risk of lung cancer.

During the planning stages in 2021, it was recognized that Connect Care was being implemented across the province. To ensure long-term efficiency, the screening program was integrated within Connect Care, even though this added some additional time to the implementation phase. This integration made it the first screening program to be entirely managed within Connect Care, covering all aspects from receiving referrals and calculating risk to requesting CT scans, interpreting results, tracking program metrics, and communicating outcomes to family physicians and patients.

The program opened for screening in September 2022 and successfully enrolled 3,000 participants within approximately 20 months. Enrollment criteria is based on a personalized individual risk of lung cancer using the PLCO model, as tested in the PAN-CAN and ALCS Studies. Individuals identified with a 1.5% or more risk of lung cancer over six years are eligible. Referrals came from both primary care providers and self-referrals via the online tool screeningforlife.ca.

Initially, the project was conducted in Calgary, Edmonton, and Grand Prairie, and has since expanded to include High River and Wainwright. With the pilot initially scheduled to end in April 2024, there are hopes to transition to a full-scale Provincial program in 2025. Interim funding has been secured to extend the pilot to March 2025 with additional support from CPAC allowing for screening 800 more individuals while Alberta Health evaluates the pilot results and Provincial proposal. Efforts are ongoing to refine the Risk Prediction Model to optimize screening intervals and patient care efficiency for those at higher risk.

Resource Challenges

Resource challenges have become apparent as the project progresses, necessitating additional funding and approval. Diagnostic imaging requirements, particularly capacity for CT scans, must grow significantly to meet the demands of a province-wide screening program. If fully implemented, the program could increase provincial CT scan volumes by 20%. The goal is to screen 50% of all at-risk Albertans within five years and 25% within three years. Although new resources are required, the Cancer SCN has estimated that by reducing the high cost of treatment for advanced lung cancer, LCS would be overall cost-saving for the health care system.

“It’s better to know now than to find out when it’s too late... Having a screening program is vital for people to have a much better quality of life and see their dreams come true.”

- Patient Partner
  _{Quoted from from AHS News article by Vanessa Gomez - 'Pilot Focusses on Early Detection of Cancer' - Feb 17, 2023}

Early Outcomes from the Pilot are Promising

Within six months of referral, 98% of participants had undergone their scans, indicating high patient engagement and follow-through.

The screening program detected cancer in 10.8 cases per 1,000 people screened, with 83% of cancers found at an early stage. Early-stage (Stage 1) lung cancer has a cure rate of 90%.

This contrasts sharply to the current clinical practice where 66% of lung cancers are diagnosed at a late stage. Overall, lung cancer has a survival rate of 28% with current clinical processes, but this drops to just 5% for stage IV diagnoses.