Diagnosis Working Group briefing on the protocol for the Targeted Lung Health Checks Programme
The Diagnosis Working Group of the Taskforce for Lung Health supports the NHS England Targeted Lung Health Checks programme. Announced in 2019, the Targeted Lung Health Checks programme has funded 14 pilot lung health checks (LHCs) across England which aim to identify and diagnose lung cancer at an early stage. The programme has provided funding for the sites for four years, during which time lung health checks will be open for people aged between 55 and 74 with a history of smoking. In line with the published standard protocol, participants who take up the offer to attend will have a spirometry test and a discussion about lung cancer risk, with those at higher risk being offered a subsequent low-dose CT scan onsite.
We hope the checks will be successful in diagnosing both lung cancer and other lung conditions at an earlier stage, which is an overarching ambition of the Taskforce. Survival for people with lung cancer is closely linked to the stage at diagnosis. When diagnosed at the earliest stage, more than one in three people with lung cancer will survive their disease for five years or more, compared with around just five in 100 people when diagnosed at a later stage.
The Taskforce for Lung Health made a recommendation in its 2018 Five Year Plan to implement a comprehensive national lung cancer screening programme in England, targeting those at high risk of developing lung cancer, and offering them low dose CT screening. National screening programmes are the responsibility of the UK’s National Screening Committee, so this NHS England pilot does not guarantee wider rollout. However, LHCs are likely to provide substantial evidence for the National Screening Committee on the value of lung screening programmes.
LHCs have the potential to make significant improvements to the timely and accurate diagnosis of certain lung diseases. This briefing provides an overview of the Diagnosis Working Group’s recommendations for improving the programme as it stands, which if implemented will optimise the lung health checks. Our recommendations are on the following areas:
- Governance across LHC sites
- Spirometry testing
- Smoking cessation
- Referrals for incidental findings
- Data collection
- LHCs in light of COVID-19
In addition, the Diagnosis Working Group supports in full the recommendations radiological aspects of the programme made by the Royal College of Radiologists (RCR) and the British Society of Thoracic Imaging (BSTI), who are members of the Diagnosis Working Group, in their paper Considerations to ensure optimum roll-out of targeted lung cancer screening over the next five year.
Governance across LHC sites
NHS England has produced a standard protocol for LHCs which aims to ensure a consistent approach for delivery lung health checks across England. A second document sets out quality assurance standards for various aspects of the programme.
However, we have concerns that guidance does not go far enough to ensure LHCs are using the same processes and procedures across areas. A clear programme of quality assurance across sites helps to ensure that as a whole the programme of targeted lung health checks provides a good quality of service, is effective in its aims and can be easily and accurately evaluated.
There are specific concerns that the lack of external quality assurance for the radiology readings has the potential to threaten the effectiveness of the lung health checks pilots. We urge NHS England to follow the RCR and BSTI recommendations on implementing a programme of external quality assurance.
We also support the wider RCR and BSTI calls that the lessons and findings from several ongoing LHC pilots and lung cancer screening trials should be continually evaluated and used to refine the nuances of the standard protocol.
Recommendation: NHS England to require external quality assurance of radiology readings at the LHC pilot sites, as per the RCR and BSTI guidance.
NHS England Standard Protocol currently advises that all participants undertake spirometry. However, there is currently limited evidence that people who are asymptomatic but at-risk gain an overall health benefit from having spirometry. We believe that further detail would be useful for LHC providers as to the circumstances in which a spirometry test should be carried out, identifying which patients should be prioritised for investigation. Additionally, there is a lack of detail about what kind of spirometry should be used in the programme and whether this should include reversibility testing.
Spirometry results alone do not diagnose COPD; a known cause and symptoms such as breathlessness are also necessary. This should be made clear to participants.
It’s also important to consider local primary care capacity, especially with regards to the workforce who are trained to deliver and interpret these findings. The Respiratory Delivery Board for the Long Term Plan are in the process of allocating funding to priority areas for spirometry training and accreditation, and we urge the cancer team to link up with this work.
Recommendation: NHS England to review guidance on which patients should be prioritised for spirometry, and to cascade this to LHC sites.
Providers are required by the NHS England protocol to discuss participants’ smoking habits and offer smoking cessation advice and treatment. It’s really important that providers are proactive in talking about people’s smoking history and providing support to quit, because we know the majority of smokers (60%) want to stop smoking.  Smoking is the leading cause of lung cancer and some lung diseases, such as COPD, so participating in an LHC is a significant ‘teachable moment’ which could encourage people to make a quit attempt. Moreover, where participants have a ‘clear’ CT screening – which the majority will - it’s essential to make clear this does not exclude a future diagnosis of lung cancer and that comprehensive cessation support is available to them.
All LHC sites should endeavour to provide onsite support to quit smoking, involving behavioural support and dispensing of nicotine replacement therapy (NRT) and pharmacotherapy (varenicline). This is because the most effective way to quit smoking is to have behavioural support combined with pharmacotherapy. We recommend that all providers make clear to all participants that they can guarantee an offer treatment for tobacco dependency.
As part of this all health care professionals on site should be trained in delivering Very Brief Advice (VBA) for smoking cessation. VBA is a 30-second intervention and training can be found in free online modules.
As behavioural support and treatment for smoking cessation is provided over a number of weeks, it’s essential that participants can be referred directly from a lung health in to a specialist stop smoking service to continue support or initiate a new quit attempt. However, we are concerned that in many areas of the country – including some areas hosting LHC sites – local authority commissioned stop smoking services have had their funding cut. LHCs must therefore work with colleagues in public health to create a clinical pathway into specialist support. Participants who are given support onsite shouldn’t be left without ongoing support. This is particularly important where regional stop services are limited or restricted to certain population groups, because participants may otherwise face continuing a quit attempt unaided.
Recommendation: All LHCs to establish clear pathways into local stop smoking services, and to provide an onsite service wherever possible which includes direct access for NRT and pharmacotherapy. All health care professionals involved in the LHCs to be trained in delivering VBA for smoking cessation.
Referrals for incidental findings
The Lung Health Checks will find significant numbers of people living with suspected respiratory conditions other than lung cancer, including COPD, bronchiectasis and interstitial lung diseases (ILD). Leeds Lung Health Check – a separate trial funded by Yorkshire Cancer Research – found 40 cases of lung cancer and 200 cases of COPD for instance in its first year, from 3,000 checks. As per the NHS standard protocol however, the overall target referral rate for each LHC site is less than 15%.
When people are found to have suspected COPD it will be vital to refer to primary care for further investigation as quickly and efficiently as possible. NHSE’s Quality Assurance Standards for the LHCs state that where COPD is identified, referral to local community respiratory team should be considered. We would suggest a named responsible primary care health professional is appointed locally to help ensure a smooth transition, in the same way as a named respiratory physician is required for suspected cancer. Moreover, it is essential there is a clear diagnostic pathway in place for suspected COPD to ensure accurate and timely diagnosis for patients.
Not all respiratory conditions will be dealt with in primary care. Suspected ILDs will need to be referred to secondary care for investigation and to confirm a diagnosis. It’s important there’s clarity for how this will work to avoid patients being passed between different parts of the health service multiple times before they see the right team.
Recommendation: NHSE should produce clear guidance for CCGs on necessary patient pathways for incidental findings. This should include pathways into primary care for people with suspected COPD and mild bronchiectasis, a pathway into secondary care for people with suspected cases of ILD and other urgent lung disease.
Information for participants
Participants must be given clear information about the lung health check, right the way through from being invited to attend, to receiving a diagnosis and beyond. An overview of the information participants should be given is provided in the NHS England protocol.
In addition to what’s already listed, it should be highlighted from the outset that the aim of the screening CT scan is to identify early stage lung cancer, because of the benefits of early detection. However, participants should be aware that other pathologies may be found and they should be informed that any other findings which are considered actionable will be managed according to standardised protocols.
One of the most common incidental findings is suggested COPD. As already highlighted above, spirometry results alone do not diagnose COPD and this should be made clear to participants. In the case of suspected COPD or otherwise abnormal spirometry results, participants will need to be provided with good quality and clear information on why they’re being referred to primary care for further testing, what tests are likely to be carried out and what the possible outcomes are.
Recommendation: NHSE to expand the required information for participants to include information on incidental findings.
It is incredibly important that data is collected both on how many people are referred for follow up of incidental findings, and the numbers who are subsequently diagnosed with a non-cancer respiratory condition.
The NHS quality assurance standard outlines how incidental respiratory findings will be codified. We would like reassurance that this database will be evaluated and made public.
Furthermore, it’s currently unclear whether subsequent diagnosis of non-cancer conditions will be collected. This will undoubtedly be more challenging as referrals are largely managed in primary care and diagnoses may not be made straight away. However, it’s important consideration is given to this if the wider outcomes of the programme are to be understood.
The RCR and BSTI have highlighted a number of other requirements and recommendations endorsed by the Diagnosis Working Group regarding data collection:
- A national lung cancer screening database is needed to collate findings, including metrics of radiology performance. Local systems need to collate this data, and at national level this should form a real-time dashboard.
- The use of a curated national cloud screening repository is also recommended. This would integrate all sites under a single framework. Using NHS number as a unique identifier, all centres would publish to the repository. This allows for a national screening data set, image sharing, reporting networks, training and a quality assurance portal.
Underpinning this, it is crucial that efficient IT systems are in place. IT systems at LHCs should be robust and be able to work in connection with all relevant sites in primary and secondary care, and further guidance on this would be helpful.
The Respiratory Delivery Board for the Long Term Plan are currently developing metrics to measure increases respiratory diagnoses, so this would be useful information for them to access. It will also help to make the programme sustainable in the longer term if we can demonstrate the benefits it has to patients and the NHS more widely than lung cancer.
Recommendation: NHSE team to issue guidance to LHCs on data collection requirements for cases of non-cancer respiratory conditions. NHSE to also review the requirement for a national lung cancer screening database, as well as a central database
LHCs in light of COVID
The Lung Health Check programme has been paused as a result of COVID-19. This has been for the protection of participants and staff, and as staff are redeployed to other areas of the health system. For sites already up and running before the pandemic, this has meant winding the programme down; for those yet to open, which is thought to be around half, this will have had a significant impact on planning.
It is imperative this programme is re-started as soon as possible to utilise NHSE’s funding offer and to save lives through early diagnoses. Additional hygiene and infection control measures may need to be introduced to minimise the risk of COVID-19 spreading and these measures will reduce scanner throughput. In addition, we recognise a key consideration should be given to the fact that CT scanners and staff may have been redeployed from already reduced staffing levels as HCPs themselves shield or are unable to work.
We require urgent clarity on the future of the LHC programme, including consideration of how this postponement will impact the delivery of the rest of the funding and on the initial four year timeline for the programme.
Recommendation: NHS England to issue guidance on future of LHC programme
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Senior policy officer
 Office for National Statistics (2017) Adult smoking habits in the UK: 2016 – Supplementary data tables
 Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. (2016) Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD008286
 Yorkshire Cancer Research, ‘Lives Saved as Leeds Lung Health Checks Reach 3,000’. Available at: https://yorkshirecancerresearch.org.uk/news/lives-saved-as-leeds-lung-health-checks-reach-3000
 NHS England, Targeted screening for lung cancer with low radiation dose computed tomography: standard protocol prepared for the Targeted Lung Health Checks programme. January 2019. Available at: https://www.england.nhs.uk/wp-content/uploads/2019/02/targeted-lung-health-checks-standard-protocol-v1.pdf