Establishing a Swiss National Lung Cancer Screening Program

With an estimated 3'200 deaths yearly, lung cancer is the leading cause of cancer-related death in Switzerland. Every year about 4'300 new lung cancer cases are diagnosed (4’363 in 2015, 4’252 in 2014, 4’293 in 2013). The major risk factor for lung cancer is smoking: incidence and mortality closely follow smoking trends with a time-lag of around 20 – 30 years.

This explains why death rates in Switzerland are declining in men, but increasing in women. Given that lung cancer has a detectable, yet frequently asymptomatic pre-clinical phase with an effective treatment option (i.e. surgery), the effectiveness of early screening methods has been extensively investigated over the last 20 years.

Low-dose computed tomography (LDCT) is a sensitive imaging technique allowing detection of early stage lung cancer. Importantly, an appropriate diagnostic and treatment strategy achieves a reduction in lung cancer-specific and all-cause mortality. The results of the US National Lung Screening Trial (NLST) showed that lung cancer screening significantly reduced lung cancer mortality by 20%.The results of another landmark study, the Dutch-Belgian Lung Cancer Screening Trial NELSON, presented for the first time in September 2018 at the 19^th World Conference on Lung Cancer, demonstrated a 26% reduction in lung cancer deaths. In a smaller subset of women, LDCT screening even reduced mortality by as much as 50%. The NELSON trial is also of key importance since the volume-based approach to assess lung nodules substantially reduced false positive results and associated harms. These developments unambiguously confirm that lung cancer screening has the potential to save lives and our recent micro-simulation study indicated that this is likely to be a cost-effective intervention (around 30’000 Swiss Francs per life year saved). To date, the USA, UK, and Poland are still the only countries where lung cancer screening with LDCT has been or is being implemented following recommendations of various international associations.

In Europe, most countries including Switzerland still await publication of the NELSON study and an updated health technology assessment on which the decision for or against implementation of a lung cancer screening program would be based on. Much of the hesitation arises from the high false positive rate in the NLST trial and potential harms from diagnostic follow-up (e.g. repeated CT scans, as well as CT-guided, bronchoscopic, and surgical biopsies) or treatment.

In addition, although LDCT screening is likely to be cost-effective (which is a relative term), the cost impact (i.e. the absolute cost) of LDCT screening is substantial: Assuming a participation rate of 10% of all eligible persons, the additional annual cost is estimated around 16 Mio Swiss Francs.

This project will address this area of unmet need in Switzerland by exploring the following aims:

(1) To assess the feasibility and financing of a high-quality LDCT lung cancer screening program with quality assurance in Switzerland from the multi-stakeholder perspective of persons eligible for lung cancer screening, health care providers, and the health care system.

(2) If aim (1) is deemed feasible and affordable, to establish standard operating procedures (SOPs) and a quality assurance program for the implementation of a LDCT lung cancer screening program in close collaboration with involved Swiss national stakeholders.