Lung cancer screening in Canada: 2021/2022

British Columbia
Through the Lung Cancer Screening (LCS) project, BC Cancer has completed the pre-implementation and implementation activities required to offer low-dose computed tomography (LDCT) within each Regional Health Authority (RHA) in a centralized, standardized way. A focus was placed on promoting equitable access. The program will leverage, as appropriate, processes and systems currently being used, including the LCS pilot and resources produced by the Partnership and the Canadian Association of Radiologists. The new screening services launched in May 2022.

Alberta
Alberta Health Services supports the implementation of a lung cancer screening program for people who are at high risk and submit an expression of interest (EOI) under the Accelerating Lung Cancer Screening initiative. It seeks to build program capacity through a phased-in pilot approach to ensure the necessary resources, scalable processes and adequate infrastructures are in place before the launch of a province-wide program. Specific objectives are to:

• set up the screening program’s governance structure and decision-making process
• develop lung cancer screening pathways and relevant clinical protocols and processes
• offer LDCT for high-risk individuals (limited enrollment) starting in Q1 2022
• develop lung cancer screening materials for eligible Albertans, primary care physicians and specialist physicians
• develop necessary IT infrastructures to allow integration into existing systems (i.e., the provincial screening database and ConnectCare)
• develop an evaluation framework to support monitoring and rapid feedback
• engage with primary care and Indigenous groups to learn how to support their knowledge and access to lung cancer screening services

Overall, the proposed pilot project seeks to implement a phased implementation of lung cancer screening, coupled with engagement and education initiatives meant to raise awareness of the risks and benefits for high-risk populations. This multi-pronged approach includes a planning phase and a pilot implementation phase. The pilot will include primary care engagement, relationship building with community organizations and individual-level strategies, to improve overall health and reduce the mortality caused by lung cancer. An evaluation of the project activities will determine the expansion of the program by June 2023.

Saskatchewan
The Saskatchewan Cancer Agency will use a collaborative, equity-driven, phased-in approach to developing a provincial lung cancer screening program, starting with the implementation of a pilot.

For a provincial screening program to be effective in serving underscreened and underserved populations, it must be designed in a way that addresses the specific needs of communities. The project’s goal is to move beyond consultation to collaboration and co-creation with communities, which will help ensure that the resulting screening program will reflect the needs of patients and communities most affected by lung cancer, now and into the future. This will help reach more people who could benefit from lung cancer prevention and screening and also avoid inequities in access. It is the only screening program in the Agency that works in and with the community — an innovative approach that could be built upon to improve other cancer control services across the Agency.

Pre-implementation planning activities have begun. Current and future activities include:

• continued stakeholder engagement using established collaboration frameworks
• implementation of a governance and shared decision-making model
• completion of a full business case and analysis of lung cancer screening
• determination of operational and technology requirements
• co-development of an implementation plan using logic models, evaluation frameworks and quality indicators

Manitoba
Through the Accelerating Lung Cancer Screening Program Development and Implementation initiative, a number of activities are underway in preparation for a fully organized lung cancer screening program in Manitoba. This includes the development of all aspects of the program, including LDCT testing, managing and following up with patients, assessing public acceptability, and identifying target populations.

Ontario
The Indigenous Cancer Care Unit (ICCU) is co-leading a project with the Akausivik Inuit Family Health Team titled Building Pathways to an Inuit-Informed Lung Cancer Screening Initiative in Ontario.

The primary focus of the project is to understand the current barriers to lung cancer screening, sharing test results with participants, and facilitating access to treatment and follow-up care among Inuit (particularly in the Ottawa/Champlain region). Secondly, by utilizing existing data, the project will evaluate mainstream/current eligibility criteria for the Ontario Lung Screening Program and verify this against clinical data and population health data. This work will ultimately contribute to the development risk-based screening guidelines and also risk-based eligibility criteria appropriate for Inuit. The project may also help inform people-specific criteria that are applicable to Indigenous populations, while remaining grounded in an understanding and respect for Indigenous determinants of health and ways of knowing.

Ontario Health is also working with the Partnership to support jurisdictions in their efforts to develop lung cancer screening programs. This support may include the sharing of lessons learned from the Ontario lung screening pilot; leveraging technical and operational lung cancer screening expertise; and building partner capacity in areas such as engagement with high-risk populations, best practices for integrating smoking cessation into lung screening programs, engagement with clinicians (e.g., radiologists, primary care) and evaluation.

Quebec
Eight institutions have adopted the lung cancer screening demonstration project that started on June 1, 2021. The project aims to recruit 3,000 participants: smokers or ex-smokers between the ages of 55 and 74 who quit smoking less than 15 years ago but smoked for more than 20 years in total.

Referrals come from primary care (namely family physicians and specialized nurse practitioners), specialist physicians or self-referrals. The eligibility criteria follow the risk assessment model. Including the project evaluation period, the project takes place over three years. The first LDCT exams took place in June 2021 and the recruitment for participants took place between June 1, 2021, and July 31, 2022.

New Brunswick
The New Brunswick Cancer Network is developing an implementation plan for an organized provincial lung cancer screening program. It will include work on:

• an assessment of the current practices for lung cancer diagnostic, treatment and follow-up pathway
• lung cancer screening practice guidelines
• requirements for the IT infrastructure to support the screening program
• a communication and awareness strategy
• the integration of smoking cessation support within the screening program
• recommendations for the budgetary and human resources needs required to support implementation and sustainable ongoing administration and operation of the screening program

Nova Scotia
The project will focus on moving key elements of the provincial and Partnership business cases to implementation while organizing a phased-in provincial lung cancer prevention and early detection program. The proposed approach begins organized screening in the central zone by fiscal year 2022–2023. Ongoing monitoring and evaluation of the program will facilitate the implementation process in the other three zones in the province. Using an evidence-based risk assessment model to determine eligibility for low-dose computed tomography screening, access will be targeted to high-risk individuals only.

Individuals may either self-refer or be referred by a healthcare practitioner. Smoking cessation support will be integrated at every step, including for those who don’t meet the criteria for screening. Informed decision-making and navigation will be incorporated into the screening pathway to ensure a safe, client-centred experience. Strict work-up protocols and appropriate use of diagnostic imaging resources will ensure a standardized, cost-effective approach.

The needs of First Nations (Mi’kmaq) communities will be identified and met through ongoing partnership development and full community engagement, ensuring the provision of culturally safe screening, cessation support and care. The phased-in implementation approach will include consulting and engaging with high-risk communities to inform program deliverables and implementation activities. These communities include those without a primary healthcare provider and underserviced communities identified through consultation with the Nova Scotia Department of Community Services. By 2024–2025, all high-risk lung cancer screening participants will be screened via a fully operationalized program available province-wide; no lung cancer screening will occur outside the program.

Newfoundland and Labrador
All working groups have initiated meetings. A preliminary business case was prepared in February 2022. Preliminary discussions are underway with IT vendor Deloitte on building the infrastructure for lung screening, coinciding with the planned second phase of the Health Connect Project. The Partnership’s OncoSim micro-simulation tool will be used to present modelling scenarios for the implementation of a provincial lung cancer screening program.

Anticipated challenges lie in integrating a comprehensive smoking cessation program into the screening program, and in building capacity within the pathology and respirology divisions to take on the workload associated with screening program.