Lung cancer pathway insights from Dr Zaheer Mangera part 1: early diagnosis and screening

Speaking at Hospital Healthcare Europe’s recent Clinical Excellence in Respiratory Care event, Dr Zaheer Mangera shared insights into the lung cancer pathway and its management and diagnosis in accordance with NICE and other guidance, paying particular attention to the benefits and challenges of early diagnosis and lung cancer screening.

Cancer waiting times are never far from the headlines, and recent figures on these targets for all cancers show mixed success, with the target for the faster diagnosis standard being met (77.4% vs 75%) but the 31-day decision to treat and 62-day referral to treat standards falling short of their respective targets (91.0% vs 96% and 69.4% vs 85%).

When it comes to lung cancer, more than 5,000 cases have been identified through the NHS Targeted Lung Health Check Programme since its launch in 2019. Some 76% of these were found at the earliest stages of one and two, offering those patients the best chance of survival.

In fact, NHS data shows a 7.4% improvement in lung cancer early diagnosis rates from April 2023 to March 2024 compared to March 2019 to February 2020. However, the overall picture is varied and there’s still work to be done to ensure targets are met, screening successes continue and patients receive the best treatment as early as possible.

Respiratory consultant Dr ZaheerMangera is the lung cancer lead at North Middlesex University Hospital NHS Trust in London, UK. Optimising and delivering a successful lung cancer pathway is one of his main focuses, and this requires a careful balance of speed, accuracy and resource.

What should physicians note about the latest advances in lung cancer diagnosis and management?

There hasn’t been much dramatic change to NICE guidance – since 2019, it’s been more subtle. Some of the big changes have been around early diagnosis, specifically lung cancer screening, which I’ll come onto shortly.

The way I look at NG122 is that it provides a basic framework, setting down the minimum criteria for delivering a lung cancer pathway. Lots of the guidance relates to order, process and speed. It doesn’t really provide a manual of how you should treat lung cancer, but it does touch on some important aspects.

Faster diagnosis consumes us as lung cancer physicians – everything is about speed, getting patients discharged off the pathway as quickly as possible, and trying to get those who do have lung cancer through it so they can get treatment at lightning speed.

The document Millimetres Matter, published by the United Kingdom Lung Cancer Coalition in 2018, is an important first stepping stone in terms of speeding up the lung cancer pathway. It recognises that when looking at the T-stage of a tumour, the stage of a patient can change just by a millimetre. And those changes can happen within the course of a 62-day lung cancer pathway.

We want everyone to be sprinting towards that finish line, whether it’s discharging from the pathway or making a lung cancer diagnosis. But we know from numerous lung cancer audits year-on-year that there’s huge variety of performance. Some Trusts are doing an excellent job getting patients through the pathway rapidly, others not so good.

But this speed is important as this report highlights a 16% mortality increase if the time from diagnosis to surgery goes beyond 40 days. So, it’s important we challenge ourselves to 62 days, knowing significant numbers of patients’ cancers will progress within the lifetime of that pathway.

How do patient experience and the postcode lottery come into this?

Patient experience is really important. Sometimes my patients say everything’s going too quickly for them, but most want to get their diagnosis the day before yesterday.

Many would have been to their GP or emergency department several times before even arriving on the pathway. It’s all about trying to consistently drive standards up and recognise what specific standards we should be focusing on to even out performance across the different Trusts.

With the lung cancer pathway, Trusts aren’t actually competing with each other, but we want them to be within a hair’s breadth of each-other – like in the Paris Olympics 100m final – because we don’t want to see an ongoing postcode lottery as to whether patients survive the pathway and get access to the best treatments within a rapid timeframe. This all coincides with the faster diagnosis standard.

A lot of my time is spent looking at how many patients are breaching the 62-day pathway and how many are inside it, but the faster diagnosis standard is important. It’s quite a simple principle: within 28 days of the referral being sent by primary care, the patient needs to know whether they have a cancer or not. They don’t necessarily need to know the treatment plan or next steps, but they need to be told that much.

At my Trust – a medium-sized district general hospital in London – the last audit showed that for every 100 GP referrals, there were three cancers found, meaning there are 97 patients sitting there worrying they may have lung cancer. So, the benefits are huge if we can achieve this 28-day target of telling patients.

What are the ideal steps for progressing towards that 28-day diagnosis target?

If we look at the National Optimal Lung Cancer Pathway (NOLCP), we’re expecting Trusts to ensure that the patient has had an X-ray, ideally, before they’ve even seen us. We’re also looking at the CT being done within 72 hours of that referral.

We’re failing at this in my Trust quite abysmally at the moment, which is really disappointing. It’s even more disappointing that we were achieving this pre-Covid and so post-Covid there has clearly been a catastrophic collapse in how we arrange and deliver our radiology. There are lots of different factors behind that, but we certainly haven’t been able to achieve this CT target for quite some time.

But the way we mitigate that is by trying to fast-track high-risk patients, particularly those with an X-ray abnormal for lung cancer specifically. Something being developed in a number of Trusts, which I think is live in Manchester, is artificial intelligence (AI) reporting of X-rays. If there is an abnormality, it can get flagged for reporting by a radiographer or radiologist earlier on. This is one area where we may be able to pick up these high-risk cancers much more quickly.

And how about approaching the various targets for diagnosis and starting treatment?

Ideally, we want patients to meet a lung cancer specialist – or a clinical nurse specialist in Trusts that have them – within the first six days. By day 14, we want the whole panel of tests done: PET/CT, if relevant, spirometry and more advanced lung function tests like gas transfer.

Then by day 21, we want that full multidisciplinary team (MDT) discussion where we make a treatment plan, so by day 28 we’re giving the patient the all-clear or telling them the diagnosis. That gives plenty of time to get treatment started by day 49 – the maximum length of the NOLCP.

The paradigm shift is that rather than giving ourselves 62 days, we’re trying to get that treatment within 49 days, which is what we’re increasingly being audited against. Although the National Lung Cancer Audit is still publishing the 62-day results, but it’s the 49 days that’s quite important now.

What are the barriers to achieving this?

More hospitals have endobronchial ultrasound (EBUS) as part of their suite of investigations compared to a decade ago, so there’s less referral into other centres. But time to EBUS can still be problematic and patients in some areas, particularly for general anaesthetic EBUS procedures.

We’ve also seen a whole range of barriers in my own Trust around PET/CT scans. We’ve been waiting three to four weeks for a PET/CT and more recently have got them done within three to four days as more scanners come online. The issues are the physical infrastructure required to get a PET/CT scanner in, radiology reporting limitations and the fact that there won’t be this scanner in every hospital – there is going to be a hub and spoke model.

Perhaps most pertinent barrier is getting access to molecular markers for treatment plans, epidermal growth factor receptor (EGFR) status and immunohistochemistry. In my practice, it can be a full four weeks from the day I take the biopsy before we’ve got access to the full molecular markers.

Another innovation is access to circulating tumour DNA (ctDNA) blood tests. It’s been online for over a year, and my Trust has been part of a pilot for the last six months. A simple blood test is sent to a specialist lab and you get a very detailed report within two weeks. It’s particularly good if you’ve got somebody with stage three cancers or above where there’s metastases and some tumour DNA has spilt into the blood. We’re getting quite a few false negatives where the patient may well have cancer, but there’s just not enough tumour DNA present for any meaningful results to be gained from the blood test. But this can speed things up, and you can use it alongside your biopsy results to determine appropriate treatments.

What are some of the factors causing improvements in lung cancer early diagnosis rates?

The first thing to say about early diagnosis is that within the NHS, there is almost a pseudo screening programme, given how many patients are receiving all kinds of CT scans that incidentally pick up early lung cancers.

These are all very fruitful pathways for us lung cancer physicians because we tend to pick up asymptomatic lung cancer from, say, the chance CT colonogram that may have included a CT chest as part of its protocol. There are hundreds of CT coronary angiograms being done every month at our local tertiary cardiology centre and we’ll see a small percentage of them, but it actually ends up being quite a large number with reported nodules.

For those of you working alongside rapid diagnostic centres where, typically, patients will present with symptoms of weight loss, but no clear pathway for them to be referred to, they’ll be churning out quite a lot of CT chest-abdomen-pelvis. There’s direct access to CT pancreas in many areas for GPs, which can sometimes include a CT chest – the list goes on. We’re seeing lots of imaging, and we’re finding lots of incidental findings, and it’s quite a rich resource.

The message is that all lung MDTs – whether diagnostic or treatment – are absolutely being flooded with incidental findings but as some of these are picking up early lung cancers, it’s very difficult for us to say we want that Pandora’s box to be closed and we want this imaging to be a bit more thoughtful and a bit more targeted. This is going to be an area that becomes increasingly important for us to navigate.

How does lung cancer screening impact early diagnosis and mortality risk?

Lung cancer screening has captured the imagination of the UK, particularly of England, and we’re seeing more lung cancer pathways. Some are hospital-based, some are in community hospitals, and some are roaming around with patients sometimes being invited to screening on lorries in supermarket car parks.

The lung cancer screening story started back in the 1970s, but real major changes to practice were first initiated by a study initiated in the 2000s and reported on around 2010/11. Here, America’s National Lung Screening Trial found you could secure a 20% reduction in lung cancer mortality if you started screening high-risk patients, typically smokers between age 50 and 70. Subsequent studies, like the European Nelson Study, found a mortality reduction of up to 26%.

It answered the question, beyond any reasonable doubt, that if you want to try to improve cancer mortality, earlier diagnosis is the strategy, and you need an appropriate tool to do that. A non-contrast, low-dose CT is a very effective way of ruling in or ruling out lung cancers.

One interesting outcome is a differential in the mortality gain between men and women. In the Nelson Study, for example, you can get up to 33% improvement in mortality in females compared to males where it’s around 25%, and it’s listed as a risk reduction.

This doesn’t necessarily change our approach, but it tells us a bit about the biology of cancer in women, and how they may well have more treatment options and better response to treatments. But remember, this population are smokers or ex-smokers, so it doesn’t answer the whole question about the difference between men and women but it’s an interesting observation.

What’s the criteria for the targeted lung health check and what’s the uptake?

In the UK, you have to be between the age of 55 and 75, you need to be registered with a GP, and you need to have a smoking history. Different risk assessment tools or prediction models are used – whether it’s LLPv2 or a PLCO – and, depending on the risk score, you can be invited for a CT scan screening.

There are lots of challenges around targeted lung health checks and the first is how many patients are agreeing to have a scan. CT scans aren’t usually as problematic as other types of screening – such as bowel screening – and may feel less invasive for some patients, but they still require the patient to engage, taking time off work or travelling quite some distance in some cases.

Nationally, the most recent update reveals around 42% of patients have a CT scan when invited. Some areas, like North East London, for example, have an uptick of around 80%.

It all depends what strategies are in place to try to improve uptake and how you can engage with your community and engage with people who may be at risk, including people without English as their first language and other groups that are more difficult to reach.

How are workload and systems issues being tackled?

The number of nodules that our colleagues are finding in these targeted health checks is monumental. AI reporting and having a clear protocol for these does help, and a lot of these incidental findings can be dismissed without ever coming directly into an NHS lung cancer pathway.

In my experience, we’re only seeing those who are genuinely higher risk or are borderline. We’re not seeing too many patients who just need a standard lung nodule follow-up.

It’s a challenge in terms of aligning clinical systems and ensuring everything works, given most hospitals don’t have integrated systems. You’ll have a targeted lung health check serving a number of different hospitals that all have different systems that don’t talk to each other.

Where I work, we’re still receiving referrals by email, which of course is problematic if an email isn’t read or actioned in the usual way.

There are questions over whether we should be scanning younger or older patients and that will always be a big debate – have we got the age groups correct?

And this is all being done in the context of an under-resourced lung cancer service. Looking at the national picture, our mortality rates are still well behind most of Europe. A lot of this is to do with the actual resources and numbers of PET/CT scanners, chest physicians and oncologists.

What are some of the added benefits of targeted lung health checks for patients?

We can identify other life-threatening findings, like an aortic aneurysm that’s about to rupture, for example. Patients will get spirometry during the testing phases as well, so you can diagnose COPD. The CT findings themselves can offer important lung findings, such as undiagnosed pulmonary fibrosis or other interstitial lung diseases – bronchiectasis, for example – and cardiac conditions such as the degree of calcification of the coronary arteries.

It’s also an opportunity to offer a tobacco dependency service, because many of these patients will be current smokers, and so it’s a good way of offering a treatment for their tobacco dependency.