4-IN THE LUNG RUN: towards INdividually tailored INvitations, screening INtervals, and INtegrated co-morbidity reducing strategies in lung cancer screening

Project Information

4-IN THE LUNG RUN

Grant agreement ID: 848294

DOI

10.3030/848294

Project closed

EC signature date 6 December 2019

Start date 1 January 2020

End date 31 December 2025

Funded under

• SOCIETAL CHALLENGES - Health, demographic change and well-being

Total cost

€ 7 999 948,75

EU contribution

€ 7 999 948,75

Coordinated by

ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM
Netherlands

Periodic Reporting for period 4 - 4-IN THE LUNG RUN (4-IN THE LUNG RUN: towards INdividually tailored INvitations, screening INtervals, and INtegrated co-morbidity reducing strategies in lung cancer screening)

Reporting period: 2024-01-01 to 2025-06-30

Summary of the context and overall objectives of the project

With 338,000 EU-deaths annually, lung cancer is a devastating problem. CT screening has the potential to prevent ten-thousands of lung cancer deaths annually. The positive results of the Dutch-Belgian screening trial (NELSON), with relatively low referral rates, and the NLST in the US, with annual screens only, provided conclusive evidence on the benefits (and possible harms). However, EU-implementation is likely to be limited, slow and of variable quality throughout European countries, and current international guidelines could easily require up to 25 million CT screens annually. The most optimal strategy in risk-based lung-thoracic screening is still unknown regarding the optimal and most cost-effective (e.g. targeted) strategy 1) to recruit high-risk individuals, 2) to integrate smoking cessation and co-morbidity-reducing services, and 3) to determine the preferred personalised (risk-based) screening interval. Personalised regimens based on the baseline CT result can potentially retain 85% of the LC mortality reduction achievable through screening at 45% less screens, thus potentially saving much unnecessary harm associated with screening, and 0.5-1 billion Euros per year.

The heart of 4-IN-THE-LUNG-RUN is a European randomised controlled multi-centred implementation trial amongst 20,054 individuals, at high risk for developing lung cancer, evaluating whether it is safe to have risk-based less intensive screening intervals after a negative baseline CT.
Various methods to improve participation of hard-to-reach individuals will be assessed in five different healthcare settings/countires. Innovative co-morbidity reducing strategies will be tested including other markers on CT imaging, as Calcium Score and COPD. Cost impact and cost-effectiveness analyses using a natural history model will steer implementation. The experienced consortium will strongly interact with key stakeholders, and discuss interim results with key other international initiatives on CT screening, biomarkers, and smoking cessation practices. This proposal will form the evidence base for risk-based lung cancer screening with huge benefits for the EU, on health outcomes, cost savings, and innovation in the long run.

Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far

The definitive clinical study protocol, nodule management protocol and the acquisition protocol have been agreed by all countries and were finalized. All recruitment materials has been developed for all individual countries. Based on the first results, different recruitment methods can be used to adequately recruit the target population for lung cancer screening. Lessons are learned from interviews, focus groups and questionnaire about preferences of the target population and also the informed decision making proces. Further indept analyses will contribute to recommendations.

An online data management system was developed to coordinate the trial from begin to end of the trial, which was an intensive process of developing all relevant aspects needed for high-quality lung cancer screening in which the data/privacy of participants will be protected and legal requirements of all centres were carefully implemented in the system. The system consists of several units (central unit = administrative tasks; screening unit = planning of the CT scans and performing of the CT scan; reading unit = reading of the CT scans). These units together thus include the whole screening workflow from recruitment until end of screening. Thereby, the system is configurable to all localities to support the implementation of high-quality lung cancer screening.

Currtently, high-quality European implementation of lung cancer screening is in all partner regions ongoing. Ten thousands of CT scans were performed and the (last) Biennial Screening Round started in September 2024. Many lung cancer were dectected and further analyses will have to provide more evidence about whether the screening interval can be personalised and less intensive based on previous results.
A new nodule management protocol (based on NELSON results) was developed and integrated in the data management system. This protocol has been refined based on the experiences of the baseline scans and first annuals scans. Furthermore, machine learning approaches for lung cancer (and cardiovascular disease and COPD) were developed and implemented in the screening protocol/ data management system to improve biomarker identification and to explore novel algorithms applied to measure those imaging biomarkers.
An (online) training programme about lung cancer screening was developed for radiologists that enter the reading programme about lung cancer screening. AI research contributes to the development of the integration of AI reading to reduce the workload for radiological readings drastically.
Furthermore, the natural history models for lung cancer screening that incorporate country-specific data on lung cancer epidemiology, smoking behaviour and health care services (costs) were developed for several countries

Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)

The aim of 4-IN-THE-LUNG-RUN concerns the remaining key steps in the development of an optimal risk-based low-dose volume CT lung cancer screening programme for all high-risk European citizens, and to substantially reduce unnecessary harms, while maintaining the huge benefits of lung cancer screening, through a personalised approach.
It is expected that our proposed programme and strategy will decrease health care cost and suffering for patients in the advanced palliative phase by ten-thousands individuals per year. These programmes will reduce the amount of anxiety, false positives, radiation risk and possible complications, all directly benefiting European citizens, proportionally tackling more lower socio-economic groups. Screening cost may be reduced by half compared to the anticipated annual screens in non-risk based screening intervals. Furthermore, the suitability for implementation is an important part of the project design and capacity building programmes and quality assurance schemes will be developed.
Moreover, we ensure special attention to individuals with lower socioeconomic backgrounds, by tailoring different groups differently at recruitment, and encompass all earlier expertise in population-based screening trials across the participating countries into the ethical components (including communication to low risk individuals).
In conclusion, the project will determine if personalised risk-based lung cancer screening (as compared to annual screening): 1) is safe, 2) is less morbid, 3) is more accepted by the hard-to-reach high-risk population, 4) enables prevention (especially smoking cessation) and 5) has greater health care value for decades to come.

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