Discussions about lung cancer screening in Poland started in 2006, and between 2008 and 2010 four lung cancer screening programs were independently implemented by thoracic surgeons in Szczecin, Gdańsk, Poznań, and Warsaw, each with separate funding. From that point until 2018, more than 50,000 individuals at high risk of developing lung cancer were examined through these programs, with low-dose CT (LDCT).1 In practice, some were only early lung cancer detection programs, with one or two rounds of screening financed within each program; there was no further systematic control of screened individuals. Further controls were performed in the public healthcare system. In Szczecin and Poznań, the programs were fully financed by regional government funds. In Warsaw, the program targeted the regions with the lowest resection rates and was financed by the national Ministry of Health. In Gdańsk, screening was funded by grants from Polish scientific institutions. Inclusion criteria were similar in all these sites: individuals who were 50 to 70 years old, or 75 years old, and who had a smoking history of at least 20 packyears.
In Gdańsk, we have received five grants related to the lung cancer screening: three of them were completed between 2011 and 2018, and two began in 2018. The total funding from these grants, provided by Polish national institutions, was the equivalent of 6 million Euros. In two of these grant-funded programs, we performed three rounds of lung cancer screening with LDCT. In the other three, we searched for molecular and radiomic signatures of early lung cancer (we termed these programs “mollecular test for early lung cancer,” or MOLTEST). From these screening programs, performed in a single center and by a single radiology department, through the work of this radiology team we have gained a great deal of practical information that has been very useful in planning future regional and national screening programs.2
Recruitment strategy was the most important aspect in ensuring the success of the programs. There was great interest from participants in the first 2 years, but later on, interest waned. Establishing very close cooperation with family doctors proved to be a successful strategy; however, it was difficult to achieve, for several reasons. Postal notification, which has been effective in the Netherlands and Scandinavia, failed in Poland during previous efforts to recruit participants for prostate cancer screening; thus, we did not attempt to use this method in our program. Experience of the screening team was another important issue. Experience gained by the team in the first program resulted in a reduction in false positive results, unnecessary invasive diagnostics, and futile surgeries.2 Of the patients in whom cancer was detected, 65% versus 75% underwent surgery in the first and second programs, respectively. Stage I or II lung cancer was detected in 85% of all patients who underwent surgery, and both programs had a mortality rate of zero and a low complication rate.2
Implementation Process
In Poland, intensive discussion on lung cancer screening resulted in the appointment of an interdisciplinary group comprised of thoracic surgeons, oncologists, pulmonologists, epidemiologists, tobacco control specialists, and healthcare organizers, which prepared a consensus statement on lung cancer screening, a basic agreement of how to implement the Polish national program.3 But that was not enough, of course. The main challenge after achieving consensus within the academic community was to carry out the implementation process through state institutions. In the act of constructing this implementation plan for lung cancer screening, it was crucial to have on board not only the most important professional personalities, but also high-profile politicians. We were lucky to have such a representative—a thoracic surgeon, Professor T. Grodzki, who is currently a speaker of the Senate in the Polish parliament.
Thus, a long road that was embarked on in 2015 led to funding of a national pilot program in 2020. This program is based on recommendations from leading Polish and European guidelines, namely: to build centers capable of multidisciplinary evaluation, with expertise in dealing with lung cancer and options for video thoracic resections; reduced morbidity and options for stereotactic radiotherapy for those who may choose not to pursue surgery; prioritization of quality monitoring and education of physicians participating in the screening; and, of course, mandatory inclusion of a smoking-cessation program.4,5,6
Healthcare is free for all citizens in Poland and is delivered through a publicly funded healthcare system. In general, this system, similar to many systems in European countries, is centralized and controlled by the National Health Fund. However, private healthcare is being used more and more extensively, which prompts the question of whether to build the national screening program only in the centralized forum.
All these steps led, after 2 years of carefully orchestrated efforts, to the decision to finance the pilot program through an EU-supported POWER grant provided through the Polish Ministry of Health. This grant is designated for 3-year programs that are administered in all Polish provinces. Our screening program covers the whole country, which is divided into six macroregions comprising two to four provinces each. One leading center in each macroregion was appointed. In each macroregion, during 1 year, an average of 4,000 individuals at risk of developing lung cancer will be screened. Individuals for whom no suspected nodules are diagnosed will undergo an additional two rounds of screening. Individuals for whom nodules are detected will be sent to the public healthcare system—that is, the leading institution in each region is appointed to follow the diagnostics and treatment.
The criteria are 50 to 75 years of age and a smoking history of at least 20 packyears. In each macroregion, two to four screening centers were established, and each center signed a cooperation contract with family-doctor centers. Cooperation of these family-doctor centers is very important for future nationwide implementation. It would also be best, for quality and consistency, to use one central radiology center for interpretation of images. However, none of the radiologists decided to devote themselves entirely to lung cancer screening. Therefore, all LDCT images will be read in the center where the CT is performed, with supervision by radiologists from the leading centers. Radiologists from other participating institutions will systematically be trained in these appointed centers as well.
In such a centrally administered program, implementation of efficient software that collects all participants’ data and stores all CT images is essential for both practical reasons and quality control. Such software helps with communication between the different specialists and family doctors involved in the program. This helps to optimize multidisciplinary clinical decisions, which are often critical for patients with lung cancer. We are using cloud-based technologies and services for radiology, including an integrated radiology information system and picture archive and communication system and a teleradiology platform to collect the data and images. Based on recommendations of the VA-PALS Implementation Network (VA-Partnership to Increase Access to Lung Screening), the networking software was constructed to facilitate radiologic work-up and decision making concerning next steps for detected nodules.
We are planning to implement a new image-quality approach in our program that will be based on phantom testing, as well as adjustment of CT machines that are used in all accredited radiology departments, with support of the Radiological Society of North America. We will also implement a smoking-cessation intervention, which is essential for the success of lung cancer screening. The practical solution to how this intervention is applied depends on local circumstances. In some places, a tailored approached is scheduled, beginning with a short intervention onsite during the visits in the family-doctor office and in the radiology department by the trained staff, followed by registration at an anti-smoking clinic.
Start of the Program
The program started January 1, 2020, and was suspended March 5 because of the COVID-19 pandemic. It opened again in August 2020. The immediate future of the program is uncertain because of the expected second wave of COVID-19, and it will be steered by the government agencies that are financing the lung cancer screening. Also uncertain is the future of national screening after this pilot program is completed. Until now, no specific decisions have been made by the Ministry of Health.
References:
- Adamek M, Biernat W, Chorostowska-Wynimko J, et al. Lung cancer in Poland. J Thorac Oncol. 2020;15(8):1271-1276.
- Ostrowki M, Marjański T, Dziedzic R, et al. Ten years of experience in lung cancer screening in Gdańsk, Poland: a comparative study of the evaluation and surgical treatment of 14 200 participants of 2 lung cancer screening programs. Interact Cardiovasc Thorac Surg. 2019;29(2):266-274.
- Rzyman W, Didkowska J, Dziedzic R, et al. Consensus statement on a screening programme for the detection of early lung cancer in Poland. Adv Respir Med. 2018;86(1):53-74.
- Rzyman W, Szurowska E, Adamek M. Implementation of lung cancer screening at the national level: Polish example. Transl Lung Cancer Res. 2019;8(suppl 1):S95-S105.
- Oudkerk M, Devaraj A, Vliegenthart R, Henzler T, Prosch H, Heussel C, et al. European position statement on lung cancer screening. Lancet Oncol. 2017;18(12):e754-e766.
- Pedersen J, Rzyman W, Veronsei G, et al. Recommendations from the European Society of Thoracic Surgeons (ESTS) regarding computed tomography screening for lung cancer in Europe. Eur J Cardio-Thorac Surg. 2017;51(3):411-420.
