A call for hope

Cancer is expected to rank as the leading cause of death and the single most important barrier to increasing life expectancy in every country of the world in the 21st century. The recently published GLOBOCAN 2018 report begins with these words.¹ The report contains the cancer incidence and mortality rate estimates compiled by the International Agency for Research on Cancer (IARC), the most cited source on cancer epidemiological data. According to the report, in 2018 there will be an estimated 18.1 million new cases of cancer and 9.6 million deaths worldwide, with 23.4% of the new cases and 20.3% of the deaths occurring in Europe, despite the fact it only has 9% of the global population.

Closely related to these data is smoking, which continues to be the largest preventable epidemic in the world. Smoking was responsible for the death of an estimated 100 million people over the course of the twentieth century, more than the total number of deaths caused by the First and Second World War together. In Spain, in the five-year period 2010–2014, there were 259,348 deaths attributable to smoking, half of which were deaths from cancer (49.9%). Although over the last few decades there has been a significant decrease in the number of smokers, according to the Spanish National Health Survey of 2017, 18.8% of women and 25.6% of men still smoke daily.

The close relationship between smoking and lung cancer has long been well known, but this has not prevented lung cancer from even today continuing to be the leading cause of cancer death in the world. According to the GLOBOCAN report, in 2018, 2.1 million new cases of lung cancer were diagnosed and 1.8 million people were expected to die. In Spain, lung cancer is the second most common cancer in men (after prostate cancer) and the fourth in women, in addition to being the leading cause of death from cancer (20.5%). In other words, a preventable disease is responsible for one in five cancer deaths in Spain. Over recent years, we have seen how lung cancer has also started to be common in women. In fact, lung cancer is already the leading cause of death from cancer among women in 28 countries; those where smoking among women became popular earlier. In the United States, more women die from lung cancer than from breast, colon and ovarian cancer combined, a trend that is expected to be reproduced in other countries in our region where smoking among women did not become popular until later.

Consequently, in addition to persevering in the fight against smoking, it is time to remind ourselves of the importance of lung cancer screening. The most relevant study for a long time was the National Lung Screening Trial published in 2011.² It analysed the utility of selective screening with low-dose computed tomography (LDCT) in 53,454 smokers or former smokers who had stopped for less than 15 years, with a cumulative minimum consumption of 30 pack-years and aged from 55 to 74. The study demonstrated the utility of LDCT in achieving a relative reduction in death from lung cancer of 20% and in the overall mortality rate of 6.7%.

However, the number of false positives, the need to perform invasive tests in some cases and the cost-effectiveness have limited implementation. According to a recent study in the United States, only 262,700 of the 6.8 million eligible smokers were screened despite it being included in the guidelines and reimbursed by the major insurance companies.³ On the subject of screening, at the end of 2017, a position statement was published in which experts from eight European countries called for the implementation of lung cancer screening, opening the document with the sentence “Screening for lung cancer can save lives”.⁴

In Spain, aware of the additional challenge posed by the fragmentation of our health system and at the request of the Spanish Society of Medical Oncology, a working group was set up, with different scientific societies being invited to participate, to discuss the need to promote implementation within the framework of the National Health Service. The efforts of the working group resulted in the publication of the document “Reflections on the Implementation of Low-Dose Computed Tomography Screening in Individuals at High Risk of Lung Cancer in Spain”.⁵ Unfortunately, this document has not had the repercussions we had hoped for, despite the fact that it was shared with all the healthcare bodies.

The good news is that we now have a new opportunity to promote this debate and once again raise the issue of the need for pilot projects to guide us on the best way to implement lung cancer screening in our environment. This opportunity has been prompted by the recently reported NELSON study,⁶ which confirms that screening in an at-risk population reduces deaths from lung cancer. This study, carried out in more than 15,000 people at risk, again demonstrated a decrease of 26% in lung cancer deaths in men and 39–61% in women through screening with LDCT.

Considering the magnitude of the problem (high incidence, astronomically high mortality rate) and the scientific evidence now supported by two positive studies, we firmly believe that it is necessary to promote a debate in our environment in which scientific societies and those responsible for the different healthcare bodies decide on the best way to address this situation. We cannot sit back idly by in the face of such a serious health problem if it is in our power to help reverse these dramatic figures. Of course, any approach or debate on lung cancer screening must be linked to a commitment against smoking. We need to promote smoking cessation units, finance the treatment of addiction to smoking and, in our opinion, we need to raise taxes; a measure which could be particularly effective among young people. We also need to remember that we have a law which is not always abided by and that there are many voices demanding greater control in leisure facilities and restaurants.

Healthcare professionals have much to contribute to this issue, not only through scientific leadership, but also through our personal commitment and by improving training. This training has to begin when medical students are at university and should not be limited to simply learning about the risks of smoking. It needs to include in-depth knowledge about lung cancers (lung cancer as a single entity no longer exists, but instead there are different types with different approaches and prognosis), as medical students often know little about this area due to the lack of priority given to Oncology as a subject in the undergraduate programme. We would like to see this as our contribution to a future where there is no such thing as a doctor who smokes. The training must be continued during the residency period, so that no patient has their diagnosis delayed due to a lack of knowledge about the new clinical presentation profiles, and to ensure that multidisciplinary teams are prepared to make decisions on X-ray and CT scan findings in at-risk population or in chance discoveries, which are so common in some settings. The training must also be aimed at convincing our residents to stop smoking. Lastly, the training has to accompany us throughout our professional career, to help us provide the best treatments and the best quality of life to our patients, and help us learn about and be able to implement the extraordinary technological advances we are making.

By following this path, I hope, we will be better able to positively influence a society in which one in every five people still smokes, because you need to help us to save lives by responsibly promoting screening for lung cancer in our environment.