No complaints, due to the CT scan: ‘The sooner we detect lung cancer, the greater the chance that someone will be cured’

No complaints, but a higher risk of lung cancer; More than a thousand people from the Drachten region have passed through the CT scanner in Nij Smellinghe hospital since May last year. 51 of them were referred to a pulmonologist because of suspicious spots on the lungs. Of the referred people, it was expected that more than half actually had an early stage of lung cancer. Those patients are now being treated.

Nij Smellinghe Hospital in Drachten is one of three screening locations in the Netherlands for the European pilot population study 4-IN-THE-LUNG-RUN, in addition to the Antoni van Leeuwenhoek in Amsterdam and the Link2Care clinic in Bilthoven. In the study, which is also being conducted in England, Germany, Spain, Italy and France, researchers detect lung cancer at an early stage so that the risk of dying from the cancer is reduced. The Erasmus Medical Center in Rotterdam coordinates the research in Europe.

Other places in the body

“Normally, people only go to their doctor when they have complaints, such as prolonged coughing or shortness of breath. If it turns out to be lung cancer, then in more than half of the patients the cancer has already spread to other places in the body,” explains Maarten Smeekens, pulmonologist in Nij Smellinghe. “In many cases the patient cannot get better anymore. The sooner we act, the greater the chance that someone can still recover, because there are more treatment options, such as surgery or radiation treatment.”

Nij Smellinghe started as a screening location in May 2023. In total, more than 300,000 Dutch people between the ages of 60 and 79 received an invitation to participate in the study. Those who were willing to participate first had to complete a questionnaire to assess whether they have a higher risk of lung cancer. These are mainly people who have been smoking for a long time, or have smoked for a large part of their lives. Of that group, 9,000 people have now had a first scan. Just under eight in a hundred people are referred for additional testing. More than half of them actually have lung cancer.

Roll out nationally or European

Ultimately, the intention is to roll out the population survey nationally or at European level. This large-scale trial should show whether the target group for the research can be sufficiently reached and how the research can be properly implemented. “In the population screening for breast cancer we select based on age and gender, for lung cancer the question is ‘who do you invite?’ more difficult,” explains Carlijn van der Aalst (40), associate professor at Erasmus MC. “In addition, it is a group with different information needs. People at a higher risk of lung cancer are more likely to be less educated and less likely to participate in these types of programs and studies.”

So far, reaching the target group has been going very well, she explains. “We seem to be reaching the right people, and the response is also good. Of the 300,000 people contacted, many thousands were willing to cooperate.”

Evil balls

People who participate in the study are assigned to a program. Depending on this, they will receive two or three scans over a two-year period. This scanning is done with a scanner that makes it possible to scan in great detail and with a low radiation dose. “That is necessary because we scan people who have no complaints,” explains radiologist Daniël Lubbers of Nij Smellinghe. “Then you are not allowed to scan with too high a dose.”

The CT scanner in Nij Smellinghe is so accurate that even very small abnormalities can be detected early. Such a scan is then assessed by radiologists. Lubbers: “We look for masses in the lungs that differ from normal lung tissue. If we find that, it is not immediately a bad thing, because many people in this age category show abnormalities, for example in the form of benign bumps. So we have to estimate the risk that such a ball is malignant. To do this, we look at the volume and density of the tissue, and whether it contains calcium or moisture, for example. Based on this we can estimate the risk. If it is very difficult, we take the time as an indicator. Then we look at the next scan to see what has happened to the tissue. Has it grown? Then that is suspicious, because benign tissue often does not grow that quickly.”

The scan and assessment are then sent to Erasmus MC, which informs the GP and the participant if suspicious tissue is visible. The participant is then referred to the pulmonologist and leaves the research program.

Healthy lifestyle

If a national population screening for lung cancer is actually introduced, this must always be accompanied by the promotion of a healthy lifestyle, says Smeekens. “The large-scale introduction of such a screening depends on addressing lifestyle issues, such as quitting smoking, more exercise and a healthy diet.”

In Nij Smellinghe, participants can already go to the Samen Gezond Consultation Hour, an initiative of elderly care organization Sûnenz and Sportbedrijf Drachten. During consultation hours, people can talk to a coach about how they can implement a healthy lifestyle. Smeekens: “For example, they can be referred to a coach who can help them to quit smoking.”

‘Stopping smoking is always good’

Quitting smoking is always good, Lubbers and Smeekens emphasize. However, quitting smoking may not always provide a sufficient solution for people with a higher risk of lung cancer. Van der Aalst: “We sometimes receive criticism of these types of programs. People who believe that screening is not necessary, because the risk of lung cancer is people’s own fault. But it’s not that simple. Firstly, people have often been smoking for so long that quitting smoking cannot sufficiently reverse the damage to the lungs, and secondly, people have often become addicted during puberty.”

For the target group of this study, screening can contribute up to ten times more to recovery than quitting smoking, she explains. “Because the damage is already there. A combined program makes the most contribution.”

A population screening for lung cancer must therefore always be accompanied by promoting smoking cessation, says Smeekens. “Stopping smoking also helps for good treatment outcomes, reducing complications and preventing other conditions. For example, it can improve the success rate of surgery or radiation. Stopping is not always a solution, but it is always better than not stopping.”

“Ultimately, lung cancer is largely avoidable,” Van der Aalst adds. “Preventing young people from smoking or ensuring that people stop smoking earlier helps prevent people from developing such a high risk of lung cancer. In this way, lung cancer screening may ultimately become unnecessary.”

The pilot population study will continue for at least 2.5 years, because the participants will be followed for at least two years after the first scan. Erasmus MC will then submit an advisory report on how lung cancer screening could be implemented. Ultimately, the Minister of Health, Welfare and Sport decides whether there will actually be a population screening for lung cancer.