Original Title: Évaluation du projet pilote de dépistage du cancer du poumon : effets sur la santé des participants et impact organisationnel sur le système de santé

Authors' objectives: Lung cancer is the most frequently diagnosed and most fatal neoplasia in Quebec, notably because it is often diagnosed at an advanced stage. In Canada, the distribution of lung cancer cases according to stages I, II, III and IV is 21%, 8.2%, 20% and 49% respectively (unknown stage: 2.0%). For early-stage disease (stages I-II), surgery is the preferred treatment, as it offers the best chance of survival. Some stage IIIA cases are also eligible for surgery. In Canada, the 5-year net survival rates for stages I-IV are 62%, 39%, 16% and 3.1% respectively. In previous work commissioned by the Ministère de la Santé et des Services sociaux (MSSS), the Institut national d'excellence en santé et en services sociaux (INESSS) evaluated the relevance of implementing low-dose computed tomography (LDCT) lung cancer screening in Quebec (report published in 2019). As a result of this work, the INESSS recommended that screening should first be offered and accessible as part of a rigorous evaluation in a real healthcare setting. Thus, in June 2021, the MSSS proceeded with the gradual deployment of a lung cancer screening demonstration project. This project aimed to recruit 3,000 participants aged 55 to 74 who met the established eligibility criteria, and to follow them through 2 screening cycles. Ten facilities affiliated with seven health and social services institutions offered screening as part of the project. Three partners collaborated in the demonstration project evaluation: the MSSS Direction de l'évaluation, the Bureau d'information et d'études en santé des populations of the Institut national de santé publique du Québec (INSPQ) and the Direction de l'évaluation et de la pertinence des modes d'intervention en santé of the INESSS.

Authors' results and conclusions: RESULTS: A total of 3,200 people took part in the demonstration project and had a LDCT screening at one of the 10 participating facilities, affiliated with 7 institutions. These facilities are located in 6 of Quebec's 16 health regions. All Quebecers eligible for screening were eligible. As of September 5, 2023, 64 participants had been diagnosed with lung cancer following a Lung-RADS 3 or 4 screening result during cycle 1 or 2. The proportion of early-stage cases (I-II) was 85%, more than four times higher than in the Canadian lung cancer population (29%; see the background section above). Treatment, health system impact and partial budget impact analyses were conducted. Where possible, the results of screening participants were compared with those of the Quebec population of lung cancer cases (INESSS Lung Cancer cohort). The 1-year allcause mortality rate, certain indicators related to adverse effects, and the parameters of certain additional economic analyses will be calculated at a later date, as they require database matching (to come). (#1 THE VAST MAJORITY OF PARTICIPANTS WITH LUNG CANCER RECEIVED CURATIVE TREATMENT, MAINLY SURGERY): The proportion of screening participants with lung cancer who received curative intent treatment as their first treatment far exceeds the set target (95%, target ≥ 65%). (#2 LUNG CANCER SCREENING COULD REDUCE MORTALITY AMONG DETECTED CASES ): The high proportions of early-stage cancer cases and use of surgery suggest that screening could help reduce mortality among detected cases. The 1-year allcause mortality rate, which will be analyzed at a later date, will help to corroborate or invalidate this hypothesis. (#3 THE DEMONSTRATION PROJECT WAS SET UP AT A TIME OF DIFFICULT GENERAL ACCESS TO CT SCAN AND LUNG SURGERY): General access to CT scans and lung surgery remained difficult everywhere during the demonstration project, with a few exceptions. These results indicate that the facilities concerned were at the limit of their capacity when it came to providing these services. • However, there were a few exceptions: – During the screening period, overall access to CT scans remained favorable at IUCPQ-UL, but not to lung surgery. – At the CISSS de Laval - Hôpital de la Cité-de-la-Santé, general access to CT scans has improved significantly, to the point of being able to offer the service with low-level delays over the last administrative periods observed. (#4 OVERALL, THE VOLUME OF SERVICES ASSOCIATED WITH SCREENING APPEARS TO HAVE HAD LITTLE IMPACT ON THE OVERALL VOLUME OF ACTIVITY AND ACCESS TO SERVICES): In the majority of facilities, CT scans and lung surgeries associated with screening represented a small (between 1% and 5%) or negligible (<1%) proportion of the total of each of these services. Similarly, positron emission tomography coupled with CT scan (PET-CT), non-surgical invasive diagnostic procedures, and radiotherapy arising from screening accounted for a negligible proportion of all services. These results suggest that services associated with screening had a minimal impact on difficulties in accessing services, where difficulties existed. Nevertheless, during a time of already difficult access, any additional demand contributes to increasing wait times. (#5 ACCESS TO THE FIRST LOW-DOSE COMPUTED TOMOGRAPHY SCREENING WAS A MAJOR ISSUE AT SEVERAL PARTICIPATING FACILITIES): At the time the analyses were completed (November 2023), the number of people waiting for a first LDCT screening was particularly high in half of the institutions / facilities (from 285 to 563 people waiting): CISSS de l'Estrie - CHUS, CUSM, CHUM and CISSS de Laval - Hôpital de la Cité-de-la-Santé. Access to a first LDCT screening was favorable in the other institutions/facilities. (#6 A GROWING BUDGET IMPACT): According to estimates, with the deployment of a provincial program, the gross budgetary impact associated with the lung cancer screening program could rise from $7.2 million in 2021-2023 to $8.6 million in 2023-2024, $13.4 million in 2024-2025 and $17.5 million in 2025-2026. Sensitivity analyses show that the investigation rate after LDCT screening is the main parameter that could influence results. By modifying this parameter alone, costs could rise up to $28.7 million in 2025-2026 if the investigation rate reached 10%. These results do not take into account certain costs, such as those for treatment of diagnosed cancers (except surgeries), which were not available at the time of the evaluation. CONCLUSION: The INSPQ, MSSS and INESSS collaborated on the evaluation of the lung cancer screening demonstration project - see complementary reports from partner institutions. The results suggest that the beneficial effects of screening, as demonstrated in the scientific literature, can be achieved in the Quebec context under the current conditions of the demonstration project. However, the evaluation highlighted a context of difficult general access to CT scans and lung surgery. The deterioration in access to the first LDCT screening, observed in several facilities, reflects this problem and represents an issue likely to limit screening performance. With the implementation of a provincial screening program, the number of participants is set to increase. Measures to improve access to LDCT screening, other CT scans and lung surgery are therefore necessary to ensure the success of a provincial screening program and to provide care to the population. The budgetary impact of the screening program is expected to increase by 2025-2026, and while estimates remain below $20 million for this period, they exclude some cost data currently unavailable. These additional data are needed to evaluate the true magnitude of the total costs associated with the eventual screening program.

Authors' methods: The demonstration project was divided into six evaluation components: 1) budgetary impact; 2) screening and investigation process; 3) health effects/clinical effectiveness; 4) effects on smoking cessation; 5) organizational impacts on the healthcare system; and 6) implementation of the demonstration project. The INESSS was responsible for component 1, part of component 3 and component 5. The aim of component 1 was to estimate the costs of deploying a potential screening program. The objectives of component 3 were to analyze, among screening participants with lung cancer, first treatments received, all-cause mortality at 1 year, and certain adverse events associated with screening. The objectives of component 5 were to estimate the proportion that the volume of screening-associated services represents of the total services of each institution/facility, to evaluate the capacity of institutions/facilities participating in the screening project to meet the demand of the general population for computed tomography (CT) and elective primary lung surgery, and to evaluate access to the first LDCT. Analyses were performed using the SI-POUMON database (screening project), the SMOD (billings), MED-ÉCHO (hospitalization and day surgery), FIPA (insured person registration) and SMED (pharmacy services) clinical-administrative databases (BDCA), as well as data from GESTRED (access to CT) and SIMASS (access to oncological lung surgery). The budget impact analysis included costs for the following activity categories: coordination, clinical, quality assurance, communication, smoking cessation, follow-up and evaluation.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/evaluation-du-projet-pilote-de-depistage-du-cancer-du-poumon-effets-sur-la-sante-des-participants-et-impact-organisationnel-sur-le-systeme-de-sante.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/evaluation-du-projet-pilote-de-depistage-du-cancer-du-poumon-effets-sur-la-sante-des-participants-et-impact-organisationnel-sur-le-systeme-de-sante.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)