European lung cancer initiative: focus on early detection and effective treatment

A European Commission plan aims to improve early cancer detection and treatment. Could lung cancer patients also benefit from this?

Matthias Manych
Published on November 11, 2021

You can be symptom-free and yet seriously ill: Globally, lung cancer is the second most common cancer and the deadliest. The lack of clear symptoms in the early stages means it is often detected too late. Early detection strategies are key, but this is a type of cancer that challenges medicine and health policy alike. We paid a visit to Professor Felix Herth, head of the Heidelberg University Hospital thorax clinic.

<p>Heidelberg is a hub for cancer research and treatment. The German Cancer Research Center (DKFZ), the National Center for Tumor Diseases (NCT), the Hopp Children’s Cancer Center Heidelberg (KiTZ), the Heidelberg Institute for Radiation Oncology (HIRO) and the Heidelberg Ion Beam Therapy Center (HIT) are all located here. The Heidelberg University Hospital thorax clinic performs an important function within this network. It is the largest lung clinic in Europe and most of Germany’s lung cancer patients are treated here. For the patients there is a clear advantage in being treated in such a center of expertise. Indeed, many cancer patients who come to the clinic are already at a stage where they require treatment.&nbsp;</p>
<p>“That’s the problem,” says Professor Herth, chief physician and medical director of the thorax clinic. He is not just referring to the high number of lung cancer patients to be treated.</p>
Prof. Herth, Heidelberg in Germany
What makes lung cancer so deadly is that the symptoms are non-specific, and patients often only come to the clinic when tumors have exceeded a critical size, or when cancer cells have attacked the lymph nodes or have metastasized. “We have considerably improved therapies to the point that patients live significantly longer and enjoy a better quality of life. But I don’t have a curative therapy approach for patients in advanced stages of cancer,” explains Herth. Of 57,000 people newly diagnosed with lung cancer in Germany in 2017 alone, around 45,000 have now died of the disease.[1] Lung cancer is the deadliest form of cancer worldwide.
The high mortality rate shows that even with all the therapeutic advances it is still crucial to detect lung cancer as early as possible. Except for small-cell lung cancer, tumors can be surgically removed at an early stage and there is a high probability of the cancer being cured. In many cases, however, the malignant cell change is detected early only by chance, for example during examinations of the spine. Uniform screening could close this gap in care. The Heidelberg lung specialist is very hopeful uniform screening will be introduced soon, to offer more patients with early-stage cancer the prospect of a cure. According to Herth, currently the only suitable screening method is low-dose computed tomography (CT).
Lung imaging
<p>Technically, CT is very well suited to screening. Compared to the X-ray image, the computed tomogram enables a precise visualization of smaller tumors. Since CT images are created layer by layer, physicians can also use the fine sectional images to assess the spatial extent of the tumor and obtain important information for a possible surgery. </p> <p>For a long time, there was a discussion about radiation exposure from CT screening. The risk of possibly causing radiation-induced damage to health is unacceptable, especially where people undergo screening examinations repeatedly over many years. Current CT technology offers the possibility of examinations with very low radiation doses. The resulting average radiation dose is just 0.6 to 0.8 millisievert (mSv). In comparison, the cosmic radiation on a flight from Germany to Japan causes radiation exposure of up to 0.1 mSv.[2]&nbsp;</p>

“The devices that we are now using are so low in radiation that I see no risk to those facing an examination,” says Herth.

<p>“A good screening program consists of a complex package of criteria and measures,” explains the lung specialist. This includes, among other things, defining standards regarding the quality of the CT images and their evaluation. There is also a need to specify how physicians should scientifically evaluate the resulting information. The follow-up examinations must also be clearly planned: which patients will receive them and at what intervals? That is why, in Herth’s opinion, it is unlikely that every radiology practice or radiological center will be able to offer screenings; instead, he believes they should take place at certified interdisciplinary centers. </p> <p>The large number of imaging examinations will also result in the discovery of many <a href="pulmonary nodules">pulmonary nodules</a>. These do not necessarily indicate cancer, but could be caused by tuberculosis or an abscess, for instance. Herth points to his computer monitor, which shows a low-dose, thin-slice CT image of a lung. It records individual layers of just 0.75 millimeters. Initially the air-filled lung tissue shows up as a black area in the cross-sectional image. Then the pulmonologist scrolls through the image layers and points out a nodule approximately 6 millimeters big.</p> <p>With a nodule of this size, there is no need for immediate treatment. Nevertheless, a CT check-up is recommended after six months. Given the fact that the patient scanned in this CT is a smoker and over 50 years old, he has an increased risk of lung cancer.</p> <p>In practice, a screening program is likely to reveal a large number of nodules. It is therefore essential to do a comprehensive evaluation, since not all findings automatically point to a malignant disease: The visual similarity between benign and malignant lesions in CT carries the risk of overtreatment, for example through unnecessary biopsies.</p> <p>To avoid unnecessary interventions, the German Radiological Society and the German Society for Pneumology and Respiratory Medicine are calling for certified centers to conduct the screening as part of a quality-assured process, with specialists from various disciplines assessing findings.[3] The experience of other countries, e.g., the UK, shows that with this approach the risk of unnecessary interventions in the case of benign tumors is extremely low.</p>

Tissue areas in the lungs that appear round and bright in the CT image (physicians speak of shading or compaction), with a diameter of up to 3 cm and clearly defined edges.

In deciding whether a pulmonary nodule should be surgically removed or treated by other means, size is not the only factor to be considered. A tissue sample, a so-called biopsy, is important in determining treatment. The biopsy is taken by means of a bronchoscopy where pulmonologists look directly into the respiratory tracts. Then interventional radiologists obtain the sample using a needle passed through the bronchoscope.
An increasing number of techniques help to detect nodules using bronchoscopy and make the method even more safe and exact. For instance, the biopsy can be planned by means of a virtual bronchoscopy using high-resolution CT images. In the future, robot-assisted navigation systems will help guide the flexible bronchoscope equipped with a camera and sensors through the narrow respiratory tract. If a <a href="microwave probe">microwave probe</a> is additionally inserted into the working channel of the bronchoscope, a tumor can be destroyed by the application of heat during the procedure. Herth and his team will soon also be working with a mobile 3D X-ray device that creates cross-sectional images like a CT, the so-called cone-beam CT. This compact X-ray unit is moved to the patient table during the bronchoscopy so that the examiners can see immediately by means of real-time images whether they have reached the target area.
The probe, which is also passed through the working channel to the tip of the bronchoscope, emits electromagnetic vibrations to the tumor. This creates heat that destroys the tumor from within.
<p>Looking ahead, Herth concludes that with cone-beam CT and robotics very few niches in the lungs will remain inaccessible. In addition to ‘classic’ imaging, modern diagnostics offers other methods, e.g. the visualization of individual cells with imaging techniques or bronchoscopes. Besides imaging, research is being done using <a href="liquid biopsy">liquid biopsy</a>, for example. However, the lung expert does not believe that any one procedure will provide sufficient information to replace the biopsy, at least in the near future. So far, none have provided either the necessary sensitivity or the specificity; Herth requires that both reach a level of 95 percent.&nbsp;</p>
Instead of a tissue sample, a blood sample is taken. As a result, the method is not invasive. In principle, it can be used to detect tumor cells or tumor DNA by molecular genetics.
The EU Commission estimates that new cancer diagnoses will rise by around 24 percent in the next 10 to 15 years – if nothing is done.[4] Europe’s Beating Cancer Plan aims to counteract this development. A variety of measures are to be initiated in the fields of prevention, early detection, diagnosis and treatment, as well as improving quality of life, that will receive a total of €4 billion in funding.&nbsp;<p>The Commission has formulated ten flagship initiatives for implementation, including an EU-wide network of cancer centers, cancer imaging procedures, equal access to diagnosis and treatment, and an updated early cancer detection program. The latter could in the future cover more types of cancer than is currently the case. On the basis of current scientific knowledge, consideration is being given to expanding early cancer detection to include lung, prostate and stomach cancer.[5]&nbsp;</p><p>Herth regards this plan as a first step, particularly with regard to the required lung cancer screening. But various questions still have to be answered. For example, who covers the costs, which groups of people are eligible for screening, and how many cases of advanced lung cancer could be avoided as a result of screening. The decisive factor is whether and how the development of an early detection program is implemented and financed at national level. In Germany this is now a matter for the Federal Joint Committee (G-BA), after the Institute for Quality and Efficiency in Health Care (<a href="IQWIG">IQWIG</a>) gave a positive assessment. In fact, successful early detection has a significant impact on cancer patients’ chances of survival for the next five years. </p>
Independent institute in Germany with the legal mandate to assess the advantages and disadvantages of examination and treatment methods based on study data and to report on its findings.
Lung Cancer Screening Stage Shift
<p>This gives Herth a clear idea of how the treatment pathway for lung cancer patients would change if lung cancer screening was successfully introduced. He puts it very simply: “I would be able to treat the patient early, in <a href="stage 1">stage 1</a> of the disease, and he or she would be operated on and cured.”</p>

Stage of development in which the tumor is still small or medium sized and is beginning to spread but has not yet affected the lymph nodes and has not metastasized.

By Matthias Manych
Matthias Manych, a biologist based in Berlin, works as a freelance scientific journalist, editor, and author specializing in medicine. His work is published mainly in specialist journals, but also in newspapers and online.