Baldwin, DR

Beeken, RJ

Bhowmik, A

Dickson, JL

Duffy, SW

Janes, SM

McEwen, A

Navani, N

Quaife, SL

Ruparel, M

Sennett, K

Waller, J

English

UCL Discovery

Reply to: Improving Lung Cancer Screening UptakeSamantha L Quaife1 PhD, Mamta Ruparel2 PhD, Jennifer L Dickson2 MBBS, Rebecca J Beeken1,3 PhD, Andy McEwen4 PhD, David R Baldwin5 MD, Angshu Bhowmik6 MD, Neal Navani7 PhD, Karen Sennett8 FRCGP, Stephen W Duffy9 PhD, Jo Waller1,10 PhD, Samuel M Janes2 PhD.Affiliations: 1Research Department of Behavioural Science and Health, University College London, London, UK; 2Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, University College London, UK; 3Leeds Institute of Health Sciences, University of Leeds, Leeds, UK; 4National Centre for Smoking Cessation and Training (NCSCT), Dorchester, UK; 5Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals, Nottingham, UK; 6Department of Thoracic Medicine, Homerton University Hospital, London, UK; 7Department of Thoracic Medicine, University College London Hospital, London, UK; 8Killick Street Health Centre, London, UK; 9Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; 10School of Cancer and Pharmaceutical Sciences, King’s College London, London, UKCorresponding Author: Samantha L Quaife, samantha.quaife@ucl.ac.uk, Research Department of Behavioural Science and Health, University College London, Gower Street, WC1E 6BT, UK.Page 1 of 4 AJRCCM Articles in Press. Published June 11, 2020 as 10.1164/rccm.202005-1699LE  Copyright © 2020 by the American Thoracic Society To the editor,We read Wilson’s response letter to both our Lung Screen Uptake trial (LSUT, 1) and accompanying editorial by Burnett-Hartman and Wiener (2), with great interest and value the insightful discussion they raise.  Together we share in the challenge of achieving both equitable and informed uptake of LDCT lung cancer screening by high-risk individuals, but the differences between the UK and US that Wilson raises are important for how we intervene.  The UK benefits from a coordinated and universal primary care system and we appreciate that sending postal invitations directly from the individual’s PCP is a strategy that may not translate directly to the US context.  We also note the requirement by the Centers for Medicare and Medicaid for a separate shared decision-making session prior to the screening intervention in the US.  However, evidence suggests that the behavioural components of LSUT’s strategy (healthcare professional endorsement and proactively inviting and arranging appointments) are the ‘active ingredients’ which could be implemented in different ways in the US context.We also share Wilson’s interest in broadening LSUT’s ‘Lung Health Check’ approach to screening to include other aspects of lung and heart health in the future.  Framing lung cancer screening as one optional test within a ‘Lung Health Check’ was intended to improve engagement by minimising fear (that could lead to information avoidance and uninformed non-participation) and to provide an in-person supportive environment where shared decision-making about the screening offer could be achieved.  Through this we found potential for other lung and heart health interventions – the key focus of Wilson’s point.  This includes parallels with the Pittsburgh Lung Cancer Screening Study (PLuSS, 3) which found prevalence of emphysema and airway obstruction increased with individual lung Page 2 of 4 AJRCCM Articles in Press. Published June 11, 2020 as 10.1164/rccm.202005-1699LE  Copyright © 2020 by the American Thoracic Society cancer risk.  For example, work led by Ruparel found a significant proportion of undiagnosed COPD (4) and untreated coronary artery calcification (5) within our LSUT cohort, suggesting opportunities for early diagnosis of COPD, instigating cardiovascular risk assessment and primary prevention.  The UK taxpayer’s universal healthcare system may in the future fund LDCT screening scans and so we would not have the financial disincentives as the US in this respect.  However, the UK does have limited resource for subsequent health care provision for incidental findings.  This makes the feasibility of delivering a holistic health assessment challenging and policy decision-makers would (rightly) first require evidence for the public health benefit and cost-effectiveness of such an approach.  Page 3 of 4 AJRCCM Articles in Press. Published June 11, 2020 as 10.1164/rccm.202005-1699LE  Copyright © 2020 by the American Thoracic Society References1) Quaife SL, Ruparel M, Dickson JL, Beeken RJ, McEwen A, Baldwin DR, Bhowmik A, Navani N, Sennett K, Duffy SW, Wardle J, Waller J, Janes SM. Lung Screen Uptake Trial (LSUT): Randomized Controlled Trial Testing Targeted Invitation Materials. Am J Resp Crit Care Med 2020;201:965-975.2) Burnett-Hartman AN, Wiener RS. Lessons Learned to Promote Lung Cancer Screening and Preempt Worsening Lung Cancer Disparities. [editorial] Am J Resp Crit Care Med 2020;201:892-893.3) Wilson D, Weissfeld J, Fuhrman C, Fisher S, Balogh P, Landreneau R, Luketich J, Siegfried J. The Pittsburgh Lung Cancer Screening Study (PLuSS): Outcomes within 3 years of prevalence CT scan. American Journal of Respiratory and Critical Care Medicine 2008;178:956-961.4) Ruparel M, Quaife SL, Dickson JL, Horst C, Tisi S, Hall H, Taylor MN, Ahmed A, Shaw PJ, Burke S, Soo M, Nair A, Devaraj A, Sennett K, Hurst JR, Duffy SW, Navani N, Bhowmik A, Baldwin DR, Janes SM. Prevalence, Symptom Burden and Under-Diagnosis of Chronic Obstructive Pulmonary Disease in a Lung Cancer Screening Cohort. Annals of the American Thoracic Society 2020. DOI: 10.1513/AnnalsATS.201911-857OC5) Ruparel M, Quaife SL, Dickson JL, Horst C, Burke S, Taylor M, Ahmed A, Shaw P, Soo M, Nair A, Devaraj A, O’Dowd EL, Bhowmik A, Navani N, Sennett K, Duffy SW, Baldin DR, Sofat R, Patel RS, Hingorani A, Janes SM. Evaluation of cardiovascular risk in a lung cancer screening cohort. Thorax 2019;74:1140-1146.Page 4 of 4 AJRCCM Articles in Press. Published June 11, 2020 as 10.1164/rccm.202005-1699LE  Copyright © 2020 by the American Thoracic Society 

Reply to: Improving Lung Cancer Screening Uptake

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Reply to: Improving Lung Cancer Screening Uptake

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