So I would like to thank the organizers for inviting me to take part in this symposium. So I'm going to highlight some of the work we do in Canada in programmatic lung cancer screening and some of the lessons that we learned. So Canada consists of 10 provinces and 3 territories. So healthcare delivery is at the provincial or territorial level. So we have a common eligibility criteria for screening. But if you look at the provinces that have implemented screening, 4 provinces already have a provincial screening program or are going to start one next year. And there were two pilot programs, and then the remaining are in different phases of preparation to initiate one. So our screening eligibility criteria varies from 50 to 55 in the lower end to 54 in the upper end. We all use the Martin Tememagi PLCO risk prediction model. The risk threshold for screening varies from 1.5% to 2% six-year lung cancer risk. In the national level, we have the Canadian Partnership Against Cancer, Pan-Canadian Lung Cancer Screening Network. So this is a network of people representative from the health ministries, the screening program directors, cancer control research experts, represented from indigenous health, patient family partners, as well as clinicians. So the partnership support implementation of screening in different provinces and territories, establish national quality indicators, engage indigenous communities, and also facilitate knowledge sharing and also share best practices across Canada. So in 2021, British Columbia announced the first in Canada province-wide provincial lung screening program. And in May of 2022, we started screening the first patient in the first health authority. And by May of 2023, all 36 sites in five health authorities went live to recruit patients for lung screening. So Ontario has a pilot study, a pilot program in 2017 to 2019. And the results are published by Martin Tememagi in Nature Medicine. They also announced a full program in 2021. Currently there are five primary sites and two hub sites. We plan to expand to all 15 sites across Ontario. So this is our kind of a centralized program workflow scheme. So the participants can either be self-referred or referred by their primary care providers. And then the participant can contact the program, or the program can call them after receiving referral from their primary care provider. We have trained navigators to confirm the screening eligibility criteria, do a shared decision-making kind of discussion. If they're still smoking, we provide a smoking cessation discussion as well. If they don't have a primary care provider, we try to attach them to one. So the ones that are eligible, we schedule them for a CT scan in the site nearest to where they live. In British Columbia, a unique feature is we have a screening program information system called a cascade system that we can kind of generate a CT referral and also track when the CT is done and make sure the CT is reported within a two-week timeframe. And then once you receive the results from the radiologist, we generate a report both to the primary care provider and also to the patient. The program also automatically generates a repeat CT scan in two years or one year to early record CT if the radiologist recommended that. If there's any suspicious lesion, the program also initiate a fast-track referral to one of our designated diagnostic team. The program also track outcomes. We pull data regularly from the cancer registry so we know about the biopsy, surgery, or other treatment. This is for reporting and also for quality assurance and quality improvement. In terms of nodule management protocol, Ontario Health use a lung rat system. In British Columbia, we use a PanCan nodule malignancy risk predictor for the baseline screen and volumetric measurement for subsequent scans. So just to give you some idea to the performance of the screening program in Ontario and also British Columbia, you see the performance are substantially similar because we use a very similar approach. So we have very good support by the primary care providers in referring people to us. 85% or more are referred by the primary care provider. Just by way of example, in British Columbia, in less than two years, we have 18,000 people contacted us for screening, and both three-quarters of them are eligible for screening, and 93% of them receive a CT scan. Because we use the PLCO risk prediction model, we can see we achieve what we hope to achieve in terms of sex, the equity, and also indigenous people participation, and also people with lower socioeconomic status. So in BC and in Ontario, about 2% of the population are indigenous, but in the screening program that you can see that over 5% participation in our screening program. Ontario Health also look at the income quintile in the neighbourhood where people come from. You can see it track very well to the education level. When people have high school or less education, they tend to come from lower income neighbourhoods. So about half of them actually coming from poorer neighbourhoods. So in terms of the local CT trials categories, on the right side, they show the real-world data in our screening program now. So 84% of people have a repeat screening, but 70% of this 84% actually have a biannual screen instead of all 84% have an annual screen, and only 3% were referred for diagnostic workup. So this parallels very well to our pilot program as part of the international lung screening trial that Dr. Williams is going to present in the presidential symposium. So this is very important for program planning in terms of the downstream implication of screening. So in terms of lung cancer detection rate, in the BC program, we have a 1.63% cancer detection rate. Ontario Health use a higher threshold for screening, they have 2.18%. This compares favourably using age and PEG years criteria in the US. We also achieved a stage shift we would like to see, both in BC, Ontario, over 70% of our screen-detected cancers are stage 1 or 2, compared to less than 30% without screening. So I just want to show the importance of training and quality assurance that we learn. All the radiologists that go through the training modules and also a group session before they start reading the CT. But we also notice there are misclassifications that are more commonly occurred that depend on the type of the nodule. So for example, a nodule like this can be classified as a ground-glass nodule, but it's actually a multilocular atypical palmitic cyst that has a much higher malignancy risk compared to a ground-glass nodule. Another one that we notice is a semi-solid nodule, appearance of a solid core or the presence of a solid core can be missed. But fortunately, we're using the VLT CAD, just turn on the CAD, it can show the solid core. So the one other point I would like to make is the real-world performance may not be the same as the pilot. So Health Authority 1 is where we had the pilot program since 2007, and the others are just started in 2022-23. So we can see that when we have the program running for a long time since 2007 with two pilot studies, we achieve a very high stage one lung cancer rate and very low other stages. There's more variable in other health authority. So it's important to understand some of these differences, why they are different. We have periodic meeting every three months among all the radiologists and the clinicians to review typical cases and learn from each other. So one of the thing is the comfort level to resect very small lesion. So for example, this is a very small nodule, a semi-solid nodule with a 7-millimeter solid core. At three months, going to about a 30-millimeter solid core, and we would have resected that. But because of a lower level of comfort that the surgeon decided to wait another six months to repeat the scan, there's obviously no change in terms of growth. And by time of surgery, it's already a stage two lung cancer. So something we need to know about. So in summary, from what we have learned in Canada so far, a risk model-based lung cancer screening program is very practical. We have a high cancer detection rate compared to H and PEG years criteria. We have excellent buy-in from primary care providers and patients, resulting in a good screening uptake. We have very good stateship. But it's important to continue to monitor the program performance of quality assurance and quality improvement.

lung cancer screening

Canada

PLCO risk model

indigenous participation

quality assurance