Thank you, Dr. Kazerini. Now we have our panel Q&A session. So this is about 30 minutes for anybody here in the audience to please come up to the microphone and ask questions. When you do, please announce your name and where you're from, and then I can get us started with Dr. Kazerini. That was a great presentation. So I'm wondering, I think many of us in the audience still have that 5% number in terms of lung cancer screening uptakes, about 5% in the U.S. in our heads. What would you recommend quoting now? Well, with those two papers I just showed you, it's probably 18% in 2022. If you were to follow the trends, and I've talked to Bob Smith about this, amazing epidemiologist at the American Cancer Society, we're probably trending towards about 20% right now. So that's 1 in 5 versus 1 in 20. That's pretty good. It's this national quilt of health care insurance and all the levers you have to pull makes it challenging, but we are on the right pathway to acceleration. Great. Thank you. That's definitely, yeah. That's worth applauding. It's definitely much more optimistic than 5%, so that's very promising. Do you have any questions? Yeah. I have a question to Stephen. It's very interesting, the British Columbia program, I see that, you know, and this is a big focus in Australia, our program will be rolling out next year in July 25. And in our Aboriginal Australian population, their lung cancer rates are very high, so it's a big target of our program is to ensure that we have engagement with our First Nations people and to get them screened. And they often live in very remote and regional areas. So it's really heartening to see in the VC program, Stephen, that you have such a high uptake, a large proportion of your screen population, 5.5% with First Nations, and that's higher than in the general population, which is about 2%. How do you think that's been achieved? I think there are two things. Number one, we have a First Nation authority representative to reach out to First Nations people. The second thing is we use the Tebemaki race model. We find that most people don't refuse to answer the race ethnicity question, contrary to concern raised by some people. Why won't they? Because we give them an advantage to take part in the screening program, because they're more likely to be qualified for screening if we use the race model. Thanks, Stephen. Please go ahead. Yeah, I have a question. My name is Huyen Kim. I'm a pulmonologist from South Korea. I have a question for Dr. Ashijala. I think it's really important and very impressed by the fact that you get to get informed constant about the potential benefits and harms about CAT-CT screening. But the thing is, I have two questions. The thing is that physicians may not be well aware of the potential benefits and especially harms about CAT-CT screening, so do you have like a centralized guideline or something like that? That you could provide for the physicians to what you should inform for the patients? And my second question is that, do you have data about how these informed concept really affects the decision of a patient to get screened or not? Like, does it really encourage the recommended screening and discourage unrecommended and potentially harmful screenings? I'm sorry, I cannot understand your questions. One at a time. Briefly. Oh, briefly. Okay. First one is that, do you have a centralized guideline for physicians what to tell about the potential harms and benefits about the CAT-CT screening? And the second one is that, do you think that actually influence, beneficially influences the patient's decision to get screened or not? Was it not clear? Could you just summarize the... The first question is, sorry, it's a bit hard to hear. Thank you. The first question was, do you have guidelines in Japan to give patients to discuss benefits and harms? Because a lot of them are never smokers and light smokers. Do you have established guidelines? I mentioned in my talk, now we are discussed in terms of the guidelines, including the benefit and the harm of Rankin's Roto-CT screening, especially in the academic conferences. But the Japanese government did not decide to perform the Roto-CT screening for heavy smokers. And the second question... Second question, sorry. The second question was that, I thought that you said that you have to have an informed consent about the benefits and harms about CT screening, right? Do you have a data that those kinds of informed consent affect, beneficially affect the screening decisions? Which one? Can you explain to us? I'm sorry. It's hard to hear. It's difficult to hear. Yeah. Could you speak louder? I'm sorry. Oh, well then, maybe I could ask you after. Yes, yes, yes. Of course, yes. I have some papers to explain to the participant, in terms of Roto-CT screening, including the benefit and the harm of the Roto-CT screening, right? Yeah. Okay. Thank you. Great. Good morning. My name is Andrea Barani-Kitz, and I'm from the Rescue Lung Society in the U.S. My question is also for Dr. Ashik Sattwa. Can you hear me? Yes, yes. Okay. So, my question is, a large part of your talk focused on people who never smoked and their high risk of lung cancer, yet the only lung cancer screening with CT scan that's being considered in Japan is for people who smoke heavily or have a heavy smoking history. Can you explain why that is and what you plan to do in Japan with the people who never smoke toward high risk? Yeah. So, I mentioned in my talk, for heavy smokers, Japanese government will start to discuss the Roto-CT screening. There is no evidence in terms of the utility of the Roto-CT screening for light or non-smokers. Therefore, I mentioned the ongoing JEC study and just finished to recruit the 27,000 participants. Therefore, we are waiting for more than 10 years to compare between the two groups. 10 years? Yeah, 10 years. Thank you. Just to clarify, to follow up on that, thank you. The current program in Japan, which is funded largely by employers, is that correct? Yeah. So, including the employee. Yeah. But the pending approval in smokers will be a federal or national program, not funded by employers? Up to now, not national program, yeah. Yes, but you're thinking about it. Yes, yes. And that would be a federally funded or national funded program? Yeah. So, based on the workplace examination. Great. And then, Dr. Sagawa, just had another quick question. For the JEC study you were mentioning, there are people who have never smoked who can participate, right? Yes. Is there any specific criteria for them other than they have never smoked? You mean the family history? Yeah, like is there a family history? There is no criteria. Okay. So, it's just anybody who has never smoked is in the tribe. Yes, but never were light smokers. Never were light. Okay. And it starts at 55, right? Yes. Yeah. Okay. Great. Thank you. Dr. Schell, New Jersey, United States. Ella, this is for you. I'm not quite sure how using the HEDIS criteria or using any of the electronic health record data with respect to pack years is of any value, whatever. It is so notoriously unreliable. And so, it would be so nice if we had the ability to say in this 100,000 patients we can accurately say this is the pack year history, but we can't. There is no such information in the health records. So, I'm not quite sure why we would embark on that. So, one of the things that HEDIS measures do is they drive change. They drive payers to push health systems to drive for changes in their electronic health records. While there are pack year fields, I think we all know that it is notoriously heterogeneously used in the United States right now, that we had a meaningful use criteria that was pressed down almost a decade ago which required you to document yes or no for smoking, but did not require pack years. We know that some of the EHR vendors are making some improvements and others have been slow to do so. The way HEDIS measures are executed is, yes, it's electronic health record data and that's how the calculations are made. One of the parts of HEDIS measure development is importantly working with EHR vendors. They know that they cannot execute without the EHR vendors. So they test their proposed guidelines, their proposed measures on EHR data working with EHR vendors. So the EHR vendors are already on notice that they have to do something. It may not push all of them across the bar until a HEDIS measure is out. And now healthcare insurance companies are going to press the hospitals and healthcare systems and facilities to be documenting so that they can meet those criteria. So it's a little bit of a, it's a driver to make change. And they test this as part of the development implementation. So they're in a testing phase currently. I just think the fundamental problem isn't with the EHRs, the fundamental problem is people don't want to give the information accurately because they don't want to get lectured again about smoking. And the people taking the information, whether it's a clerk, a nurse, an aide, whoever it is, doesn't take it accurately and doesn't follow up in the discussion. »» 100% agree with you. You can't just blame EHR systems for not having the right information in the right place to make it easy for you to do. This is an interaction of human beings and education with EHR systems. We need to do a better job at educating people like our medical assistants who are often asked to do this intake about why it's important to get that number right. And it's also important to create lung cancer screening outreach in a way that is stigma-free to help people come forward to recognize and educate them on the importance of this benefit and the reason why they're being asked the question. So I completely agree. This is EHR and human beings. It's education and systems working together. »» That's a great point. »» Our resident pack your smoking expert is sitting in the second row, Alex Potter right there. »» Thanks. I'm Dr. Ossoff, Mark Ossoff, I'm a radiologist at William Osler in the greater Toronto area. I thought the presentations were excellent, so thank you. One thing that I noticed was quite a significant variation in the inclusion criteria for which patients would be eligible for lung cancer screening in the different areas. I was wondering if I could just ask, this is really an open question to all of you, but I could start with maybe Dr. Lam and Dr. Casarini just from U.S. and Canada, in terms of deciding to do something like an open-ended eligibility which is just based on age and pack your smoking history versus risk calculator and what the calculus is in deciding which way to go. Thanks. »» So in the U.S., our recommendations are driven by the U.S. Preventative Services Task Force and data that is analyzed in support and modeling studies in support of their decision-making. They intend to be evidence-based. I would say this information kind of goes into the dark room that is the USPSDF and their decision-making and then the guideline comes out. But it is supported by a manuscript that is published which explains their decisions and the evidence that is provided to help make those decisions. They qualify in there why they do or don't do certain things. The evidence at this time based on primarily the NLST, first large randomized controlled trial, Nelson, second largest randomized controlled trial over about a decade's worth of data, plus supplementation by modeling studies are what led our USPSDF to have the recommendations that they have today. Even with that, USPSDF says 50-80, Medicare coverage stops at 77. That is yet another arm for advocacy for all of us in the U.S. who are trying to push the boundaries of lung cancer screening to advocate to Medicare to change that upper bound of 77. There are also differences in guidelines from professional societies. I mentioned the American Cancer Society guideline which is creating a bit of a challenge for us right now. It's great because it's a pusher. The ACS guideline similar to the National Comprehensive Cancer Network guideline had already done eliminated years since quit entirely and showed that you can increase the population of people who are getting screened largely by keeping older individuals in screening who don't tap out because now they hit 16 years once quit. By doing that, more people are screened, more lives are saved. But now we have to go back to USPSDF, get them to make an update. We have to go back to Medicare and advocate for them. They won't touch it until USPSDF does because of federal regulations that tie those together. How we come to decisions, that's how we do it in the U.S. I have to say that the Canadian guidelines sound much more restrictive because compared to the guidelines from 50-80 years of age, 20-pack years, you're talking that that's just the eligibility to get to the screening model and then many people won't get to the 2.6% on the PLCO2. So is this just a public health care cost calculus? So maybe it's a pragmatic decision, right? So you have to start somewhere. You can't start screening everyone without the infrastructure, the capacity to do the screening and the downstream workup. So we decided to use 1.5%, Ontario used 2% six-year lung cancer risk. But down the line, when the program runs smoothly, we might change the age limit or the threshold. So for example, the CISNET team showed that even down to 1.2% six-year lung cancer risk is still cost effective. So these are the things we just continue to monitor as to whether we should change our guidelines. I'll just make a comment there. In Australia, the work that's been done over the last five years for planning and the design of the program that was put forward to the federal government by Cancer Australia, which is our national body that promotes screening, et cetera, did include the PLCO model for enrolment that was rejected by the federal government, by the Medical Services Advisory Committee that makes the recommendations for new programs and drugs and all sorts of things. So they went with categorical criteria, which will be probably the most restrictive in the world of any screening program, with only 50 to 70-year-olds of 30-pack years being eligible. And if they've quit, it's less than 10 years. It's much more strict than the US. That's how Australia is going to start. And it will miss probably half the lung cancers in that cohort. And as Steve was saying, I think it's a pragmatic approach by the federal government. As in the public health system in Australia, we're completely overwhelmed already with a number of clinical lung cancer cases coming through the door. And if we have a huge number of people screened, we won't be able to meet capacity. So I think it will be under review in two years' time once we implement. So we did propose PLCO, but that's not what our federal government went with. Thank you. Good morning. Good morning. My name is Tan Thon, and I'm an epidemiologist and a real-world data scientist at Roche Genentech. So first of all, I really wanted to thank you, all the distinguished speakers, for touching upon the differences between pilots and volunteer biases and screening versus the real-world population. And thank you, Dr. Casaroni, for explaining the complexities of the EHR system just a minute ago, and all that we're doing on the policy level to do that. So my question is, in this day and age, with technology, big data, machine learning, AI, with all the caveats that come with AI, do you see a role of all of this working with the EHR systems to help further increase compliance to screening? And for countries outside of the US, I'd be interested in understanding how you're using, or you envision to use EHR systems in medical records to reach populations at scale. Thank you. Yeah, so if the question is about AI and technologies to help us increase screening and get more people back for screening, absolutely. We need to be using technologies that help serve up eligible individuals, rather than waiting for them to go into their primary care physicians. We need to be acting prospectively, instead of waiting for that opportunity to identify screening individuals. And EHR data has to be better, especially pack years, to be able to do that. But we often find information in EHR that's buried in free text that could be used, rather than in some discrete field. So tools like AI can help us exploit the medical record data, as good or bad as it is in its structure, to help serve that up. And also, tools to help us make sure patients are coming back for screening, using ways and tools to implement. When we did an Accelerate Lung Cancer Screening Summit in summer 2022, from the Cancer Society Roundtable, that was the number one obstacle, was the EHR and IT. We held a follow-up workshop specifically with EHR vendors. It was the hardest workshop I've ever put together, because vendors don't usually get in a room together. They're competitors. But we had eight vendors in a room, all talking to each other. They kind of set apart the industry where they came from. And we're really working together and having great discussions. And you need that kind of conversation if we're going to do what you're talking about. Does anyone else have any comments from other countries? Well, in Poland, I can talk personally about Poland, because I know the situation. The situation is such that we started to have really electronical records that you can use, that everybody can use, just four years ago. And in these electronical records, we missed the data concerning the tobacco addiction or the number of packers. I think that it will come. But so far, we don't have such information that could help us to, let's say, somehow pick up all these individuals that really need help. But the most important thing, actually, in lung cancer screening, for me, in Poland, is how to reach the hard-to-reach population. And this is really very difficult. And this is not awareness among health care policy networks, health care policymakers about this problem. It will be very difficult. Now, we are struggling, as I told you, to talk to them how to shape the lung cancer screening program, to be very dedicated to all the communities. Also, this hard-to-reach. So about the AI and use of electronic records, no, not yet. I was just going to add, I consider radiology images part of the electronic health record. And wouldn't it be wonderful if we could use these tools to not only extract the information that's in the medical record, but that's in the image part of the medical record to calculate individual risk for lung cancer and use that to drive lung cancer screening in the future. So I think we have a long way to go. But there's definitely things that we should be thinking about doing. Thank you. So good morning. Thank you for the excellent presentations and overview. My name is Thijs Mulders. And I'm a radiologist from Rotterdam in the Netherlands. And I'm looking at it at a very practical point of view. The scans, they need to be performed and they need to be reported. In the Netherlands, we also contributed to numerous studies for lung cancer screening. But I can imagine that if we would implement the screening program in two years, we would get into trouble because we don't have enough radiologists to do the reporting. And yes, we use AI and computer-aided diagnosis. But we also don't have, and that's a much more important problem, not enough radiographers to perform the scans. So I was wondering, and it's not a question to a specific person, but maybe to someone who already has experience in the conduct of a screening program, how do you cope with these problems? Do you have a lot of discussions with health policymakers about these? Because I would say we need more people in the radiology department. I would like that, always. But maybe someone can comment on that. That was the problem at the beginning when we planned pilot study because we thought how we can resolve this problem. We wanted to have centralized Lodo city reading. But that was very difficult because we tried to find the radiologists who can do that. And we found no radiologists that want to do only this job. So we decided to implement a platform that is very helpful, the Lancance Screening Platform, a software that was built actually based on the program that David and Claudia provided for the military service, yes. And this software was very helpful to all radiologists. But finally, as I told before, we decided that city reading will be performed only in these high quality centers. One region, one high quality centers. So Lancance city can be performed everywhere. But then only the qualified radiologists can do that with the help of this software. That was really very helpful because they had in-built also study aids that had in-built guidelines that are changing very quickly and risk calculators. And each radiologist could use it during the reading of the CT. And that was really, really very helpful. OK. Thank you. I was going to say, in the US, health care is a business. It's an industry. And the economics are based on facilities' ability to generate enough revenue to pay for the services that are being delivered and collect for those. The drivers in health care are a bit of a push and a pull. If something new comes out, if something is approved to be done, if systems know that there's a positive ROI, they will implement. But it doesn't occur overnight. So to go from 0 to 19 million people screened doesn't happen like this. There's no federal system of saying we're going to train more technologists or train more radiologists. There's no federal oversight of that. It's really the economics of health care that drives it. And we're seeing that rate of return. We developed at the Cancer Society National and Cancer Roundtable a tool called Lung Plan. And it allows facilities to put in some information about how many people they think they're going to screen. And it uses formulas based on things like lung RADs and probability of positive and negative and downstream tests and eventually cancer diagnosis and cancer treatment to generate a financial ROI, if you will, for an individual facility to say, if I screen 200 more people next year and 200 more after that and 500 after that, this is your ROI that you can take to your hospital administrators. And that's been very important in helping facilities get the resources like nurse navigators critical in making sure lung cancer screening programs come home and making sure that we have enough CT scanners and imaging technology and so on. So the investment is there. So our model is going to be very different than countries where it's governed at a regional or national health level. OK. Thank you. Good morning. Thank you to all the organizers for an amazing session so far. My name is Sarah Gandahari. I'm a pulmonologist in Los Angeles. I practice in a city that has a significantly diverse population from all over the world with first-generation immigrants. And the question is directed to Dr. Casarone, but others can also comment. I often have a hard time as there are different population risk profiles and perhaps indication for screening maybe varying as we see in practices as well around the world. Are there recommendations for those of us who have were in a position to discuss risks at individual level to have a varying practice even within our own so that when I see someone who has potentially at higher risk I would persuade them or their insurance company to allow screening or find another reason to scan them. Yeah, so it kind of gets back to how the economics of health care in the US. We have USPSF recommendations. We have CMS coverage. We have state by state Medicaid. We have Veterans Health Administration and they make their decisions about what they pay for and not. There may be people at higher risk for lung cancer who are not getting captured by the current guidelines. And there may be people even within the guideline who are on the lower end of the lung cancer risk spectrum. Those are some of the limitations of the way health care is performed in the US and for screening and preventative services how those decisions are made. I think we're struggling with things like lung cancer in people who never smoked, who may have family history, who may have generations of family history, for example. This comes up regularly as something that we need to figure out what can we do to answer this question. So there's definitely heterogeneity of cancer risk within the screening eligible and outside the screening eligible. But payment policy is linked to those things that I described and that provides those challenges. I'm not aware of many health care companies that will reimburse for lung cancer screening outside those kind of guidelines that we have, which then makes it difficult to do exactly what you're saying. Maybe I'll add that we do look at personal risk of lung cancer. So that's the reason why we use the risk prediction model like the Tememaki PLCO 2012 model to look at personal risk. May not be the ultimate model we use, but it's a very good start. In the USPSTF last statement 2021, in the paper summary, they talk about why they didn't include risk calculation and they thought we were not ready to roll that out or there was not a single agreed upon risk calculator for use. Potentially, that's something that we can advocate for in the next update to the guideline. Great, thank you. So we have three minutes for three questions. Yeah. So very quick. Thank you for the great talks. My name is Mahdi Sheikh. I'm a scientist at the International Agency for Research on Cancer, IARC. So my question is about smoking cessation interventions and treating tobacco dependency. Well, I just want to very quick question about to hear your thoughts and also whether the implementation of any data on implementation of treating tobacco dependency in these programs across countries because it's a critical moment and it may be very useful. I just want to hear the thoughts about each country. Thank you very much. Is anyone including it? Steve, are you including, I think in the BC program, you're including pre-NRT in that? So both Ontario and British Columbia screening program, we do smoking cessation intervention to different degree. In Ontario program, correct me, Martin, they do on-site cessation intervention, 10 minutes counseling for four times nicotine replacement. But we do online counseling plus free nicotine replacement therapy that is free to people living in the province. In the US, smoking cessation is a critical part of lung cancer screening programs for organizations like Medicare. Having those conversations with patients is part of the shared decision-making process. Great. Thank you. Thank you all for your presentation. I'm Louis Gros from Medical Oncology from Switzerland, currently in New York at LCAP. I have a short question. To increase public interest, should we advertise lung cancer screening as part of a comprehensive health check for both the heart and lungs? You have one minute. Yes. Yes. Thank you. Thank you. Great, thank you. And our last question. OK, it's our last question. I have some more time because of a very, very brief discussion before. I'm Yeol Kim from Korean National Cancer Center. Korea is the world's first national lung cancer free program that started from 2019. I know USA started to implement a lung cancer screening reimbursement system by insurance that started from 2013. I'm not sure. But still, participation rate is lower. In Korea, we have a five-year experience to the national screening program. Our uptake rate is over 50s. It's quite higher because our system is organized. It means we select eligible high-risk smokers based on national centralized data systems. The system has people's questionnaires based on national health screening, including the smoking history. Our system is very advantageous to send invitation letters to the selecting from the centralized systems. But the patient participants do not have a chance to discuss about the harm and benefits by physicians before the screening. It's our disadvantage. But the organized systems, it's a very advantage to increasing the uptake rates. But I'm wondering, I'm concerned about the smoking cessation after screening. It's a very important matter. In a very early time after NLST reported, we worry about the false positives in screening because very high false positives may increase the medical costs and increase the harm. But recently, many of your country's implementation experience is decreasing the positive rates. But it means many of our high-risk participants received negative results from screening. That makes insure license to smokers, smoking to the smokers who participated in a lung cancer screening. Great, thank you. So I'm wondering, your data and your experience, how you're measuring smoking cessation rate after screening? We need to compare the smoking cessation efficiencies between the organized system, like Korea, and your physicians counseling in rural system in US and other countries. So brief answer to the question, does a negative screen cause patients to keep smoking? The answer is no. How do you intervene? Based on the information that we collect when we screen individuals repeatedly and data that's been published. That is a fallacy that needs to be dispelled. Great, thank you.

lung cancer screening

screening uptake

remote populations

AI and EHR systems

radiology workforce

smoking cessation

global guidelines