Lung cancer is a disease that is treatable if caught early, however difficult, due to a lack of early symptoms.
Dr. Alain Tremblay, a respirologist based in Calgary, says by the time the patient is showing signs of the disease it’s likely too late.
“The main reason it’s so lethal is that by the time people get symptoms, by the time they start coughing or losing weight or having some related symptoms, the tumors are very advanced already. They can be treated but not cured in the majority of cases.”
Lung cancer is a cluster of abnormal cells in the lungs that causes tumours. These abnormal cells grow, destroying healthy cells in the process and damaging the health of whoever has the disease. Unfortunately, once the cancer reaches stage four where the survival rate is one per cent, it is normally too late to do anything to cure it.
Despite attributing risk factors being tobacco use or radon exposure, it’s something that can happen to anyone, and is prevalent amongst Canadians.
The chances of surviving lung cancer can dramatically go up if detected early enough. However, despite a call from organizations such as the Canadian Task Force on Preventive Health Care, no organized lung cancer screening programs have been implemented in Canada.
This is a major problem because lung cancer is the deadliest cancer in Canada, killing more people than breast, colorectal, and prostate cancers combined. Over 26,000 Canadians were diagnosed and over 29,000 died from lung cancer in 2015 alone.
Here are some examples of people who experienced the impact of lung cancer being diagnosed too late.
Dominique Pottle has experienced the impact of lung cancer. Her grandfather was diagnosed in December after extensive tests.
“He started having a lot of confusion, tired, fatigued, he didn’t know what was going on and it totally changed him. He went to emergency, he went to the hospital, he got admitted, and they did tests, screenings, x-rays and blood work,” says Pottle.
Pottle, her grandfather and their families were left with the worst case scenario after the results came back inconclusive.
At the end of December, they decided to do a more thorough scan because they noticed his sodium levels were abnormally low. That was the only thing that they could find to indicate an issue.
“They would give him injections, send him home, he’d come back a few days later and he’d be sick again,” says Pottle. “After they did this for a few weeks, they decided to do some more in depth scans to see what the cause of his low sodium could be.”
Finally, after that they found nodules on his lungs; they eventually did a biopsy and found out it was stage four lung cancer. Stage four lung cancer is the most advanced stage of lung cancer, meaning it has spread to both lungs, the area around the lungs or distant organs.
“It was really really difficult, especially hearing that it was stage four,” she says.
“He had been to the doctor, he had gotten bloodwork, he’s not a smoker, he didn’t have any indicators of lung cancer and so the fact that it took so long for anything to happen for them to catch it was really difficult that no one could find it before it got so far along.”
Pottle says she would change something about the healthcare system if she could because it’s currently not doing enough.
“I wish they would have taken it more seriously at first and done these scans and kept him in the hospital until they knew what was wrong, instead of sending him home and him having to go back to the hospital three or four times.”
Brendon Kitzul has also dealt with the struggle of watching a loved one battle lung cancer. He lost his mother, Brenda Kitzul, to lung cancer nearly five years ago.
“She was an amazing woman,” Kitzul says. “Literally for a year she was not complaining, but just saying that she had a weird pain every time she’d move her arm.”
Despite multiple checkups to see if something was wrong, the doctors dismissed her symptoms as fibromyalgia and told her it was normal for someone in their fifties to see.
However, that wasn’t the case.
Almost a year later, after a visit to a nurse practitioner who recognized that her symptoms could be more serious than her previous diagnosis, she was sent for tests. “They weren’t even home yet from the hospital from the testing and they called. And they literally turned around and went back and were like, ‘Yeah, you’re in rough shape.’”
This is when she found out that the pain from lifting her arm (which had escalated to the point of her not being able to lift it at all) was a result of stage four lung cancer.
Although Kitzul had planned to send her to the Mayo Clinic in the United States for treatment, by the time the required paperwork was sent, her health had deteriorated beyond the help she could have received.
“I think catching it earlier than stage four is definitely important,” says Kitzul. “I feel like if they would have caught it sooner, maybe she would have had a chance.”
Keely Schnuth also lost her mother, Karla Schnuth, to lung cancer in November 2020.
Like Brenda Kitzul, Karla Schnuth had a pain that was dismissed by doctors, later to find out it was from lung cancer.
“She all of a sudden had neck/shoulder pain and for five months doctors, chiropractors and physiotherapists all told her it was just a pinched nerve and it would eventually get better.”
Five months later, when a doctor decided to look deeper into her issue, they found out that her neck pain was the result of lung cancer spreading to a bone in her neck, although there was still hope. However, after a vigorous treatment including chemotherapy, immunotherapy and radiation, she still hadn’t recovered.
“My mom tried her best to enjoy her last couple months knowing that she used all her strength possible to fight this horrible cancer but her fight did end in November 2020 when her body just couldn’t handle it anymore,” says Schnuth. “She was so strong for what she went through in her last year. She had more strength and courage than I could ever imagine having.”
Like Kitzul, Schnuth feels if there was a change in the healthcare system to catch lung cancer at an earlier stage, they may have been able to have more time with their mom.
“All the cancer clinic doctors, nurses and our family doctor were great to her and our family, but I do truly believe the system let down my mom and my family for not taking her seriously,” she adds. “I feel if someone had taken her symptoms of this ‘pinched nerve’ more seriously, I could have had more time with my mom.”
What is being done?
Erika Nicholson is the director of screening for the Canadian Partnership Against Cancer (CPAC).
“In the last two years, my organization [CPAC] has refreshed Canada’s strategy for cancer control. We are stewards of that strategy,” says Nicholson. “In the process of talking with people in Canada, from coast to coast to coast, one of the priorities that emerged was to strengthen cancer screening efforts, and in particular to introduce lung cancer screening and make it available to the people of Canada.”
There are very rigorous trials that have happened in the world that have shown that lung cancer screening, using a technology called low-dose CT, can reduce deaths from lung cancer by 20 to 26 per cent and studies suggest it appears to be cost-effective in the publicly funded Canadian healthcare system, estimating the treatment savings at $28.1 billion if screening was conducted over a 20 year period.
“While lung cancer is the leading cause of cancer death, we have a method to screen that can make a significant positive impact on lives,” says Nicholson.
Research for lung cancer screening began in the 1970s looking at technology such as x-rays, according to Dr. Tremblay. However this did not lead to success and could be attributed to part of why there has not been more done today for screening efforts.
“There were huge efforts in the ’70s with studies, with tens of thousands of patients that were really all negative in the end, and did not help them,” says Tremblay. “So that led to several decades of pessimism as to whether lung cancer screening was worthwhile at all.”
He notes that at the turn of the century, with the success of screening programs for cancers such as breast and cervical, CT scans provided an opportunity to properly screen lung cancer, while significantly lowering the risk for the patient.
“The CT scans are probably in the range of the radiation equivalent of five chest x-rays where there used to be 100 chest x-rays, for example.”
Nicholson and her team at CPAC also know that there are risks to lung cancer screening. They are funded by Health Canada, and work with partners from every province and territory professional associations, to identify some shared priorities where we can advance lung cancer screening.
“One of the things we’ve done is we’ve bundled the evidence for lung cancer screening into a business case. Part of doing that, is that screening is always about optimizing the benefits and minimizing the potential harms that could come from screening,” says Nicholson.
Nicholson explains that for lung cancer, screening is particularly important because it is much different than other forms of cancer such as breast, cervical and colorectal cancer screening programs in that to minimize the harms and maximize the benefits, it needs to be targeted to individuals who stand to benefit the most.
“People who are at a high or increased risk of getting lung cancer. That’s one way you can minimize the harm,” says Nicholson. “The other way you can minimize the harms, is to provide guidance for how to safely manage the appropriate care and follow-up for people who have suspicious findings on their screening test.”
Tremblay says that lung cancer screening is really geared towards older populations.
“For screening purposes, you need to have enough cancer in that age group if you want to make it worthwhile. So typically we start at age 55 and older, and most of the research that’s been done, some people have said maybe we should go to 50 if we can, if we can find particularly high risk individuals that are that age. Now, people below 50 can get lung cancer, unfortunately, but it becomes relatively rare. So you would have to screen a lot of people to find cancers so that it becomes a fairly efficient way to screen.”
However, it’s not just older people who are at an increased risk of getting lung cancer. People with lower income are at a higher chance of getting lung cancer and are more likely to be diagnosed in the advanced stages of the disease when curative treatments are less helpful. This translates to them being 13 to 25 per cent less likely to survive three years, depending on their stage at diagnosis.
People with lower income are nearly twice as likely to be diagnosed with lung cancer. Systemic, economic and geographic barriers can all play a role in lung cancer, which can result in groups like First Nations, Inuit and Métis having a lower survival rate if diagnosed.
It is important when introducing lung cancer screening that it is done using a system that can measure and monitor, and make sure that the right people are being screened using the right technology at the right time. The end goal is getting the right care to the people who need it most, and that means putting plans in place to organize how a lung cancer screening program can roll out.
Nicholson says that these plans are already being discussed. “There’s already a lot of evidence, good evidence, which is why groups like the Canadian Task Force on Preventive Health Care have recommended lung cancer screening. We want to put that into practice.”
The current state of lung cancer screening
Surprisingly, the United States is the only country in the world with a proper lung cancer screening program, according to Tremblay. “It hasn’t been implemented, but in theory, there has been a full-scale supported lung cancer screening program since about 2016.” Tremblay adds that the program is funded by private insurers and through programs like Medicare. “Only a small number of eligible people are actually getting screened, but in theory they all could get screened. That’s the only country where that’s the case.”
In Canada there are three noteworthy programs that are making waves in lung cancer screening, according to Tremblay.
Ontario is in a pilot program (a publically funded, implementation project), that is slowly being phased into a full-scale program. This includes identifying high risk individuals and screening them at the recommended interval, appropriate and timely follow-up of abnormal findings, ongoing quality monitoring and reporting and performance management. There are currently four different hospitals that are serving as screening sites and they use low-dose computed tomography (LDCT) to conduct the screening.
British Columbia will launch a full-scale screening program in 2022. “They’re ready to go, because I think the pilot has been quite successful,” says Tremblay. Quebec is following in Ontario’s footsteps by starting their own 3,000 person pilot program in June.
CPAC works with partners to develop the core indicators that they want to be watching as lung cancer screening programs are established across the country.
“Each program, as I said, will likely have some core pieces that are shared, but will be operationalized in a way that respects the local needs and local context. That presents a really great learning opportunity that we have as a health care system in Canada,” says Nicholson. “It’s less of the big research, but it’s more about our organization and working with partners to facilitate learning and that continuous quality improvement cycle.”
Unfortunately, in provinces like Alberta, it is quite challenging to get a screening program up and running, despite it being the leading cause of cancer death in Alberta.
CPAC has a grant program for up to $1 million for provinces to start lung cancer screening programs. But according to Tremblay, there’s a catch to using the funds.
“To access that grant, you have to commit to funding it once the start-up funds are used. So for example, in Alberta, we still don’t have approval to ask for that million dollars because the province has to agree to it because it puts them in its way. It forces them to commit to take it at all, taking it on afterwards. So it’s kind of an interesting way that CPAC obviously means that as a catalyst to get things going, which is what it’s meant to be.”
But, as Tremblay adds, “There’s actually potential in Alberta that they say ‘no, we don’t want the money.’ We’ve been waiting for nine months now for an answer on whether we can apply for the funds.”
“They don’t want to take on the costs afterwards. We’re in a situation in Alberta where the province is not looking for new programs, they’re looking for programs to cut.”