UK Lung Cancer Diagnostic Services: Time to Step Up

The UK’s national health system needs to take a hard look at their priorities and procedures to ensure that rapid advances in molecular diagnostics in lung cancer are translated into a practical service for all patients, according to a report launched today at the British Thoracic Oncology Group Annual Conference.

The UK’s largest multi-interest group in lung cancer has released a thorough and practical report which highlights the urgent need for change, in order to help the UK keep up with advances in lung cancer therapies. The UK has among the worst five-year survival rates for lung cancer in Europe¹ and the NHS is said to be slow to respond, with ‘patchy’ services.²

While the constant discovery of new targets and agents is encouraging, it does make it difficult for clinicians, pathologists and drug regulators to keep up.

Certainly not unrelated, is the lack of workforce capacity in pathology laboratories; only 3% of departments who responded to The Royal College of Pathologists Histopathology Workforce Census in 2018³ said they had enough staff.

Professor John Gosney (Consultant Thoracic Pathologist, Royal Liverpool University Hospital), who was instrumental in the UKLCC’s Molecules Matter report, notes:

“We need to appoint thoracic pathologists with an interest in molecular diagnostics. This recruiting could be done nationally with planned placement in chosen existing centres of excellence where expanding services are often run currently by a single overwhelmed pathologist. Centralisation of thoracic pathology services is impossible without this.”

The report was written by the United Kingdom Lung Cancer Coalition (UKLCC) - a coalition of the UK’s leading lung cancer experts, senior NHS professionals, charities and healthcare companies.

The UKLCC aims to raise political and general awareness of lung cancer, improve lung cancer services, and empower patients to a) recognise early symptoms and b) empower patients to take part in their care.

When asked if there were any countries in the world that stood out as being ‘ahead of the game’, Professor Gosney said:

 “No country has solved these problems, which are same everywhere.”

Therefore, this forward-thinking group is working to put steps in place so that pathology and molecular diagnostics services can keep up with the changing treatment landscape.

Here is a summary of some of the recommendations listed in the report:

Technical	Organisational	Professional	Data
Biomarkers and diagnostic tests need to be assessed regularly by NICE and NHS England	Services should work towards goals of the National Optimal Lung Cancer Pathway	Pathology and Genomics Laboratory Hubs need to communicate effectively	Reporting templates should be developed and managed on a national LIMS system
The National Genomic Test Directories should be updated on an ad hoc basis– not annually	Inform patients as much as possible on next steps, expected timelines, etc	The cellular pathology workforce is under pressure; budget must be set aside for this	Data from diagnostic tests should be linked to other patient-related data to guide treatment
Will testing be reflex or on-demand?*	Ensure rapid and efficient movement of samples	Check and address: is there a lack of biomedical students coming through? In what areas?	It should be mandatory that high quality data is submitted to a national dataset
Next generation sequencing panels vs multiple/single gene tests*	Pathologists: follow the Royal College of Pathologists guidelines for lung cancer	Training of those taking tissue samples needs to be standardised	A scheduled 2020 report should be used to monitor services, identify trends and reduce variation

*Services should be clear about when these will be used.

Divergence in the devolved nations

Another group of challenges was also highlighted, regarding ‘divergence in the devolved nations.’ In other words, differences exist between England, Scotland, Wales and Northern Ireland, with regards to funding models and access to medicines and testing options. However, this does present best-practice learning opportunities:

“This lack of alignment across the UK has resulted in a mixed picture of funding for new diagnostic tests in Northern Ireland and Wales. With Northern Ireland not having access to the CDF (Cancer Drugs Fund) until recently, patients could not access ROS1 to date. In Wales however, the One Wales system – using a generic panel for solid tumours – has seen a big step forward.”

Consistency needed in tissue sampling

There should be some kind of quality assurance program, for those involved in the collection of tissue samples – according to Professor Michael Peak, Chair of the Clinical Advisory Group to the UKLCC. In the foreword to the report, he writes:

“The range of tissue sampling techniques has also been widening in recent years, in particular with the development of endobronchial ultrasound (EBUS) sampling of the mediastinum and wider use of CT guided needle biopsy. The increasing range of pathological tests needs larger, better quality tissue samples and there is strong, though largely anecdotal, evidence of wide variation in the quality of samples being received by pathology laboratories.”

When asked about this variation, Professor Gosney noted:

“There are two reasons for inadequate specimens for lung cancer profiling; poor technique by the endoscopic or radiologist performing the procedure (endobronchial ultrasound, needle biopsy etc) and wastage of the tissue by non-specialist, inexperienced pathologists, usually in DGHs (District General Hospitals), performing unnecessary immunochemistry to arrive at the initial diagnosis before referring the specimen for profiling. These services should be centralised.”

So – having sufficiently trained staff is key. It seems that funding is lacking, but are the training opportunities actually available?

“Training opportunities already exist in the labs in the existing major thoracic centres; the posts just need establishing with the necessary funding,” notes Professor Gosney.

Goals have been set, it’s time for action!

According to the report, a diagnostic level of 85% should be attainable when definite tumour is visible. To achieve this, a coordinated strategy will be required. The frontier in pathology and molecular diagnostics is said to be ‘moving at pace’, yet there are many barriers that are preventing these advances from being available to patients.

As Professor Peake concludes:

“If the UK wants to achieve the best cancer outcomes in the world,⁴ then these issues must be addressed, and urgently!”

References:

1. London School of Hygiene and Tropical Medicines: Cancer Survival Group, CONCORD Programme, via: http://csg.lshtm.ac.uk/research/themes/concord-programme/
2. Molecules matter: Turning the science of molecular diagnostics in lung cancer into a practical service for all patients. UK Lung Cancer Coalition. January 2019. Accessible at:  www.uklcc.org.uk/our-reports/  
3. The Royal College of Pathologists, Histopathology Workforce Survey 2018 
4. Independent Cancer Taskforce, Achieving world-class cancer outcomes: a strategy for England 2015-2020, July 2015