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Pregled raka pluća spreman je spasiti tisuće od smrti: Može li EU poduzeti akciju?

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Iako Europa razmišlja o više hvalevrijednih shema ograničavanja štete nanesene rakom, jedna od najperspektivnijih mogućnosti zanemaruje se - a mnogi Europljani zbog toga nepotrebno umiru. Rak pluća, najveći ubica raka, još uvijek je na slobodi, uglavnom je nekontroliran, a najučinkovitija metoda za borbu protiv njega - probir - neobjašnjivo se zanemaruje, piše izvršni direktor European Alliancce for Personalized Medicine (EAPM) dr. Denis Horgan.

Probir je posebno važan za rak pluća jer se većina slučajeva otkrije prekasno za bilo kakvu učinkovitu intervenciju: 70% se dijagnosticira u uznapredovaloj neizlječivoj fazi, što rezultira smrću trećine pacijenata u roku od tri mjeseca. U Engleskoj se 35% karcinoma pluća dijagnosticira nakon nužde, a 90% od tih 90% je u stadiju III ili IV. No otkrivanje bolesti puno prije nego što se pojave simptomi dopušta liječenje koje unaprijed metastazira, drastično poboljšavajući ishode, s stopom izlječenja većom od 80%.

Tijekom posljednja dva desetljeća dokazi su postali neodoljivi da screening može transformirati sudbinu žrtava raka pluća. Uznemirujuće je, međutim, da se države članice EU-a još uvijek dvoume oko njegova usvajanja, a ono i dalje ostaje nisko na političkim prioritetima na nacionalnoj i na razini EU-a.

A valuable opportunity to remedy this deficiency is in the offing. Before the end of 2020, the European Commission has unveiled Europe’s Beating Cancer Plan, a major opportunity to guide national actions. It will be, in the words of Commission President Ursula von der Leyen, “an ambitious cancer plan to reduce the suffering caused by this disease.” Preparatory drafts suggest it will offer a powerful, coherent and almost comprehensive response to the havoc that cancer wreaks on lives, livelihoods and quality of life across Europe.

Almost comprehensive. Because on the potential for lung cancer screening to save lives, it has little to say. The document is commendably strong on prevention, where there is, as it points out, important scope for improvement, with up to 40% of cancer cases being attributed to preventable causes. It also highlights screening as a vital tool in colorectal, cervical and breast cancer. But screening for lung cancer – which alone kills more than those three cancers combined – receives only a few passing references in the draft text, and no endorsement commensurate with the impact of its implementation at scale. This threatens to leave LC screening in its current under-exploited status in the European Union, where although the disease is the third leading cause of death, there is still no EU recommendation for systematic screening, and no large-scale national plan.

Slučaj za akciju

The most recent studies add to an accumulation of evidence of the merits of LC screening over the last two decades. A just-published IQWiG study concludes that there is a benefit of low-dose CT screening, and “the assumption that screening also has a positive effect on overall mortality seems justified.” Some studies show it saves an estimated 5 in 1000 people from dying of lung cancer within 10 years, while others warn that 5-year survival among all patients with lung cancer is barely 20%. Every year, at least twice as many people die from lung cancer as from other common malignancies, including colorectal, stomach, liver and breast cancer. In Europe it causes more than 266,000 deaths yearly – 21% of all cancer-related deaths.

Oglas

Kasno predstavljanje mnogim pacijentima onemogućava mogućnost operacije, koja je - unatoč kontinuiranim poboljšanjima u drugim oblicima terapije - trenutno jedina dokazana metoda za poboljšanje dugoročnog preživljavanja. Koncentracija pacijenata među pušačima dodaje daljnju hitnost uvođenju sustavnog probira. Pokušaji obeshrabrenja i smanjenja upotrebe duhana imat će učinka samo na duži rok. U međuvremenu, najbolja nada za milijune pušača i bivših pušača - pretežno među najpogroženijim stanovništvom Europe - je u probiranju. Ali upravo je ovu populaciju najteže doseći - što se ogleda u činjenici da je manje od 5% osoba širom svijeta s visokim rizikom od raka pluća prošlo probir.

Izgledi za promjene

Europe’s Beating Cancer Plan (BCP) holds out the prospect of many improvements in tackling cancer, and its vision embraces admirable principles – including the merits of screening, technology and enlightened guidance. It foresees “putting the most modern technologies at the service of cancer care to ensure early cancer detection.” But as long as it hesitates over endorsing screening for lung cancer, a major opportunity will remain neglected.

The BCP acknowledge that live are saved by early detection of cancer through screening. They speak approvingly of population-based screening programmes for breast, cervical and colorectal cancer in national cancer control plans, and of ensuring that 90% of the qualifying citizens will have access by 2025. For screening of these three cancers, they even envisage reviewing the Council Recommendation, and issuing new or updated Guidelines and Quality Assurance schemes. But lung cancer screening enjoys no such priority in the BCP, which are limited to allusions, to a “possible extension” of screening to new cancers, and to a consideration of “whether the evidence justifies an extension of targeted cancer screening.”

As Europe enters the third decade of the century, significant evidence has already justified action to implement LC screening. It is not the time to be debating whether the evidence is sufficient. The evidence is in. “There is evidence of a benefit of low-dose CT screening compared to no screening,” says one of the recent studies. The NLST study demonstrated a relative reduction in lung cancer mortality of 20% and a 6.7% reduction in all-cause mortality in the LDCT arm. 5-year survival in patients diagnosed early (stage I-II) can be as high as 75%, especially in patients who have a surgical resection. Earlier diagnosis moves the focus from palliative treatment of incurable disease to radical potentially curative treatment with a resultant transformation of long-term survival. LuCE claims that five-year survival rates for NSCLC could be 50% higher with earlier diagnosis.

Na povijesne prigovore LC probiru – u smislu rizika od zračenja, pretjerane dijagnoze i nepotrebnih intervencija ili nesigurnosti u pogledu modela rizika i isplativosti – uvelike je odgovoreno nedavnim istraživanjem. A s obzirom na predanost BCP-a stavljanju istraživanja, inovacija i novih tehnologija u službu skrbi protiv raka ("uporaba tehnologije u zdravstvenoj skrbi može biti spas", kaže najnoviji nacrt), mogao bi omogućiti daljnje studije za usavršavanje i razjasniti područja u kojima se LC probir može dodatno poboljšati, te konsolidirati potrebna infrastruktura i obuka.

Povećavanje mogućnosti za dijagnozu

There are other aspects of BCP linked directly or indirectly to screening which could – and should – enhance early detection and accurate diagnosis of lung cancer. Draft texts already make mention of exploring “early diagnosis measures to new cancers, such as prostate, lung, and gastric cancer.” By providing more precise information on tumours, lung cancer screening has opened the way to more personalized treatment for lung cancer and provides fertile ground for further innovations in technology, image analytics and statistical techniques, and future image interpretation will be increasingly assisted by computer-aided diagnostics. The EU’s parallel Mission on Cancer is expected to generate new evidence on the optimisation of existing population-based cancer screening programmes, develop novel approaches for screening and early detection, and provide options to extend cancer screening to new cancers. It will also contribute to providing new biomarkers and less invasive technologies for diagnostics. The new ‘European Cancer Imaging Initiative’ will facilitate the development of new, enhanced diagnostic methods to improve quality and speed of screening programmes using Artificial Intelligence, and promote innovative solutions for cancer diagnostics. A new Knowledge Centre on Cancer will function as an ‘evidence-clearing house’ for early detection through screening. An upgraded European Cancer Information System will facilitate the assessment of cancer screening programmes through improved data collection on cancer screening indicators. The analysis of interoperable electronic health records will improve understanding of disease mechanisms leading to the development of new screenings, diagnostic pathways and treatments.

To su ohrabrujući koncepti i mogli bi - ako se provedu - pomoći u usavršavanju ranog otkrivanja i dijagnoze. Ali bilo bi još obećavajuće kada bi se priznanje poboljšanog pristupa ispitivanju biomarkera u dijagnozi i progresiji proširilo na liječenje i na unapređenje pojave personalizirane medicine. BCP bi mogao biti kontekst za sustavniji razvoj ispitivanja biomarkera. Možda bi se podaci o varijacijama u stopama testiranja mogli uključiti u predviđeni registar nejednakosti raka.

Slično tome, korištenje prednosti tehnološkog napretka u liječenju moglo bi pacijentima pružiti još veće šanse za preživljavanje i kvalitetu života. Uz presudnu ulogu koju je radiologija imala u skriningu, i sama radioterapija znatno je napredovala tijekom posljednja dva desetljeća, s novim tehnologijama i tehnikama koje omogućuju sve preciznije, učinkovitije i manje toksične tretmane, omogućujući tako kraće i pacijentu povoljnije režime. Sada je uspostavljen kao važan stup u multidisciplinarnoj onkologiji. Kao i kod svih ostalih mogućnosti za bolji probir, dijagnozu i liječenje, odgovarajuće pokriće u zdravstvenim proračunima i sustavima naknada neophodno je ako se dobre namjere žele pretvoriti u akciju.

Zaključak

Bitno je da se programi LC probira provode na sveobuhvatan i koherentan i dosljedan način, umjesto da nastaju kao nusproizvod sporadičnog naručivanja skeniranja od strane pružatelja usluga bez uspostavljene programske infrastrukture. S obzirom na mogućnost da na tako velik broj života pozitivno utječe pravovremena dijagnoza bolesti koja se liječi u ranoj fazi, zdravstvene ustanove i pružatelji zdravstvenih usluga trebaju dati najveći prioritet pokretanju ovih programa. Nova shema EU za probir raka predviđena BCP-om trebala bi imati viziju izvan okvira probira za rak dojke, vrata maternice i debelog crijeva i raka pluća. Prijedlog Komisije za reviziju preporuke Vijeća o probiranju karcinoma pozitivan je korak naprijed.

The challenge now is to act, and to implement LC screening – and in so doing, to save lives and prevent avoidable suffering and loss across Europe. If the EU does not take advantage of initiatives such as BCP, long-overdue improvements in lung cancer care will be deferred again, with the worst impact felt in Europe’s most disadvantaged populations. Policy makers should recognise this unexploited potential, and should respond by driving implementation.

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