Evidence
Alert

Lung health checks in supermarket car parks reach older smokers in deprived communities

Tests carried out on mobile units parked in supermarket car parks were a popular and effective way to check the lungs of at-risk current and former smokers in a study in Manchester.    

Simple tests of lung function in these mobile units found more than a third of those screened had evidence of airflow obstruction. This is a sign of the common breathing disorder, chronic obstructive pulmonary disease (COPD). Half of those with airflow obstruction had no previous diagnosis of COPD, which is a serious health problem in its own right and also a risk factor for lung cancer. These people were invited to follow up their results with their GP.

The results of the Manchester study are so encouraging that the lung screening scheme has been expanded locally and extended to other parts of England.

What’s the issue?

Lung cancer is the world’s biggest cause of cancer death, partly because those most at risk are least likely to report with symptoms. Patients are often diagnosed only when their disease is advanced and incurable. 

Lung cancer screening could help catch the disease earlier. But there are concerns that a UK screening programme would be too expensive and would not reach the patients who need it most. This includes older smokers from more deprived backgrounds who can be reluctant to take part in screening.

What’s new?

The research was part of a preliminary study to check whether screening for lung cancer is feasible.  Between 2016 and 2018, thousands of current and former smokers from more deprived communities in Manchester made and kept appointments for lung health checks.  

The checks took place in convenient locations such as in supermarket car parks. Trained nurses gave patients spirometry tests, which involve breathing out into a tube to measure lung function.

Among those who took a spirometry test: 

  • almost all (99%) successfully performed the test
  • just over a third (37%) had evidence of airflow obstruction
  • almost one in five (19%) had evidence of airflow obstruction but no previous diagnosis of COPD
  • one in ten (10%) were likely to have undiagnosed COPD with symptoms
  • almost as many (9%) had airflow obstruction without symptoms.

Why is this important?

The study shows that COPD can be detected in a community-based screening programme. Many of the participants were older men from deprived communities, who are often missed by healthcare initiatives.

The World Health Organization projects that deaths attributable to COPD will increase by up to 30% over the next decade and become the third largest cause of death across the globe. In the Manchester study, significant numbers of the most at-risk people had COPD symptoms identified for the first time. Follow up appointments and treatment are expected to help many of them.

Beyond these immediate health benefits, the study adds to the evidence that at-risk people will turn up for lung cancer screening in the community.  It could encourage policy makers to set up comprehensive lung cancer screening programmes.

Identifying and treating COPD in thousands of people also has economic benefits, because it could avoid subsequent lengthy hospital treatment. The study suggests that simple spirometry tests performed as part of a lung cancer screening programme could potentially reduce future costs.

What’s next?

Follow up studies are tracking the health of the participants in Manchester found to have symptoms of previously undiagnosed COPD. Researchers hope to demonstrate links between the lung health checks and improved healthcare outcomes.

The positive results of this preliminary study convinced Manchester Health and Care Commissioning group to offer lung health checks across the city. The expanded £4.2 million service went live from April 2019. Almost 10,000 people have already been seen, most from deprived communities. NHS England have now set out plans for £70 million funding to rollout similar screening programmes at 10 sites across the country.

The results will feed into the ongoing debate – among academics, healthcare officials, the public and policy makers – about whether the UK and other countries should set up a national lung cancer screening programme.

You may be interested to read

The full study: Balata H, and others. Spirometry performed as part of the Manchester community-based lung cancer screening programme detects a high prevalence of airflow obstruction in individuals without a prior diagnosis of COPD. Thorax 2020

The thinking behind lung health checks is explained at: Crosbie PA, and others. Implementing lung cancer screening: baseline results from a community-based 'Lung Health Check' pilot in deprived areas of Manchester. Thorax. 2019;74:405-409

Lung health checks identify other diseases: Balata H, and others. Targeted lung cancer screening selects individuals at high risk of cardiovascular disease. Lung Cancer 2018;124:148-153

Community locations are preferred to hospital settings: Balata, H and others: Attendees of Manchester’s Lung Health Check pilot express a preference for community-based lung cancer screening. Thorax 2019;74:1176-1178

Funding

This study was funded by Macmillan Cancer Improvement Partnership. It was supported by the NIHR Manchester Biomedical Research Centre.

Commentaries

Study author

The lung health checks have been hugely popular in Manchester and we’ve had very positive feedback from participants, GPs, commissioners and staff. The response from the public has been fantastic and many people have booked appointments and attended. It has shown that people from so-called hard-to-reach deprived communities will engage with healthcare initiatives if we make it easy and convenient for them to access. The health benefits from these lung health checks could be significant in the long term and hopefully we can continue to make progress with the programme

Haval Balata, Respiratory Physician and Researcher at Manchester University NHS Foundation Trust

Respiratory Physician

The Manchester pilot was one of the first lung health check programmes and has generated important research findings in various published articles.

Lung function testing is a standard part of the NHS England Targeted Lung Health Checks (TLHC) Program, which aims to improve early diagnosis of lung cancer and other respiratory diseases.

The first phase is being delivered and evaluated in various sites around the country. If it is successful, the expectation is that TLHC will be rolled out nationally. This would mean that lung function tests, as part of lung health checks, would be available across England.

Appropriate training, and support for lung function testing as defined within the TLHC standard protocol, will be a vital component of respiratory workforce and financial planning. This study helps to inform appropriate provision and resourcing of lung function testing within lung health checks. It will be helpful to see lung function research within lung health checks replicated in other settings, for example, where there are different levels of smoking, or in other regional settings.

This will be particularly important in the COVID-19 setting since lung function testing could potentially increase the risk of infection from COVID-19. It will not be included as part of targeted lung health checks until the risk of infection has subsided further. This is a potential hurdle to the efforts to evaluate this important part of a national programme that could be mitigated by dedicated research.

Richard Lee, Consultant Physician in Respiratory Medicine and Champion for Early Cancer Diagnosis, The Royal Marsden NHS Foundation Trust

Conflicts of Interest

The study authors declare no conflicts of interest. Richard Lee is part of the leadership team for NHS England TLHC Program.