Kim Arnott and Rich Higgins, photographed at their Hamilton, Ont., home, were rejected from Ontario's lung cancer screening program despite both meeting the criteria.Nick Iwanyshyn/The Globe and Mail
When Rich Higgins turned 55, he figured it was time to get screened for lung cancer. The retired Hamilton corrections worker, whose father and grandfather both died of the disease, thought he met the criteria for Ontario’s lung cancer screening program, which invites people 55 to 74 who smoked daily for at least 20 years to get a CT scan of their chests, even if they’ve quit as Mr. Higgins did about a decade ago.
But it turned out Mr. Higgins, now 57, wasn’t eligible. A provincial health-system navigator who called to ask him a series of questions determined his risk of lung cancer was too low to qualify him for a scan.
Mr. Higgins’s wife, Kim Arnott, who has a similar smoking history, was also rejected – twice – when she tried to get into the screening program after turning 55.
As the experience of Mr. Higgins and Ms. Arnott demonstrates, qualifying for lung-cancer screening is more difficult than it appears, even for people who meet the official age and smoking criteria and live in Ontario, the province that pioneered organized lung-cancer screening in Canada.
The situation is worse in most other parts of the country. Only Ontario, British Columbia and Nova Scotia have formal lung-cancer screening programs. The remaining jurisdictions offer no screening beyond pilot projects and plans to launch screening programs in the future, despite more than a decade of research showing that screening with low-dose CT scans reduces mortality from lung cancer.
“Lung cancer kills more people than breast, prostate and colon cancer combined,” said Christian Finley, a thoracic surgeon at McMaster University. “Clearly it’s a socially stigmatized disease. Even though it is this number one killer, and it’s a terrible disease, we just can’t seem to get it over the line,” he added, referring to making lung-cancer screening available everywhere in Canada.
The lack of public attention and shortage of screening for lung cancer stand in stark contrast to the attention paid to breast-cancer screening, which has been the subject of a high-profile debate among experts and patients in this country for years.
That fight became more heated in 2023, when the U.S. Preventive Services Task Force recommended the age at which average-risk women start getting mammograms be lowered to 40 from 50. Canada’s own task force declined to follow suit, releasing new draft guidelines in May that maintained a starting threshold of 50, but which emphasized that women in their 40s who want a mammogram should be able to get one.
Federal Health Minister Mark Holland greeted the draft guidelines with a news conference criticizing them and a vow to expedite a review of the federally funded task force. The public drumbeat in favour of screening younger women for breast cancer was so loud that several provinces, including Ontario, Saskatchewan and Newfoundland and Labrador, announced plans to lower the age, rather than wait for the task force’s advice.
Meanwhile, the same organization, the Canadian Task Force on Preventive Health Care, hasn’t updated its lung-cancer screening guidelines since 2016.
Those guidelines recommend annual screenings up to three consecutive times for people 55 to 74 with at least a 30 “pack-year” smoking history who currently smoke or quit less than 15 years ago. (A pack year is the equivalent of smoking one pack a day for a year. People who smoke more packs of cigarettes per day rack up more pack years in less time.)
The U.S. task force, in revised guidelines released in 2021, recommended annual screening for people 50 to 80 with a 20 pack-year history who still smoke or who quit less than 15 years ago. Last fall, the American Cancer Society went one step further, and recommended the years-since-quitting proviso be dropped.
According to the Canadian Partnership Against Cancer (CPAC), a Health-Canada funded organization that supports national anti-cancer policies, only Ontario, B.C. and Nova Scotia have formal lung cancer screening programs. Quebec and Alberta launched pilot programs in 2022. Newfoundland and Labrador joined them this year. The rest of the provinces are planning for implementation with the help of CPAC, which has committed $8.4-million to the effort from 2022 to 2027.
The Canadian Cancer Society has also been lobbying governments for equal access to lung cancer screening, regardless of where patients live.
Lung cancer, “is an area that experiences a lot of stigmatization,” said Kelly Wilson-Cull, the society’s director of advocacy. Overcoming that is a challenge, she said, as are some of the practical hurdles to lung cancer screening, such as obtaining precious CT scanner time.
Complicating matters further is the risk-prediction model that weeded Mr. Higgins and Ms. Arnott out of the lung-cancer screening pool in Ontario. Every province with a lung-cancer screening program or pilot uses a version of the model developed by Martin Tammemägi, a cancer epidemiologist and professor emeritus at Brock University.
Dr. Tammemägi’s model, which Britain and parts of Europe use as well, factors in age, personal and familial history of cancer, the presence or absence of chronic obstructive pulmonary disease, body mass index, how much and for how long people have smoked, whether they’ve quit and for how long and their education level as a proxy for socioeconomic status.
Stephen Lam, medical director of the BC Cancer Lung Screening Program, said studies have shown the risk-prediction approach to be more cost effective – it finds more cancers with fewer CT scans by zeroing in on those at highest risk. In the U.S., Dr. Lam said, “they’re spending more money and not finding more cancer.”
Under Dr. Tammemägi’s model, each factor is weighted differently to produce a score that predicts how likely a person is to develop lung cancer in the next six years. Ontario has set a risk threshold of 2 per cent, while B.C. has chosen 1.5 per cent, which makes B.C.’s screening program easier to get into.
Dr. Tammemägi, who was the scientific lead for Ontario’s lung cancer screening program until retiring last December, said in an interview that he favours a 1.5-per-cent threshold, but officials at Ontario Health settled on 2 per cent for cost reasons.
In response to questions from The Globe and Mail, Ontario Health said its risk assessment process helps identify those likeliest to benefit from screening. The agency did not answer The Globe’s question about why it chose a 2-per-cent risk threshold. Ontario, which currently offers lung-cancer screening in five cities, plans to make the service available provincewide by 2026.
Dr. Tammemägi offered through The Globe to assess Ms. Arnott’s and Mr. Higgins’s risk using his model. Mr. Higgins declined, but Ms. Arnott took him up on the offer. The model predicted that Ms. Arnott, a freelance writer and editor with a BA, a healthy body mass index and no personal or familial history of cancer, had a 0.4-per-cent risk of developing lung cancer in the next six years – despite a smoking habit that began when she was 13. She and her husband quit together about a decade ago.
“I do feel reassured with the level of expertise that is being applied to some of this,” Ms. Arnott said. “Having said that, I still think that we tend to make policy based on loud voices and maybe there needs to be a little more volume from people that might be affected by lung cancer.”