On September 24, 2024, Hong Kong hosted the Lung Cancer Care Continuum Policy Forum Series, a pivotal event that brought together leading experts to assess the current state of lung cancer management and formulate policy recommendations specific to the region. This forum was the first in a series aimed at evaluating existing research and advancing local lung cancer care practices, with a particular emphasis on improving screening initiatives.

Lung cancer remains one of the most common and fatal cancers in Hong Kong, with 5,978 new cases reported in 2021, constituting 15.5% of all cancer diagnoses. The age-standardized mortality rates for lung cancer were 29.7 and 14.0 per 100,000 standard population among men and women, respectively. While Hong Kong has made significant progress in tobacco control, with the smoking rate declining from 12.4% in 2000 to 9.1% in 2023, the unique epidemiology of lung cancer in the region, where the majority of cases occur in non-smokers, underscores the need for a broader focus beyond smoking cessation.

The forum identified several key challenges in lung cancer management, including the absence of centralized guidelines, limited access to screening and precision diagnostics, and gaps in public awareness and healthcare integration. Currently, the Cancer Expert Working Group on Cancer Prevention and Screening of the Centre for Health Protection does not recommend routine screening for lung cancer among asymptomatic individuals with moderate risk. This lack of a comprehensive lung cancer control plan results in late-stage diagnoses and worse patient outcomes. Care is primarily managed by specialists, with minimal involvement from primary care physicians.

Lung cancer screening is recognized as a critical intervention for early detection, particularly in high-risk populations. Authorities in the United Kingdom, Australia, Taiwan, the United States, China, Singapore, Canada, Korea, and Japan have recommended lung cancer screening for individuals aged 50 to 55 years, with cessation at 70 to 74 years. However, Hong Kong has yet to establish a government-funded, population-based screening programme targeting high-risk groups. The Chief Executive’s 2024 Policy Address highlighted the need to explore an artificial intelligence (AI)-assisted lung cancer screening programme. The experts strongly supported this initiative, citing the success of the colorectal cancer screening programme for high-risk individuals, which demonstrated the feasibility of translating clinical evidence into real-world practice through a multidisciplinary approach. This model could serve as a framework for developing an effective lung cancer screening programme in Hong Kong.

The economic implications of lung cancer care were also discussed. The experts emphasized the cost-effectiveness of low-dose computed tomography (LDCT) screening for high-risk smokers and non-smokers. Evidence was presented indicating that, over a lifetime, the incremental cost-effectiveness ratios of LDCT screening are well within the affordability range for Hong Kong’s healthcare expenditures, based on prior experiences with willingness-to-pay thresholds. Consequently, there is robust justification for the initiation of LDCT-based lung cancer screening among all high-risk individuals. This approach has the potential to greatly reduce the lung cancer burden and improve population-level outcomes. A report from regions that have adopted lung cancer screening, including Taiwan, demonstrated a substantial shift towards earlier-stage diagnoses.

Innovative approaches to lung cancer screening were also presented. The ongoing LC-SHIELD study (Lung Cancer Screening in High-risk Non-smokers by Artificial Intelligence Device) utilizes AI to screen high-risk non-smokers, a critical subpopulation considering that more than 50% of lung cancer cases in East Asia occur in non-smokers. The application of AI may enhance the sensitivity and specificity of screening, particularly for individuals with unique risk profiles, such as those with a family history of lung cancer or genetic predisposition. The experts noted the limitations of conventional tools (e.g., chest X-rays), which lack the sensitivity of LDCT for detecting early-stage lung cancer. There was support for the adoption of innovative methods, including liquid biopsy and AI-enhanced LDCT interpretation, which improve early detection rates but reduce costs by minimizing false positives and optimizing the screening process. Such innovations offer promising opportunities to enhance lung cancer care in Hong Kong, making screening more efficient and accessible.

Lung cancer care in Hong Kong is primarily managed by tertiary care specialists, with limited integration across different levels of the healthcare system. The experts highlighted the success of a community-based charity programme designed to increase public awareness of lung cancer screening. This programme provided a single round of LDCT screening of the thorax to 99 asymptomatic adults with a family history of lung cancer and/or a history of smoking. Positive LDCT results were observed in 47 participants (47%), and lung cancer (all adenocarcinomas) was ultimately diagnosed in six participants (6%). This detection rate in Hong Kong appears higher than those reported in recent international trials of LDCT for lung cancer screening, indicating a need to revise eligibility criteria for greater emphasis on family history and to leverage local clinical expertise for lesion assessment. The findings from the programme were subsequently published in an international peer-reviewed medical journal and presented at the 2024 World Conference on Lung Cancer.

The published results underscore the potential for adoption of similar programmes and highlight the benefits of incorporating LDCT screening into routine health checks for high-risk individuals. These findings strengthen the case for enhancing access to screening, supporting early detection efforts, and improving lung cancer outcomes in Hong Kong.

Although LDCT is a promising tool, its effectiveness depends on collaboration among multidisciplinary healthcare teams. The experts noted the challenge posed by incidental pulmonary nodules, which are frequently detected during LDCT screening but are often benign. These findings can increase patient anxiety and place additional strain on healthcare systems due to unnecessary invasive procedures. The experts also emphasized adherence to updated guidelines, such as those from the Fleischner Society, for appropriate management of incidental pulmonary nodules. Shared decision-making between patients and healthcare providers was considered essential to ensure that individuals understand the risks and benefits of screening.

The implementation of lung cancer screening presents challenges related to the psychosocial impact, particularly ‘scanxiety’—the anticipatory anxiety associated with screening preparation, procedures, and results. The experts highlighted the importance of incorporating psychological support into screening programmes to enhance patient participation and adherence, especially among younger individuals who may avoid screening due to fear.

Based on insights shared during the session, the experts formulated five key recommendations to address critical challenges in lung cancer screening and care in Hong Kong. These recommendations reflect collective expertise and propose a holistic approach to advancing early detection, improving healthcare integration, and enhancing accessibility and outcomes for patients:

1. Develop a comprehensive lung cancer control plan: Establish a detailed, government-funded plan covering the entire patient care continuum to standardize clinical practices throughout the health system.
2. Implement system-wide screening programmes: Introduce lung cancer screening initiatives targeting high-risk populations, such as smokers and individuals with genetic predisposition, ensuring that these programmes are accessible and tailored to local needs.
3. Improve healthcare integration: Strengthen collaboration between primary care providers and specialists to streamline the patient care continuum, particularly in the management of follow-up care for individuals with incidental findings.
4. Address psychosocial barriers: Incorporate psychological support and patient education into lung cancer screening and management programmes to reduce anxiety and improve participation.
5. Expand screening programmes using AI technology: Promote research and application of AI-enhanced LDCT screening programmes to enhance early detection and cost-effectiveness.

The first session of the Lung Cancer Care Continuum Policy Forum Series concluded with an emphasis on adopting a multipronged approach that involves research, policy advocacy, and patient education. During future sessions that more fully explore the patient care continuum for lung cancer care, the aim will be to achieve consensus regarding a unified strategy that aligns local clinical and policy efforts for lung cancer management. The outcomes of these discussions will play a central role in shaping the future of lung cancer care in Hong Kong, ensuring timely detection, equitable access to care, and improved survival outcomes for future generations.