Reference: February 2025 | Issue 2 | Vol 11 | Page 19
Lung cancer remains the leading cause of cancer-related mortality in Ireland, accounting for 1,916 deaths annually between 2018 and 2020, with a median age at diagnosis of 72 years. Based on incidence projections to 2045, annual numbers of lung cancer cases are projected to increase to 2,313 (+105%) in females and 3,137 (+131%) in males – an increase to 5,450 for males and females combined (+119%). This exponential growth in incidence highlights the importance of optimising early diagnosis and treatment pathways for lung cancer patients in Ireland.
The National Cancer Control Programme (NCCP) was established in 2007 with the key aim of implementing the recommendations of the National Cancer Strategy. In so doing, the five-year net survival for lung cancer doubled, having increased from only 12 per cent in 2004-2008 to 24 per cent in 2014-2018, representing a validation of this national strategy.
The national programme for lung cancer reconfigured lung cancer care, with the establishment of eight rapid access lung cancer clinics and four surgical centres. Over the course of the past 20 years, this centralisation of lung cancer care has led to a natural evolution of complex surgical management for thoracic surgical oncology focused in St James’s Hospital.
St James’s has a long tradition of providing cancer care to the Irish population and was the first Organisation of European Cancer Institutes (OECI) accredited cancer centre in Ireland. It is one of the eight rapid access lung cancer centres set out in the National Cancer Strategy and one of only four designated surgical centres for the treatment of lung cancer in Ireland.
St James’s thoracic surgical department consistently performs more than half of all curative-intent resections for lung cancer in Ireland and, as a consequence, over the past 20 years, has developed a cross-discipline multi-specialty institutional expertise that provides a unique and comprehensive 360-degree patient-centred journey of care for lung cancer patients.
This includes second opinion referrals, advanced bronchoscopic and radiological techniques, and a comprehensive, minimally invasive, thoracic surgical programme including robotic-assisted thoracic surgery (RATS) and complex open thoracic oncology, with a dedicated team of thoracic surgeons whose primary focus is thoracic surgical oncology, which is unique in Ireland.
Almost 80 per cent of all lung cancer surgery is now performed via a minimally invasive approach, with more complex cases offered robotic surgery, including bronchoplastic sleeve resections and chest wall resections.
We are supported by a team of highly skilled cardiothoracic anaesthetists with a special interest in thoracic surgical oncology and an institutional expertise in lung protective ventilatory strategies, enabling high volume complex lung cancer care, supported by dedicated critical care resources. This programme is also supported by dedicated on-site histopathological and cytopathological thoracic oncology specialists with institutional expertise in complex thoracic surgical oncology tissue interpretation, including second-opinion referrals and next generation sequencing.
We have dedicated lung cancer research resources with the St James’s Lung Cancer Biobank, now almost 20 years established, and managed via the cross-specialty Thoracic Oncology Research Group within the Trinity St James’s Cancer Institute. Long term patient follow up is managed by the largest lung cancer survivorship programme in the State, with long term holistic protocolised surveillance for lung cancer patients.
St James’s also uniquely provides a comprehensive suite of dedicated on-site medical and radiation thoracic oncology services, including access to neoadjuvant surgical clinical trials and advanced radiotherapy techniques.
More recently, we were privileged to have welcomed internationally recognised thoracic oncology specialists to expand our team, including the Marie Curie Chair of Clinical Oncology and consultant in radiation oncology, Prof Gerry Hanna, and returning St James’s Alumni Prof Patrick Forde, the incoming Prendergast Chair and Professor of Immuno-Oncology at Trinity College Dublin and Trinity St James Cancer Institute.
The centralisation of lung cancer care, which has doubled the survival of lung cancer patients in Ireland, has enabled St James’s Hospital to develop this unique cross-specialty team of dedicated healthcare professionals who are focused on the provision of optimal, international-standard, thoracic surgical oncology care. This was recognised by our recent accreditation by the European Society of Thoracic Surgeons. We are the first European-accredited thoracic surgical oncology centre in Ireland, a key performance metric recognising excellence in the provision of thoracic surgical oncology care to Irish lung cancer patients.
The treatment of lung cancer has never been more dynamic and complex, with neoadjuvant treatment strategies evolving, most notably based on the recent seminal paper by Forde et al (NEJM 2022) demonstrating significantly longer event-free survival and pathological complete response rate with neoadjuvant chemo-immunotherapy.
Consequently, since May 1, 2024, funding has been approved by the NCCP for neoadjuvant chemotherapy with nivolumab for resectable non-small cell lung cancer (NSCLC) in patients with PDL-1 ≥1 per cent. Funding has previously been approved for adjuvant atezolizumab in patients with completely resected NSCLC with PDL-1 ≥50 per cent who do not have EGFR or ALK mutations following adjuvant platinum-based chemotherapy. Adjuvant osimertinib, a third generation oral EGFR-TKI, has also been approved for completely resected stage IB-IIIA NSCLC in patients with EGFR exon-19 or exon-21 mutations. The benefits of these treatments have been clearly shown in significantly longer disease-free survival.
While very welcome, these new developments of both neoadjuvant and adjuvant pathways pose immediate challenges for the lung cancer community due to resource challenges and inherent logistical hurdles. For example, histopathological analysis of a resected lung cancer following neoadjuvant chemo-immunotherapy is more complex compared to a traditional non-treated lung cancer specimen, taking approximately three times the laboratory resource to complete.
In addition, patients cannot begin a neoadjuvant treatment pathway without evidence of their mutation and PDL-1 status. That places additional burdens on patient work-up, both in terms of adequate biopsy specimens and time-sensitive laboratory turnaround times. Hence adequately funded programmes, capable of providing both capital and human resources across the diagnostic and treatment pathway are critical to ensure that Irish patients gain the benefits of these advances. Most importantly, however, the decision about tumour resectability is central and hence expertise from large volume cancer centres is paramount.
The European Cancer Organisation Essential Requirements for Quality Cancer Care: Lung Cancer noted that high-volume lung cancer units are associated with better outcomes, even with a patient mix with greater co-morbidities and lower socioeconomic status. The advantage was that high volume centres are likely to perform more surgical resections as a percentage of cases, and use more minimally invasive techniques such as VATS and RATS, with lower morbidity.
It was noted that if all areas of the UK had the same access to surgery as the cancer network with the highest resection rate, over 5,000 deaths from lung cancer would be prevented every three years. One would expect a comparable finding in Ireland.
As lung cancer represents the majority of our workload, and recognising the significant patient benefits that accrue from national and particularly international collaboration, we were pleased to announce St James’s involvement in the Staging and Prognostic Factors Group of the International Association for the Study of Lung Cancer (IASLC). This is the first time that surgical patients in Ireland will contribute to the IASLC’s international lung cancer staging project, signifying Ireland’s growing role in advancing global cancer care.
Historically, the majority of IASLC data has come from Asia, North America, and parts of Europe. Ireland has never before participated in the project. This contribution will ensure that Irish patients’ characteristics are accounted for in the international effort to refine lung cancer staging and ultimately improve patient outcomes. It also further highlights St James’s Hospital as the national centre for the surgical management of complex thoracic cancer care.
A key component to our success has been our close collaboration with other Irish centres, which is central to our programmes, evidenced with our longstanding commitment as the surgical site for the management of screen-detected lung cancer patients via the recently announced Beaumont RCSI Irish Cancer Society Lung Health Check programmes.
Lung cancer screening is not currently available in Ireland. However, the aim of this pilot study is to assess the feasability, including uptake, of lung cancer screening for high-risk patients in an Irish community context through primary care-based participant invitation and using a mobile CT scanner. It is testament to the exceptional leadership by Prof Jarushka Naidoo and Dr Dan Ryan at Beaumont Hospital that the recently announced Programme for Government committed to evaluating the current lung cancer screening pilot and developing recommendations for a way forward.
As a result of the implementation of the National Cancer Strategy and the centralisation of lung cancer care, lung cancer survival in Ireland has significantly improved over the past 20 years. The advent and funding of next generation medications and technology, in conjunction with advanced surgical techniques, indicate a brighter future for Irish lung cancer patients.
However, it is essential that we build on this success, continuing to develop and reinforce close collaboration across centres, ensure patients have access to the best treatment options in a timely manner in appropriately staffed and funded cancer units, and that early detection of lung cancer via a national screening programme becomes a reality in Ireland.
