Lung cancer

Fine tuning required before lung cancer screening can proceed: Aussie experts


A/Prof Gavin Wright

Australia has the evidence and the appetite for a national lung cancer screening program but there is still work to be done especially around design, implementation and funding.

Speaking in a Clinical Oncology Society of Australia (COSA) 2021 ASM session on lung cancer screening, thoracic surgeon Associate Professor Gavin Wright said lung cancer screening was definitely “a cause for optimism”.

“We have a disease which has a high case fatality rate rate due to advanced presentation; we have low resectability rates compared to other solid cancers; and we have similar stage-matched surgical cure rates as other solid cancers so we should do as well as other cancers.”

Associate Professor Wright, director of surgical oncology at St Vincent’s Hospital Melbourne, said the aim was complete reversal of the current stage spread in lung cancer – from too many stage III and IV cancers to many more stage Ia cancers.

However he said there were implementation challenges.

“We don’t want the expense of BreastScreen; we don’t want the bottlenecks that occur with bowel cancer screening,” he said.

Importantly, a lung cancer screening program had to be designed to be accessible to the least advantaged people in the community.

And there was likely to be a “bun fight” over responsibilities and funding between the Commonwealth who paid for national screening programs and the states who would be paying for the outputs such as more biopsies and surgeries

Associate Professor Wright said the private system would embrace lung cancer screening as more work meant more profitability and more jobs.

However private patients were typically not the right demographic for a screening program targeted at the people at highest risk for lung cancer.

On the other hand, more work generated from a lung cancer screening program in a public hospital setting, that was already operating close to capacity, meant more costs and more delays to treatment.

He said lung cancer screening would provide a long-term return on investment as it reduced the costs of managing more advanced disease.

However: “If this program gets a green light, we need to think about manpower issues in five years time.”

He said more cases would provide more experience for individual surgeons, more institutional volume which would lead to efficiencies, more registrar training and more surgical research opportunities.

Opportunities and challenges

CEO of Cancer Australia Professor Dorothy Keefe told the meeting that discussions on operational design of the program and funding issues were ongoing.

And stakeholders were well aware that bringing forward a diagnosis of lung cancer through screening would have workforce considerations, as flagged in the Report on the Lung Cancer Screening Enquiry.

Respiratory physician Associate Professor Lou Irving, from the Royal Melbourne Hospital said multiple RCTs, including NLST and NELSON, had confirmed that screening with low dose CT in selected high risk people could significantly reduce mortality.

“The science has given us a wonderful opportunity to act, so that we can improve the survival from lung cancer.”

However he said the challenge will be to recruit the highest risk population for screening.

They included Indigenous Australians, people from cultural and linguistically diverse communities, people with mental health issues and those in correctional facilities.

“I think we are going to have to work together to recruit these groups of people who are going to benefit the most from screening.”

Dr Nicole Rankin, a senior research fellow at the University of Sydney’s School of Public Health, said lung cancer screening was complex with challenges at multiple levels.

In particular, targeting screening on the basis of age and smoking history tended to oversimplify the risk of lung cancer.

She said other factors such as personal history, ethnicity, and occupational exposures also need to be considered.

“We need to target screening to reduce potential harms of unnecessary scans and investigations without sacrificing lung cancer detection in people at high risk,” she said.

Dr Rankin said preliminary findings from the ILST cohort were teasing out people’s motivation to consent for lung cancer screening.

She noted that people had to be both psychologically and physically able to screen.

For example, they needed faith that screening would help them and be reassured about practical considerations such as location and costs of getting there.

“We can’t afford to lose people who are eligible so we need to design strategies tailored to meeting their needs,” she said.

She noted that direct recruitment through a structured pathway was more successful than other strategies.

The session was sponsored by Janssen Oncology.

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