‘An incredible challenge’: Experts discuss lung cancer screening priorities

Lung cancer

By Siobhan Calafiore

20 Jun 2023

Thoracic oncology experts have highlighted equity of access and implementation as the two biggest challenges for Australia’s national lung cancer screening program.

On 2 May, the federal government announced it would commit more than $260 million to implement a program that will provide low-dose CT screening every two years for high risk individuals between the ages of 50 and 70.

During a presentation on public health transforming lung cancer care at the University of Melbourne last week, respiratory physician Associate Professor Emily Stone listed equity of access as the top priority for the future screening program.

She said cities such as Perth, Melbourne and Sydney will likely benefit from already being trial sites in the International Lung Screening Trial (ILST), which is investigating low-dose CT screening for lung cancer care both in Australia and internationally.

Whereas lung screening would be harder to bring to groups such as regional and Indigenous populations where the program was perhaps most needed, she argued.

“If the trial doesn’t go there, the thinking doesn’t go there, the skills don’t go there and a successful screening program could struggle unless we shine a bright light on that gap,” Associate Professor Stone, who is a NSW principal investigator for ILST, told the audience at the Centre for Health Policy seminar on 16 June.

She said limited research showed Indigenous people with lung cancer who received the same treatments versus non-Indigenous people had poorer outcomes, which might be associated with comorbidities, delays and stigma.

Implementation challenges

With screening expected to begin in July 2025, thoracic surgeon Associate Professor Gavin Wright said implementation was currently the biggest concern.

Speaking during the panel discussion, he said challenges included delivering a Commonwealth program in states and territories with completely different health systems. A more targeted and nuanced approach also made it different to other screening programs and harder to implement than “true population screening”.

“It’s going to be an incredible challenge to make this efficient. You could make it work in pilots with lots of resources and research funding, but to roll it out is going to be challenging,” said Associate Professor Wright from St Vincent’s Hospital, the Peter MacCallum Cancer Centre and the University of Melbourne.

Other implementation challenges raised in the discussion included workforce, because of the need for more thoracic surgeons to carry out procedures, and introducing the program into general practices that were already under pressure.

Associate Professor Wright, chair of Cancer Australia’s Lung Cancer Advisory Group and Research and Education Lead for Lung Cancer at the Victorian Comprehensive Cancer Centre, agreed there needed to be focus on reaching at-risk groups.

“Any screening program that works in that [Indigenous] population will have a much higher impact per person screened than the rest of the population,” he said.

“We’re hoping for 1-2% pick-up rates in the general population, and maybe 8-10% in the Indigenous population. There are Indigenous people who I’ve treated who have said, ‘I think that’s the only disease that kills my family’, because all of their close family members – siblings, parents, uncles, aunts – had died of lung cancer.”

He said unlike breast screening, there would be no single point of entry.

“They’ve made it as wide possible, whether it be in the regional areas, a clinical nurse or a local nurse, Aboriginal health officers, a mobile truck … and it needs to be easy to get into. I think you’ll still need targeted efforts on top of that,” he said.

“This will be the biggest single impact we could have on lung cancer mortality.”

Lack of communication

But one concern raised by Associate Professor Stone was a lack of communication since the announcement had left a “massive gap” between research and planning.

“We [the investigators] are hearing nothing. I feel like we sweated blood over recruitment… and we have worked with brilliant minds from around the world and then the whole concept… it’s invisible now,” said Associate Professor Stone, who is based at St Vincent’s Hospital, Sydney and the University of New South Wales.

“I can give a very solid real life example of this,” Associate Professor Wright added.

“Thoracic surgeons have not had an audit tool ever and we’ve recently developed that specifically with one thing in mind, that there’ll be an approaching lung cancer screening program. We’re capturing data that we thought would be necessary to, for example, show we are not causing harm. We want to know how many patients are getting surgery because they were suspected of having lung cancer and didn’t.

“So we’re trying to work out data items, but we’re kind of in the dark, we’re just having to have a think ourselves amongst a few motivated surgeons.

“It’d be lovely if we were collecting exactly the same data the registry [that will be used to monitor and report on outcomes for the lung screening program] needs.”

The federal Department of Health and Aged Care has said information about implementation of the program will be provided over the coming months [link here].

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