By Professor Fraser Brims, Curtin Medical School and Institute for Respiratory Health
Lung cancer accounts for approximately 9% of all new cancer diagnoses and nearly 18% of all cancer-related deaths.
The National Lung Cancer Screening Program (NLCSP) will roll out nation-wide on 1 July 2025, targeting individuals at high risk of developing lung cancer.
Lung cancer screening saves lives. Studies have demonstrated that low dose CT scan (LDCT) screening can improve lung cancer-related mortality by at least 20% when targeting a high-risk population.
LDCT identifies potential early-stage lung cancer while minimising radiation exposure. The NLCSP will target a population at high risk for developing lung cancer using LDCT to identify lung cancer at an early stage, when lobectomy may offer a chance of cure.
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Eligibility and screening methodology
The NLCSP eligibility criteria include those aged between 50 to 70 years old who have more than a 30-pack year smoking history in current tobacco users, or in former tobacco users who quit less than 10 years ago.
Screening CTs will be free for participants and there are two new Medicare item numbers for the NLCSP.
Key features of the NLCSP include:
- Bi-annual screening: eligible participants undergo a LDCT scan every two years
- Primary care will play a key role in recruitment into the NLCSP and follow up of the results, with integration with the National Cancer Screening Register (NCSR)
- Risk-based assessment of nodules: most LDCTs in high-risk populations will demonstrate a nodule, but most nodules are not a lung cancer. The NLCSP will risk-assess the likelihood of malignancy of screen detected nodules and base recommended follow up accordingly
- Integrated smoking cessation support is a critical component to realise the full health impacts of the NLCSP
- To accompany the NLCSP roll-out, the Thoracic Society of Australia and New Zealand (TSANZ) recently published guidelines for clinicians managing incidental and screen detected nodules.
Who will follow up the LDCT findings?
The medical practitioner who requested the original LDCT will remain responsible for follow up and requesting the interval CTs.
The NCSR will write to the participant and their requesting medical practitioner with the LDCT results. The NLCSP LDCT report will be synoptic – clearly stating recommended actions, both for nodule follow up and any actionable additional findings.
It is estimated that around 70% of participants screened will simply stay under bi-annual screening. Further, not all additional findings will require action or further investigations.
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Using the direct experience from studies in Australia and the risk-based nodule follow up protocol, it is anticipated that only around 3% of all LDCT scans will have a high or very high nodule risk requiring further investigation by an expert lung cancer multidisciplinary team.
All other remaining nodules will have interval CTs within the NLCSP program at three, six or 12 months.
Challenges and considerations
While the NLCSP is a groundbreaking initiative and the first national screening program in Australia for 19 years, its implementation is not without challenges.
Ensuring equitable access to screening across to the hardest to reach populations, including Aboriginal communities and those in rural areas, is a key priority for Cancer Australia.
This will be achieved in part by the commissioning of mobile LDCT trucks, which will serve regional and remote Australian communities. WA will be the first State to have access to this service in late 2025.
Minimising harm through overdiagnosis and false positives which may lead to anxiety and unnecessary treatments is critical and, therefore, the NLCSP protocol states that patients with high-risk nodules should be referred to respiratory teams linked to a cancer multidisciplinary team.
Accurate staging of lung cancer is critical to ensure an appropriate management plan.
The complexity of investigating and staging lung cancer has increased significantly in the last 10 years. Early-stage patents may require endobronchial ultrasound bronchoscopy as FDG-PET scans have a low sensitivity with most screen detected nodules.
Therefore, a multidisciplinary approach is required to ensure appropriate investigations and accurate interpretation of results.
The recent TSANZ guidelines recommend patients are discussed at dedicated nodule multidisciplinary meetings.
Community and patient education will be essential to ensure uptake within eligible populations and overcome the bias and stigma that has plagued lung cancer historically. Good communication and managing expectations will be important, with simple, positive messaging.
Summary and future directions
The NLCSP is expected to have a transformative impact on lung cancer in Australia. By shifting the focus to early detection, the program aligns with broader efforts to reduce the burden of cancer, aligned with a continuing strong tobacco control policy.
Continuous evaluation of the program will be crucial to refine the protocols, optimising and expanding eligibility criteria as new insights emerge.
Advances in imaging technology and biomarker development may further enhance the efficacy and precision of a future screening program, ensuring maximum impact for Australia’s leading cause of cancer death.
Key messages
- NLCSP eligibility criteria: 50-70 years old, 30-pack year history in current tobacco users, or former tobacco users who quit less than 10 years ago. LDCT scans will be free for eligible participants
- Most LDCT scans will detect a nodule, but most nodules are not a lung cancer
- An early-stage screen detected lung cancer may be suitable for lobectomy and cases should be discussed in multidisciplinary teams.
Author competing interests – nil
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