Lung cancer claims thousands of Australian lives every year, but a new targeted screening program could catch deadly cases earlier.
By Andrea Downey
It is Australia’s deadliest cancer with the vast majority of cases diagnosed too late for curative treatment, but a new screening program could turn that around.
The National Lung Cancer Screening Program comes into effect in July 2025, targeting people considered to be at high risk for lung cancer in the hope of detecting cases early, before they become incurable.
Lung cancer is the fifth most commonly diagnosed cancer in Australia, with about 15,100 cases diagnosed in 2024, according to the Australian Institute of Health and Welfare (AIHW). Yet it is the deadliest cancer of those most commonly diagnosed.
Just 26% of people survive past five years. Comparatively, the five-year survival rate of the second most deadly cancer, colorectal cancer, is 71%.
In WA, latest data suggests more than 1000 cases of lung cancer are diagnosed in the State every year, but many more cases could be going undiagnosed, or could be diagnosed at an earlier stage.
Consultant respiratory physician at Sir Charles Gairdner Hospital Professor Fraser Brims said the screening program offered hope that more people could survive the disease.
“Most cases tend to present at a time where we can’t offer curative therapy because things are too advanced,” he said. “About 70-80% of the time we’re not able to offer either surgery, which is the gold standard, or more recently stereotactic radiotherapy.
“We know from mature screening programs that you can turn that virtually on its head to get 70% or so of cases at stage one and two.
“That’s the challenge, to really impact hard enough that you’re consistently able to capture lung cancer early and make an attempt at curative therapy.”
Low-dose CT
The screening program will use low-dose CT scans to look for lung cancer in eligible asymptomatic high-risk people. By screening more people before symptoms occur – usually when the disease is advanced – it is hoped more than 500 lives could be saved a year.
It will operate similarly to other early detection programs such as the national bowel cancer and cervical cancer screening programs.
Early-stage lung cancer can often be treated with surgery, but if the cancer has spread outside the lung, as is often the case in stage 3 and 4 cancer, more intensive treatment options may be needed.
Treatment for advanced lung cancer (stage 4) may only focus on slowing the growth of the cancer and improving quality of life, so there is a marked need to identify cases earlier.
Estimates suggest the proportion of cases identified at stage 1 without a screening program will increase by 16%, but with a screening program that number could be as high as 60%, according to the Department of Health and Aged Care.
Through earlier diagnosis, it is estimated the proportion of advanced stage cancer will decrease from 53% to 11%.
LISTEN: Lung Cancer Screening with Professor Fraser Brims
Professor Brims, who is also Director of Early Years Clinical Skills at Curtin University Medical School, says the potential impact of the screening program is enormous.
“It is not overstating it to say it’s a game-changer, it has a huge potential impact,” he said. “It will take a cancer that has a 25% five-year survival rate and potentially turn that on its head, at least for these high-risk people to start off with.”
Who is eligible?
Due to the cost of CT scans and the minor risks associated with them, including radiation exposure and false positives, the program will only target those considered to be at a high-risk for cancer.
To be eligible people must be asymptomatic, aged between 50 and 70 and have a history of smoking at least 30 pack-years and are still smoking, or have quit in the past 10 years.
A one pack-year is defined by smoking at least one pack of cigarettes per day for one year, or two packs a day for six months.
Eligible people will be called on to have a scan every two years while they participate in the program or until a lesion is found and needs to be treated.
Those with symptoms suggestive of lung cancer should not be referred to the screening program, instead their symptoms should continue to be investigated, according to Cancer Australia’s guide for lung cancer.
Primary care’s role
GPs, primary care and Aboriginal health services are expected to play an integral role in referral of eligible and at-risk patients to a radiology provider for a CT scan, which will then be reported into the National Cancer Screening Register.
For those in rural and remote areas, mobile screening services – co-designed with the National Aboriginal Community Controlled Health Organisation, Aboriginal Community Controlled Health Services and lung cancer screening program expert advisory groups – will be delivered to support care on country where appropriate.
Following an initial screening, people who have a low or moderate risk of lung cancer will be screened again in three or 12 months and may be referred to a specialist. High-risk patients will be referred to a specialist and linked with a multidisciplinary team.
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The Royal Australian College of GPs said general practice offers a clear route into the program and that recommendation from a GP is more likely to result in screening uptake.
But in its submission to Cancer Australia’s consultation on healthcare provider guidelines for the new screening program, the College warned it could create additional workload and administration burden for GPs.
“This includes time spent explaining the program to patients, assessing eligibility, managing referrals and following up on results. The impact is likely to be greater in practices who see socioeconomically disadvantaged patients, who are also most likely to be most eligible for screening,” the College said in its submission.
“This is not an argument against the program, but it does highlight additional workload for GPs is likely underestimated and under-resourced, particularly in practices that already have high and complex workloads.”
To navigate this, the RACGP suggested a gradual implementation of the screening program to help manage potential increases to workload and resolve any pain points under lower demand.
It also called for a database of radiologists and respiratory specialists linked to a lung cancer multidisciplinary team to be established to streamline referrals from GPs who may spend unnecessary time searching for a suitable provider.
WA Primary Health Alliance Executive General Manager Primary Care Bernadette Kenny said the alliance would work with practices to support implementation of the program.
“GPs will be well placed to identify patients that will benefit from this program, being those at high risk with no symptoms,” she said.
Professor Brims encouraged GPs to be opportunistic if they have a high-risk patient who should be referred for screening. That could mean discussing screening during their next visit, or proactively sending letters to patients.
“The majority of people will be recruited through primary care and all practices will certainly be encouraged to have an organised process,” he said. “If they can search their databases for people within the right ages with a history of smoking and send out letters, that’s definitely to be encouraged.
“With appropriate advertising and communications, we would also hope that patients might see something in their local pharmacy or something on the back of a bus and say ‘Hey that’s me, I might be able to request getting screened’.”
Due to the high-risk nature of the people being screened – smoking causes more damage than just lung cancer – additional findings should be expected.
Professor Brims explained that the likelihood of finding nodules on the lungs was high in people who meet the screening criteria, but the severity of those would vary.
He likens it to melanoma and freckles – someone might be covered in freckles but that does not mean they are all melanomas.
This is where shared decision making has a role to play. Professor Brims said it will be a crucial part of the process to ensure patients understand screening and that their history means something is likely to show up.
“Maybe up to half of these people will have a nodule, but only one in 20 of those might be a lung cancer, or even lower perhaps,” he said.
“We know that about 95% of these nodules are not a cancer, so they are a nuisance, but we have to follow them through.
“If you target people who smoked a lot, then of course they’re going have conditions such as emphysema, or coronary artery calcification. These are not incidental findings, they are additional findings.
“It’s likely we’re going to find something on the scan, but if you can present that as a positive about early recognition, that’s good.”
Not just smoking
Smoking is the leading cause of preventable disease burden in Australia, it is estimated that between 1960 and 2020, it killed more than 1.2 million people.
While Australia has been a world-leader on smoking cessation, the integration of smoking cessation tactics throughout the entire patient journey in the screening process will still play an important role.
Data from a new AIHW national preventive health monitoring dashboard show the prevalence of daily smoking among Australian adults has dropped from 13.8% in 2017-18 to 10.6% in 2022 – taking the country closer to the national target of 5% by 2030 as outlined in the National Preventive Health Strategy.
After stopping smoking, in 10 years the risk of lung cancer is half of that of someone who has continued to smoke.
But incidents of lung cancer have risen in recent years and are predicted to continue rising, partly due to the ageing population and partly due to the legacy of smoking, highlighting a clear need for continued cessation efforts.
Cases are rising among women but falling among men. In 2000 there were 84 cases of lung cancer per 100,000 men, dropping to around 61 cases per 100,000 in 2024, according to the AIHW.
In contrast, women have seen an increase from 36 cases per 100,000 in 2000 to an estimated 52 cases per 100,000 in 2024.
The older a person gets the less likely they are to survive lung cancer. Five-year survival rates are around 94% for 20-24-year-olds but drop to just 36% for people aged between 40 and 79, and 9% for people aged 85 and over.
As is always the case in healthcare, prevention is better than a cure.
“Australia has, broadly speaking, led the world in terms of tobacco control and the next big step would be towards a tobacco free generation,” Professor Brims said. “That would be to effectively, over a generation, make cigarettes never available to our children. It would literally be life changing.”
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But while tobacco use is the obvious risk factor for lung cancer, it is not a standalone factor. Environmental and genetic factors play a role as well.
Those with a family history of lung cancer are twice as likely to develop the disease and among Aboriginal and Torres Strait Islander people it is the most common cancer diagnosis.
A history of other lung conditions such as emphysema and chronic obstructive pulmonary disorder (COPD) also increases the risk.
“Tobacco exposure and age are the biggest drivers. So even though much of our population stopped smoking 20 or 30 years ago, the cumulative risk given their age continues to rise,” Professor Brims said.
“In terms of other risk factors, WA has a long, checkered history with asbestos, and we know that asbestos is a strong risk factor for lung cancer.
“Although here in WA air quality is pretty good, we also have to mention air pollution as a driver as well, certainly globally we’ve seen that.”
Vaping is also on health practitioners’ radars, but it is still too early to say if the habit is linked to lung cancer.
“The bottom line is, we’re going to have to wait and see,” Professor Brims adds. “There is lab-based data suggesting there are genetic changes going on in the airways of individuals who vape that would be consistent with early cancer changes.
“That strong epidemiological link is, to be frank, going to be another 20 years away, but we can’t wait that long just to see all of our kids get early lung cancers.”
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