Policy context and impact

This section outlines the historical and current context of both Australian and international policy relating to lung cancer screening as well as the ongoing impact of lung cancer on patients, carers, and communities in Australia, and on the economy.

Lung cancer in Australia

In Australia, lung cancer accounts for 9% of all cancers diagnosed, and the overall risk of being diagnosed with lung cancer by age 80 is 1 in 25. ⁽¹⁾ For individuals who continue to smoke, the risk of being diagnosed with lung cancer by age 80 is 1 in 7, compared to 1 in 100 for those who have never smoked. ⁽²⁾ Five-year relative survival rate for lung cancer is 22% (2014-2018). ⁽¹⁾ It is estimated that in 2022, there were 9,193 lung cancer deaths in Australia. ⁽¹⁾ Despite this, Government funding for lung cancer comprised only $32 million of the $934 million spent on cancer research and programs in 2018-2020. ⁽³⁾

Among Aboriginal and Torres Strait Islander people in Australia, lung cancer was the most commonly diagnosed cancer overall between 2012 and 2016. ⁽⁴⁾ Additionally, Aboriginal and Torres Strait Islander peoples were more than twice as likely to be diagnosed with lung cancer than non-Indigenous people. ⁽⁴⁾ The five-year approximate relative survival rate for lung cancer in the period of 2012-2016 was just 12% for Aboriginal and Torres Strait Islander people. ⁽⁴⁾

Lung cancer incidence is closely associated with remoteness, with incidence being highest in remote areas (52 cases per 100,000 people) and lowest in major cities (42 cases per 100,000 people). ⁽⁴⁾ Mortality rates of lung cancer also increase with remoteness, with 41 deaths per 100,000 people in very remote areas compared with 27 deaths per 100,000 people in major cities between 2015-2019. ⁽⁴⁾ These statistics do not reflect the undiagnosed lung cancer cases at death which are expected to be higher in remote areas.

Lung cancer also disproportionately affects people living in lower socio-economic areas in Australia. Over the period 2012-2016, there were 31 cases per 100,000 people in the least disadvantaged areas in Australia, compared with 52 cases per 100,000 people in the most disadvantaged areas. ⁽⁴⁾

Health impacts of lung cancer

In Australia, lung cancer is one of the leading causes of disease burden, and this is particularly evident in the male population. For men aged 45-64, and aged 65 and over, lung cancer was the fourth leading cause of disease burden in 2022, accounting for 3.8% and 4.5% of the total disease burden respectively. ⁽¹⁾ The incidence of lung cancer in women continues to increase, in part reflecting the more recent increased uptake of smoking in women. ⁽⁵⁾ Lung cancer can have significant health impacts on an individual, as people who have been diagnosed with lung cancer often experience debilitating symptoms such as pain, shortness of breath and difficulty breathing, cough, neurological compromise, and reduced ability to move freely. ⁽⁶⁾ Lung cancer has significant impacts on mental health in the Australian population, as 50% of Australians who are living with lung cancer have experienced symptoms of distress, anxiety, and depression, and significantly reduced quality of life, as do their care givers.⁽⁷⁾ Many people living with lung cancer have severe physical functioning limitations – around 3-fold that of people without cancer. ⁽⁷⁾ Compared to people with other cancer types, those living with lung cancer have poorer self-rated health and lower quality of life.⁽⁷⁾

Economic impacts of lung cancer

Lung cancer has significant economic impacts for the Australian population. Healthcare costs for lung cancer are the third most expensive of all cancers in Australia, with the average health system costs for each person diagnosed with lung cancer from one year prior to three years post diagnosis, estimated at $51,944 between 2006 and 2013 ⁽⁸⁾, largely prior to the implementation of targeted therapy and immunotherapy treatments. Excess health system costs for lung cancer tend to be highest immediately after diagnosis, and for those who died, in the final month of life. Additionally, age at diagnosis can influence the economic impacts of a lung cancer diagnosis, with higher healthcare costs incurred for individuals diagnosed at a younger age. ⁽⁸⁾

In 2018, it was estimated that the economic burden of lung cancer for new patients diagnosed in Australia, was $297.2 million for direct and indirect costs. If the current picture of lung cancer in Australia is left unaddressed, it is estimated that the costs of lung cancer in Australia by 2028 will be $6.6 billion, including $6.2 billion in direct costs and a further $325.9 million in indirect costs, such as absenteeism from the workplace. ⁽⁹⁾

International policy landscape

There are various lung cancer screening programs which are being implemented internationally, which utilise different risk tools and criteria to define eligibility in the program, as well as different scan frequency.

United States

In the U.S., the United States Preventive Services Taskforce (USPSTF) is an independent panel of national experts in prevention and evidence-based medicine, who make evidence-based recommendations about clinical preventive services such as screening and preventive medications. ⁽¹⁰⁾

The USPSTF initially made recommendations for lung cancer screening in 2013, for individuals aged 55-80 years who had a 30 pack-year history of smoking and smoked currently or had quit within the last 15 years, with an ongoing emphasis on informed and joint decisions being made. ^{(11, 12)} A systematic review was undertaken in 2021 to update the 2013 recommendations based on new evidence on the benefits and harms of screening. The 2021 statement recommends annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years, with a 20 pack-year smoking history, who currently smoke, or have quit within the last 15 years. ⁽¹³⁾ The 2021 statement also recommends that screening stops once an individual has not smoked for 15 years or has a health problem which will limit life expectancy or the ability to undergo lung surgery. ⁽¹³⁾ It is important to note that this is not a national program.

The USPSTF recommendation for lung cancer screening is categorised as a grade B recommendation, which indicates that there is high certainty that the net benefit of the program will be moderate or there is moderate certainty that the net benefit of the program will be moderate to substantial. ⁽¹⁴⁾ Whilst a grade B recommendation is used to signify that the practice should be offered or provided to people at risk ⁽¹⁴⁾, it is important to note that the USPSTF does not consider the costs of a service when determining the recommendation grade that will be assigned. ⁽¹⁰⁾

United Kingdom

In the United Kingdom, the Targeted Lung Health Check (TLHC) Programme is a lung cancer screening pilot which has been initially offered to 23 metropolitan areas across England, (15) with the aspiration that there will be national coverage across all of England by 2024. ⁽¹⁶⁾ There are currently no screening lung health checks taking place in Scotland, Wales or Northern Ireland. ⁽¹⁶⁾

As part of the TLHC, people aged 55-74 who currently smoke, or have ever smoked previously, will be invited to participate in a lung health check. ⁽¹⁶⁾ During this health check, participants are provided with smoking cessation advice, have a spirometry test, and are assessed for their risk of lung cancer, using either the PLCOm2012 or LLP v2 risk calculation models, with a risk threshold of ≥1.51% and ≥2% used respectively. ^{(15, 17)} Those deemed to be at high risk of lung cancer, based on both the risk tools and smoking history, are invited to have two LDCT scans within 24 months. ⁽¹⁵⁾

Canada

Canada currently has two lung cancer screening programs available: one in the British Columbia region, and the other in the Ontario region. In British Columbia, individuals aged 55-74 years, with a smoking history of 20 years or greater, may be eligible to participate in LDCT screening as part of the British Columbia Lung Screen Program. ⁽¹⁸⁾ Individuals who meet this initial criteria can either discuss referral to the program with their General Practitioner, or can speak with a Program Navigator, who will conduct an assessment over the phone to determine their eligibility to participate in the program. ⁽¹⁵⁾

In the Ontario Lung Screening Program, individuals who are aged 55-74 years old, and have a 20-year daily smoking history are eligible to be referred for lung cancer screening. ⁽¹⁹⁾ Following referral to the program, individuals are assessed by a screening navigator, and those who have a ≥2% chance of developing lung cancer in the next 6 years, according to the PLCOm2012 criteria, are eligible to participate in LDCT screening. ⁽²⁰⁾

Summary of international screening programs

Uptake of screening

Internationally, participation rates in lung cancer screening programs have varied considerably. In the United Kingdom, people identified for screening through primary care recorded participation rates of approximately 53%, and in pilot programs across the country, participation rates ranged from 35-53%. ⁽²¹⁾ In Canada, the Ontario Lung Screening Program had participation rates of 50.2% in 2017-18. ⁽²²⁾ However, in the United States, participation rates have remained low, with only 5.8% of eligible individuals being screened nationally in 2022. ⁽²³⁾

Cancer Australia enquiry

In October 2020, Cancer Australia delivered its report of enquiry into the prospects and feasibility of implementing a National Lung Cancer Screening Program in Australia. ⁽²⁴⁾ The enquiry considered the benefits and harms of lung cancer screening, cost-effectiveness of implementing a targeted program, who the target population would be, as well as methods of recruitment. ⁽²⁴⁾ The enquiry proposed a biennial screening program for Australia, with screening targeted to non-Indigenous peoples aged 55 to 74 years and Aboriginal and Torres Strait Islander peoples aged 50-74 years, who are current or former smokers. ⁽²⁵⁾ Cancer Australia recommended that screening eligibility be defined by the PLCOm2012 risk calculator, with individuals with a risk greater than 1.51% over six years invited to undergo a LDCT scan, in line with the UK criteria. ⁽²⁵⁾ Cancer Australia estimated that in the first 10 years of a targeted and risk-based national lung cancer screening program, over 12,000 lung cancer deaths would be prevented and up to 500,000 quality adjusted life years (QALYs) would be gained. ⁽²⁴⁾

In 2021, the Australian Government invested $6.9 million towards a scoping review of a National Lung Cancer Screening Program. ⁽²⁴⁾ Cancer Australia undertook this work, which included stakeholder consultation and co-design with Aboriginal and Torres Strait Islander communities. The review considered screening infrastructure, data governance, and quality assurance principles for a National Program; as well as roles and responsibilities required for implementation. ⁽²⁴⁾

Medical Services Advisory Committee

The Medical Services Advisory Committee (MSAC), an independent non-statutory committee who appraise medical services proposed for funding in Australia, ⁽²⁶⁾ in late 2022 provided its advice to the Minister for Health and Aged Care regarding the implementation of a National Lung Cancer Screening Program, following Cancer Australia’s application to the committee. MSAC supported the implementation of a national program on a biennial basis, for asymptomatic individuals at high-risk for lung cancer. ⁽²⁷⁾ Specifically, MSAC supported the recommendation that screening be offered to individuals aged between 50 and 70 with at least a 30 pack-year history of smoking, and who either currently smoke or have quit within only the last 10 years. ⁽²⁷⁾ A new Medicare Benefits Schedule (MBS) item was recommended for LDCT scans for the purpose of volumetric CT lung cancer screening. ⁽²⁷⁾ The MSAC also specified the requirement for a Department of Health approved register for each LDCT lung cancer screening performed with details on the patient.

In May 2023, the Federal Minister for Health and Aged Care announced Government funding of $263.8 million to commence the implementation of a National Lung Cancer Screening Program in Australia. ⁽²⁸⁾