Introduction by Croakey: The impending launch of Australia’s national lung cancer screening program raises many challenges for the health workforce and health service delivery, and is expected to bring significant benefits for high-risk groups, notably long-term smokers.
The Aboriginal and Torres Strait Islander health workforce has an especially important role in delivering the program, reports Marie McInerney.
This is her final article for the Croakey Conference News Service from the recent conference hosted in Adelaide by the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) and the New Zealand Institute of Medical Radiation Technology (NZIMRT).
Marie McInerney writes:
On 1 July, just seven weeks from now, Australia will become one of the few countries in the world to launch a national lung cancer screening program, hoping to save hundreds of lives a year by finding and treating lung cancer earlier.
Despite dramatic cuts to smoking rates in Australia, lung cancer is the fifth most commonly diagnosed cancer in Australia, behind breast, prostate, colorectal cancer and melanoma. It is the leading cause of cancer death every year.
For Aboriginal and Torres Strait Islander people, the toll is higher, in every age group: it is both the most common type of cancer and the most common cause of cancer death. Aboriginal and Torres Strait Islander people are twice as likely as non-Indigenous Australians to both be diagnosed with and to die from lung cancer.
Peter Bligh, a Kullilli and Wakka Wakka man and director of cancer for the National Aboriginal Community Controlled Health Organisation (NACCHO), hopes the screening program will “turn the tide” for Aboriginal and Torres Strait Islander people.
He is optimistic the program will be effective, so long as it builds on the strengths and resilience of communities and invests strongly in the Aboriginal and Torres Strait Islander health workforce to address barriers like access, stigma and lack of cultural safety.
“It’s Closing the Gap in a way that’s meaningful for communities,” he told Croakey.
That hope and optimism is shared by many others, but there are still multiple questions about the program — many of which won’t be answered until after it launches.
A key concern is that referral and treatment pathways may struggle to cope with an increase in the number of people diagnosed with lung cancer.
“Patients must not be left in limbo with the threat of lung cancer hanging over them but no timely access to the downstream services such as respiratory specialists,” Professor Mark Morgan, chair of the Royal Australian College of GPs Expert Committee – Quality Care, told Croakey.
Who is eligible?
The Albanese Government committed $263.8 million over four years in the 2023-24 Budget for the program, which is being run by the Department of Health and Aged Care in partnership with Cancer Australia, NACCHO, The Lung Foundation and other stakeholders.
From 1 July, eligible participants will be able to have a free low-dose CT scan at participating radiology providers or via a mobile lung cancer screening service for regional and remote communities. Scans will be offered every two years, and more often for people identified at increased risk.
To be considered eligible, participants must:
- be aged between 50 and 70 years old
- show no signs of symptoms of lung cancer (for example, coughing up blood, shortness of breath)
- be a smoker or have quit within the last 10 years
- have a history of long-term cigarette smoking; for example, a pack a day for 30 years or 2 packs a day for 15 years.
The program has identified key priority groups: Aboriginal and Torres Strait Islander people, people in rural and remote areas, culturally and linguistically diverse (CALD) groups, people with disability, and LGBTIQ people.
Healthcare professionals will be involved in the program in many ways: through promotion and awareness, offering smoking cessation support, identifying eligible participants and providing a referral for a low-dose scan, performing the low-dose CT scan, communicating results, and providing follow up care for those whose screens reveal issues.
With up to 250,000 additional low dose CT scans expected to be done a year under the program, experts told Croakey there’s uncertainty around a range of issues, including:
- how many Australians will engage with screening – given barriers of access, stigma, fear, and lack of awareness
- whether the program will reach the people it intends
- how to work around chronic and acute GP shortages, particularly in rural and regional areas
- whether and how the bulk-billed program will be supported by private radiologists
- the impact of the program on GPs, other health services and the medical radiation sciences workforce
- what issues might arise due to the program’s differences with other national screening programs, including that it is being “shoe-horned”, as one expert said, into the Medicare Benefits Scheme (MBS)
- whether screening should expand beyond conventional risk factors, including to younger, non-smoking populations, as suggested recently in the Journal of the American Medical Association?
Other issues identified in the literature include the importance of ensuring target communities and healthcare providers are well informed about the potential for harms, described in one review as including radiation-induced cancer, false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, and increases in distress.
Such findings underscore the importance ensuring timely follow up for patients, including those who may be unnecessarily worried by false positive results.
It will also be important to evaluate the program carefully, including around patient experiences and cost-benefit questions, “taking into account the balance between benefits and harms which occur in all screening programmes”.
A 2022 paper by Australian researchers concluded that lung cancer screening could be cost-effective in Australia, contingent on translating trial-like lung cancer mortality benefits to the clinic.
Missed opportunity
The program’s impending launch meant there was great interest in a dedicated session at the Australian Society of Medical Imagine and Radiation Therapy (ASMIRT) 19th National Conference in Adelaide in late March.
Unfortunately, the Department of Health and Aged Care did not accept invitations issued “for many months” to provide a speaker, to the disappointment of organisers.
“Delegates were understandably anxious to have someone from the Department to answer their more detailed questions on the project,” ASMIRT Chief Executive Officer Sally Kincaid told Croakey.
“Given that they are the health professionals who will be responsible for acquiring the images, it was a significant missed opportunity for the Department to engage with them at a critical period pre-roll out.”
However, since then, Kincaid said more detailed information has been shared with the profession, which is allaying some of the previous concerns.
Asked whether the medical radiation sciences professions – and other associated health and medical professionals required to deliver this program – will be fully informed and ready by 1 July, Kincaid said: “We can only hope – it’s not far off.”
Asked last week about preparations, a spokesperson for the Department said: “Work is well underway to prepare the health sector for the launch, with a range of education and information resources recently published to support both healthcare providers and potential participants engage with the program.
“Radiology specific resources have also been developed in partnership with the Royal Australian and New Zealand College of Radiologists and the Australian and New Zealand Society of Thoracic Radiology. The National Lung Cancer Screening Program website is regularly updated with new information and resources.
“The Department is also committed to continuing consultation and engagement with healthcare providers, peak bodies, states and territories, consumers, and people from priority populations. This includes presentations at various stakeholder engagements.
“As it is not possible to physically attend every event, to ensure consistent messaging and equity of information for stakeholders the Department, Cancer Australia and NACCHO continue to pre-record presentations. The most recent pre-recorded presentation was provided to the ASMIRT conference.”
Early diagnosis matters
Last year, around 15,000 Australians were diagnosed with lung cancer, and up to 9,000 died from the disease, thoracic radiation oncologist Dr Sarah Bergamin told the ASMIRT conference.
Bergamin, who works at the Northern Sydney Cancer Centre at Royal North Shore Hospital in Sydney, the Western Cancer Centre at Dubbo Bass Hospital, and Genesis Care, said most lung cancers are diagnosed at stage four, “which means that the cancer has spread outside of the lungs, and we can no longer cure patients”.
Modelling for the program, based on international studies, indicates that it will prevent more than 500 deaths in the early years of screening.
It is expected the proportion of stage one diagnoses will rise from 16 percent to more than 50 percent, while the proportion of stage four diagnoses will drop from 53 percent to 11 percent, she said.
However, the program faces a number of challenges, she said, including disparity in access, healthcare resources, false positives, radiation exposure, psychosocial burden and stigma.
While much modelling has been done to predict the number of participants for each area health service and the flow on effect for healthcare services, “we still don’t know how potential participants will engage in the program”, she said.
An additional challenge is that the program relies on the private sector to deliver the scans, “and so a lot of healthcare worker upskilling is currently needing to take place, because we just don’t have the number of thoracic radiologists to report all of the scans in Australia at the moment,” Bergamin said.
Some international trials saw 40 percent of scans producing “incidental findings”, such as coronary artery calcification, nodules found in breasts, thyroids or the upper abdomen, and non cancer related lung disease, “and we’re not yet sure how GPs and how the wider healthcare community will be able to manage those”.
Research into lung cancer screening in Australia and Canada found incidental findings – mostly coronary artery calcification and emphysema – were frequent. About 10 percent required clinical followup, but clinical reporting of the findings was inconsistent, it found.
“When LDCT [low‐dose computed tomography] lung cancer screening is introduced in Australia, a standardised reporting template should be used to provide clear guidance about the clinical significance of such findings,” the researchers recommended.
Bergamin said a lot of upskilling and planning has been underway at local health services and in relevant professional bodies aiming to fill workforce and skills gaps and manage additional workloads.
She highlighted the Western New South Wales Local Health District, which is geographically the size of the United Kingdom. Aboriginal and Torres Strait Islander people are 11 percent of its population, but it has only 4.4 full time equivalent respiratory physicians, she said.
“So for them to take on all of these potential lung nodules that will be found in the screening program is going to be incredibly difficult,” she told Croakey.
Early discussions have raised the possibility of “up-skilling or side-skilling” clinical nurse consultants and other allied health specialists to address that workload.
Bergamin said there’s concern about additional workload for GPs particularly, who will be the follow up point for patients post-screening, and may need advice on how to assess results, particularly in the case of false positives, she said.
The Health Department says that, of all people screened, around three in 100 people will have a high risk or very high-risk nodule found; however, fewer than half of those will turn out to have lung cancer.
From the patient perspective, stigma is an issue that concerns Bergamin, worried that guilt and blame around smoking might deter people from accessing screening.
She cited a US study where a “small but significant proportion” of those surveyed felt that people who smoked deserved to get lung cancer.
“The big thing I want to communicate is there is no blame assigned here to patients who are diagnosed with lung cancer, and also that there is hope,” she said. “There is hope in terms of treatments, there is hope in terms of quality of life and survival.”
Listen to Croakey’s interview with Dr Sarah Bergamin here.
Reaching communities
NACCHO’s Peter Bligh says distance and travel is always the big barrier for access to healthcare for regional and remote Aboriginal and Torres Strait Islander communities.
Cancer Australia has contracted Heart of Australia, a Queensland-based service supplying medical specialists and their equipment to rural and remote communities, to provide five mobile CT scanning services to remote areas, with the first to begins screening in November, and others to be rolled out by August 2026.
NACCHO and its affiliates, state and territory governments, and other key stakeholders will identify potential locations for mobile screening services, amid general agreement that just five trucks will not be able to quickly reach all remote communities.
Community engagement grants will be available from 25 July to support ACCHOs over two years to develop community-led, locally tailored and culturally appropriate activities to support participation and engagement in screening.
Asked what will help ensure the program’s success for Aboriginal and Torres Strait Islander people, Bligh highlighted many factors: cross sector partnerships, commitment to building on strengths, cultural safety, patient-centred approaches, holistic supports not just for treatment but also prevention, investment in smoking cessation supports, emotional wellbeing support, and assistance with navigating the health journey.
Workforce matters
Modelling published in eClinicalMedicine last year highlighted the importance of smoking cessation interventions in conjunction with screening, saying this may increase the expected gains in life years from screening by up to 20 percent.
Also important, Bligh said, will be ensuring the program aligns with other initiatives, including the Australian Cancer Plan and the National Aboriginal and Torres Strait Islander Health Plan 2021–2031, and that it drives further investment in the Aboriginal and Torres Strait Islander workforce.
NACCHO is hopeful that other Budget initiatives, including the $238.5 million Improving First Nations Cancer Outcomes initiative, will assist.
“Workforce development is the big one for us,” he told Croakey. “Investing in an Aboriginal and Torres Strait Islander health workforce is essential.”
Workforce issues are also of key concern for the RACGP which, in a submission to the Department in January, urged a ‘soft launch’ of the program, saying it would likely have the greatest impact on workloads for general practices with more socioeconomically disadvantaged patients, who are most likely to be eligible for screening.
‘”These patients often experience multimorbidity at a younger age and have complex mental health and social challenges,” the submission states.
“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.”
The submission said:
“It is not clear what plans are in place to ensure increased capacity in general practices, ACCHOs, radiology services, respiratory specialists, oncology departments or lung function services to accommodate the additional workload, when we know that services (with probably the exception of ACCHOs) are distributed in inverse proportion to need.”
Professor Mark Morgan told Croakey last week that the RACGP’s Expert Committee – Quality Care had provided guidance to the program with “succinct advice” for GPs on how to manage incidental findings that show up through scans.
Both GPs and general practice electronic medical record providers also “have some work to do” to optimise the recording of smoking history – eligibility for lung cancer screening is based on how many packs are smoked a year, but this is poorly recorded, he said.
Morgan said that call for a ‘soft start’ to manage demand has partly been addressed because public health messaging about screening will be staged to reduce initial patient demand.
However, he said the program will need to remain flexible “so that unpredicted difficulties with the program are addressed promptly”.
The RACGP will update its Red Book to include information about the national lung cancer screening program.
Lessons ahead
Lung Foundation Australia has championed the National Lung Cancer Screening Program and is partnering with the Department on reaching priority groups, including through this recent webinar, which brought many key groups together. (You can register at the link to view it).
“It is very exciting as this is the first new national cancer screening program to launch in 20 years,” CEO Mark Brooke told Croakey in an email. “It is the fastest to be delivered from ideation, feasibility to implementation, and the first to be delivered in the digital age.”
It has been years in the making, with wide ranging consultation and co-design, he said.
Asked if the sector is ready for the rollout, Brooke acknowledged there will be teething problems but said “we can’t let the pursuit of perfect get in the way of good”.
“Of course, as the program rolls out and data is gathered, we are going to learn ways to improve the experience, find more opportunities to expand the eligibility criteria and ultimately help more people in the long term,” he said.
“This is akin to the evolution and changes that have been made over time to the three other existing national cancer screening programs: BreastScreen, Bowel Cancer Screening and the Cervical Screening Program.”
A concern for Alan Malbon, ASMIRT’s Diagnostic Imaging Project Officer and a former ASMIRT president, is that – unlike BreastScreen – the lung cancer screening program will have no single imaging archive. That may make follow-up difficult for patients who move away from the GP who originally referred them.
ASMIRT was also concerned that initial workforce modelling did not take into account the breakdown of factors such as full-time/part-time employment, public hospital/private imaging employment ratio and clinician/educationist and administrative ratios.
Another unknown is how many radiologists will opt into the program, given it will be delivered primarily by private services and require mandatory bulk-billing.
Dr Miranda Siemienowicz, chair of the Australian and New Zealand Society of Thoracic Radiology (ANZSTR), also acknowledged potential challenges for the program’s initial rollout, such as the delivery and integration of the National Cancer Screening Register to radiology practices.
In an email to Croakey, Siemienowicz said the likely uptake of the program by radiologists is “still unclear”.
She said the Royal Australian and New Zealand College of Radiologists had previously raised concerns that the Medicare funding for low-dose CT “may not be sufficient to ensure equitable access for participants or to support the long-term sustainability of the program”.
RANZCR would welcome a review of funding arrangements by the Federal Government to help ensure the program’s success into the future, she said.
Siemienowicz said more than 60 RANZCR members have contributed to the development of protocols and resources to help ensure radiologists are well-prepared and that CT scanning, the cornerstone of the program, is delivered to a consistently high standard.
The program recently published its NLCSP Additional Findings Guidelines, providing standardised language for radiologists reporting non-nodule findings on CT for lung cancer screening, she said.
“The Guidelines serve to focus attention on common clinically significant findings and restrain unnecessary further investigation,” she said.
This is our final article from the ASMIRT NZIMRT conference. See all our coverage at this link and stay tuned for the e-publication.
