Lung Cancer & Screening

Epidemiology

Lung cancer is the leading cause of cancer death in Australia and the fifth most commonly diagnosed cancer. Cigarette smoking is the most common cause, though ~25% of all lung cancers are not associated with smoking (a greater proportion of cases in Asian women are in never-smokers). Bronchial carcinoma accounts for the large majority of lung cancers. First Nations people have a higher incidence and roughly twice the mortality from lung cancer, with lower 5-year survival rates. Incidence and mortality also increase with remoteness and are highest in lower socioeconomic areas.

Prognosis is historically poor overall (older figures quoted 5-year survival around 12–14%), but survival after diagnosis at any stage improves with smoking cessation — cessation advice remains relevant even after a diagnosis is made. This 12–14% figure is now outdated for the population as a whole: immunotherapy has become standard of care alongside chemotherapy for many patients (e.g. durvalumab after chemoradiotherapy for unresectable stage III NSCLC, and various PD-1/PD-L1 inhibitors combined with chemo for advanced NSCLC and extensive-stage SCLC), and targeted therapies (EGFR, ALK, ROS1, KRAS G12C inhibitors) are now first-line for NSCLC with an actionable driver mutation identified via routine molecular testing at diagnosis — though the 12–14% figure remains broadly representative of late-stage disease at diagnosis.

National Lung Cancer Screening Program (NLCSP) — new since 2025

The NLCSP is Australia’s first national, Medicare-funded lung cancer screening program, using a bulk-billed low-dose CT (LDCT) scan every 2 years for high-risk, asymptomatic people — around 931,000 people were estimated eligible at launch.

Baseline eligibility (all of the following):

• Age 50–70
• ≥30 pack-year tobacco cigarette smoking history (packaged or roll-your-own cigarettes; vaping/other tobacco forms don’t count)
• Currently smoking, or quit within the last 10 years
• No signs or symptoms suggestive of lung cancer (if symptomatic, follow the diagnostic pathway below instead of screening)

Patients do not need to quit smoking to participate in the program. Once enrolled, smoking-history eligibility does not need to be reassessed at subsequent rounds.

Exit criteria (any of): age >70, unable to undergo an LDCT scan, develops symptoms suggestive of lung cancer, or a previous scan finding means they’re no longer eligible. Patients who exit or opt out can re-enter if they still meet the original eligibility criteria (or have recovered from an intercurrent illness, or have been successfully treated for lung cancer).

Suitability for LDCT: able to lie flat ≥5 minutes (ideally with hands above the head); no symptomatic lung infection in the last 12 weeks; no full chest CT within the last 12 months (or none planned in the next 3 months) for other clinical reasons; within scanner weight limits (typically ≤200 kg). Poor functional status/severe comorbidities should prompt a shared decision-making conversation about suitability, but unsuitability for lung surgery specifically should not be treated as a screening contraindication, since non-surgical management options exist.

Be alert to under-screened priority populations: First Nations people, people in rural/remote areas, culturally and linguistically diverse communities, people with disability or mental illness, and LGBTIQA+ communities. Be mindful that stigma around smoking — internalised guilt/shame that lung cancer is “self-induced” — is a recognised barrier to people seeking care, and should never colour the consultation.

Enrolment: via the National Cancer Screening Register (NCSR), either through integrated clinical software or the NCSR Healthcare Provider Portal; imaging request forms are usually available as an “NLCSP” template.

Results and follow-up by risk category

Category	Risk	Action
0	Incomplete	Additional imaging as advised in the report
1	Very low	Continue 2-yearly screening
2	Low	Follow-up LDCT in 12 months
3	Low-to-moderate	Follow-up LDCT in 6 months
4	Moderate	Follow-up LDCT in 3 months
5	High	Refer to a respiratory outpatient clinic or private respiratory physician linked to a lung cancer MDT
6	Very high	Refer to a respiratory outpatient clinic or private respiratory physician linked to a lung cancer MDT

The NCSR only proactively notifies patients directly for very-low-risk results — for all other categories, the patient is advised to contact the requesting practitioner, so the requesting GP retains a duty of care to communicate results in a timely manner and act on them, even though the NCSR manages routine screening reminders. Scans may also report clinically significant incidental findings outside the lungs (e.g. coronary/aortic valve calcification, abdominal aortic aneurysm ≥42mm, adrenal or renal lesions, thyroid nodules ≥15mm, reduced bone density) — these require the same re-assessment and referral as any other actionable finding.

Diagnostic assessment (symptomatic patients)

Red flags — refer to emergency department immediately: massive haemoptysis, stridor, respiratory distress, signs of severe SVC obstruction (marked stridor, syncope, significant shortness of breath).

Consider lung cancer with any unexplained, persistent symptom/sign lasting >3 weeks (or less in patients with risk factors):

• New or changed cough, chest/shoulder pain, dyspnoea, hoarseness
• Weight loss or loss of appetite
• Unresolved chest infection, persistent localised wheeze
• Abnormal chest signs, finger clubbing
• Cervical/supraclavicular lymphadenopathy
• Signs of pleural effusion
• Haemoptysis, stridor
• Features suggestive of metastasis

Classic triad: cough + haemoptysis + unexplained weight loss (also consider TB). Horner’s syndrome (ptosis, miosis, enophthalmos, anhidrosis) suggests a Pancoast (apical) tumour.

Risk factors: heavy smoking (≥30 pack-years), current smoker or quit within 15 years, chronic lung disease (COPD, pulmonary fibrosis), heavy marijuana use, passive smoking, radon exposure, occupational exposure (asbestos, diesel exhaust, industrial pollution), air pollution, increasing age, family history of lung cancer, personal history of lung/head/neck cancer.

Investigations

• CXR first-line — a normal CXR does not exclude lung cancer. If high clinical suspicion despite a normal film, proceed directly to CT chest with IV contrast. If low suspicion, monitor and re-image/escalate if symptoms persist ≥6 weeks. A pulmonary nodule on CXR should be compared against any prior imaging.
• CT chest with IV contrast — indicated for a CXR suggestive of cancer, high clinical suspicion despite normal CXR, a pulmonary nodule, persistent consolidation (>6 weeks), persistent cough/respiratory symptoms despite normal CXR, persistent haemoptysis, or pleural effusion.
• Further imaging as directed by history/exam — lung cancer commonly spreads to bone, brain, skin, adrenals and liver.
• Bloods: FBC, U&E, calcium, LFTs.
• Tissue diagnosis (sputum cytology, bronchoscopy, biopsy) and PET staging arranged by the specialist team once a lesion is identified.

Referral

Refer to a diagnostic lung clinic/MDT or a respiratory physician within 2 weeks (with chest imaging included) for diagnostic assessment and staging. The respiratory physician typically coordinates any subsequent oncology/ cardiothoracic surgical referral. For histologically proven metastatic disease, refer to a medical oncologist (fit patient, good performance status, locally advanced/systemic disease) or radiation oncologist (symptomatic local disease — lung, bone, skin, nodal, brain metastases).

Small cell vs non-small cell lung cancer

Small cell lung cancer (SCLC) — historically ~15–20% of lung cancers, a very poor prognosis with ~80% having metastases at diagnosis; chemotherapy-based treatment, now often combined with a PD-1/PD-L1 inhibitor for extensive-stage disease.

Non-small cell lung cancer (NSCLC) — historically ~80% of lung cancers; traditionally surgical resection + chemotherapy for early-stage disease, radiotherapy for palliation in advanced disease. Durvalumab after chemoradiotherapy is now standard for unresectable stage III disease, and targeted therapy (EGFR/ALK/ROS1/KRAS G12C inhibitors) is first-line where an actionable driver mutation is found on routine molecular testing at diagnosis.

Community management and supportive care

• Educate about and monitor for complications: hypercalcaemia of malignancy, spinal cord compression, superior vena cava (SVC) obstruction (most commonly caused by lung cancer — dyspnoea, hoarseness, dizziness, syncope, cough, facial/neck/arm oedema, cyanosis, distended neck/upper chest veins; can develop suddenly and is a medical emergency — arrange urgent CT chest even if recently imaged), constipation on opioids, pain.
• Manage physical symptoms: pain (paracetamol/NSAID for mild-moderate; opioid + prophylactic laxative for moderate-severe), breathlessness (breathing control/relaxation techniques, fan/cool air, physiotherapy/ pulmonary rehabilitation referral, oxygen if hypoxic and not smoking, low- dose opioid if refractory — e.g. oral morphine 1–2.5mg 1-hourly PRN, ceiling effect around 30mg oral morphine equivalent/24h), cough (dry: dextromethorphan, or a morphine trial if refractory; productive: nebulised saline, mucolytics e.g. bromhexine), malnutrition (screening tool + dietitian referral), hoarseness (speech pathology referral).
• Provide psychosocial support: ask about emotional wellbeing at every visit; screen for depression/anxiety; counsel patient and family about diagnosis and foreseeable psychosocial/financial issues; involve oncology nursing support and, where available, a psycho-oncology service.
• Support family/carers; check for travel and accommodation subsidies if travelling >100km for care, and discuss cancer-related fitness to drive.
• Advise healthy lifestyle choices (reduced alcohol, exercise, nutrition); offer smoking cessation support regardless of screening/treatment status.
• Introduce advance care planning early; refer to palliative care for symptom control and end-of-life support in collaboration with the cancer team, not only when treatment options are exhausted.
• For First Nations patients having difficulty accessing/managing care, consider referral to Integrated Team Care (ITC)/Care Coordination and Supplementary Services (CCSS) programs.