The announcement of scoping for a targeted lung cancer screening program in Australia is welcome news, given the burden of disease. The Cancer Australia Screening Enquiry was evidence-based and subject to wide consultation. If implemented, questions will be asked. Will the benefits outweigh the harms in the Australian setting? Will it be embraced by the community? Will our health system cope?
There is sufficient published data (NELSON, NLST) to predict significant reduction in cancer deaths. But, other than in Manchester UK, implementation has rarely been subjected to large studies of efficacy. Our biggest risk is therefore failing to screen the highest risk populations.
Integral to implementation is the delivery of appropriate surgery when required. We do not want a repeat of long waiting lists for colonoscopies from the bowel screening program (which only recruits about 40% of the eligible population). There is already evidence of the association of poorer outcomes with > 3 months delay in stage I lung cancer. State public hospitals will need to manage the outputs of the screening program, even though the Commonwealth will fund the program itself.
For surgeons, there are additional advantages to screening beyond the reduction in lung cancer deaths. Small screen-detected cancers are easier to resect and consume fewer resources. Our challenge will be localising small mixed solid lesions. It is crucial in an asymptomatic population that we deliver the best quality surgical care possible to ensure harms do not reduce the benefits and raise the costs of screening. Surgical benchmarking will be a critical component of screening. The blunt tool of 30-day mortality will detect only the very worst cases of surgical selection or care.
We will be ready for screening if we reach the right people without overloading our public health systems whilst ensuring that best value, benchmarked surgical care is accessible by all those with resectable lung cancer.