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NEED TO KNOW

Most lung cancers present with non-specific symptoms and are diagnosed at a late stage .

The proposed national lung cancer screening program for asymptomatic people should help improve early diagnosis and treatment outcomes .

Consider an urgent chest X-ray for patients who have unexplained , persistent symptoms .

Repeat the chest X-ray or request CT when the X-ray is normal but symptoms persist .

Surgery remains the standard of care in early-stage non-small cell lung cancer ( NSCLC ), with modern targeted radiotherapy an alternative in patients medically or surgically unsuitable for surgery .

Treatment options for locally advanced NSCLC include surgery with chemotherapy or chemoradiotherapy .

| THE | RESPIRATORY ISSUE

Advanced / metastatic NSCLC is not one disease . Options for metastatic NSCLC should be tailored around tumour genetic mutations and biomarkers .

Targeted therapies and immunotherapy are first-line treatments for selected patients with metastatic NSCLC .

Dr Lauren Gray ( left ) Medical oncology fellow for lung and gastrointestinal cancer at Westmead Hospital , Sydney , NSW .

Professor Nick Pavlakis ( right ) Medical oncologist and current board chair of the Thoracic Oncology Group of Australasia ( TOGA ).

Conflict statement

• Professor Pavlakis has sat on advisory boards , received honoraria and / or spoken at meetings for Boehringer Ingelheim , MSD , Merck Healthcare , BMS , AstraZeneca , Takeda , Pfizer , Roche , Amgen , BeiGene , Novartis , AllVascular , and Pierre Faber . His institution has received research funding from Bayer , Pfizer and Roche .

• Dr Gray has no conflicts of interest .

• Merck Healthcare provided support to Dr Gray and Professor Pavlakis in the writing of this article .

INTRODUCTION

LUNG cancer is an important , widespread disease creating a significant global public health problem . 1 It continues to be the leading cause of cancer death worldwide with an estimated 1.8 million deaths in 2020 ( about 18 % of all cancer deaths ). 2 , 3 In Australia , while lung cancer is the fifth most commonly diagnosed cancer , it accounts for the highest number of cancer-related deaths for both men and women ( see table 1 and figure 1 ). 4

While many lung cancers present symptomatically , the pathway to diagnosis in primary care can be complex , involving factors such as comorbidity , plausible alternative diagnoses , and symptoms suggestive of a different malignancy . 5 The more common lung cancer symptoms , such as cough and breathlessness , are non-specific and commonplace in general practice , and it can be difficult to differentiate new ( and potentially malignant ) symptoms in those with an underlying respiratory condition / illness . 5

Outcomes for lung cancer are still relatively poor , largely influenced by the cancer already being locally advanced or disseminated / metastatic at diagnosis ( see figure 2 ). 5 , 6 However , much is changing in the diagnosis and treatment of lung cancer . Despite overall survival rates still being low compared with some other cancers , there have been tangible improvements in five-year survival rates among patients diagnosed with lung cancer in recent years ( see figure 3 ). 6

The treatment for lung cancer currently involves three main modalities : surgery , radiotherapy and systemic therapy ( including chemotherapy , targeted therapy and immunotherapy ).

Treatment varies according to pathology and the stage of disease , specific tumour histopathologic and genetic characteristics , along with individual patient factors such as comorbidities and functional status , and disease factors such as degree of symptoms due to tumour burden .

Traditionally , lung cancer has been divided into two broad histologic categories : small cell lung cancer ( SCLC ) and the more common non-small cell lung cancer ( NSCLC ). Advances in genomic profiling mean NSCLC can be further characterised and classified

Table 1 . Australia ’ s five most commonly diagnosed cancers in 1982 , 2002 and 2022 ( persons , all ages , cancer cases ) and age-standardised incidence rates ( ASR ; cases per 100,000 persons )

1982 ( Actual data )

2002 ( Actual data )

2022 ( Projections data )

Rank Cancer type Count ASR Rank Cancer type Count ASR Rank Cancer type Count ASR 1 Colorectal cancer 6996 58.1 1 Colorectal cancer 12,575 63.7 1 Prostate cancer 24,217 72.0 2 Lung cancer 5949 47.1 2 Prostate cancer 12,322 62.4 2 Breast cancer 20,640 68.5

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This information was correct at the time of publication : 16 June 2023