National Lung Cancer Screening Program (NLCSP)
Australia National Lung Cancer Screening Program (NLCSP)
- Aim: Detect lung cancer early in asymptomatic but high-risk Australians using low-dose CT (LDCT).
- All scans under the program are covered by Medicare.
- Early detection improves treatment outcomes and survival.
- Expected benefit: 12,000 lives saved over the next decade.
- Over 70% of lung cancers to be diagnosed at earlier stages with screening.
✅ Eligibility Criteria for Free Lung Cancer Screening
- Age: 50 to 70 years.
- No signs/symptoms of lung cancer (e.g. no cough, haemoptysis, dyspnoea).
- Smoking history: ≥30 pack-years, currently smoking or quit within past 10 years.
- Pack-years = (cigarettes/day ÷ 20) × years smoked.
🚩 If Lung Cancer Symptoms Are Present
Seek GP review immediately if experiencing:
- Persistent cough
- Coughing up blood
- Unexplained shortness of breath
- Unexplained fatigue or weight loss
- Chest/shoulder pain that doesn’t resolve
Pros of LDCT Lung Cancer Screening
| Benefit | Details |
|---|---|
| Early Detection | Detects lung cancer at earlier, potentially curable stages (often Stage I–II rather than Stage III–IV). With screening (LDCT): ~70% of lung cancers are found at an early, more treatable stage. Without screening: Only ~7% of lung cancers are found early, as most present late due to lack of early symptoms. |
| Mortality Reduction | Large trials (e.g. NLST, NELSON) showed up to 20–24% reduction in lung cancer-specific mortality among high-risk groups. |
| Non-Invasive | Simple, quick, and non-invasive imaging test. No need for contrast agents or fasting. |
| Less Radiation Exposure | Uses much lower radiation doses (~1.5 mSv) compared to standard CT chest (~7 mSv). |
| Can Detect Other Conditions | May incidentally detect other clinically relevant findings (e.g., emphysema, coronary artery calcification). |
| Improved Risk Stratification | Helps differentiate benign nodules from malignant ones over time with serial imaging. |
Cons / Risks of LDCT Screening
| Risk / Limitation | Details |
|---|---|
| False Positives | Can lead to – unnecessary anxiety – further tests (PET/CT, biopsy) – surgery Around 3 in 100 people screened will have a high or very high-risk lung nodule detected. Fewer than half of these nodules will be cancer. May lead to follow-up scans, biopsy, or referral, even if ultimately benign. No screening avoids these unnecessary tests but loses the chance to detect early cancers. |
| Overdiagnosis | Detection of indolent cancers that may never have caused symptoms or death. May lead to overtreatment. |
| Radiation Exposure | Cumulative radiation from repeated scans (biennial or annual) may pose a small increased lifetime cancer risk. |
| Incidental Findings | May lead to unnecessary investigations for non-cancerous findings (e.g., thyroid nodules, lymphadenopathy). Early treatment of these incidental findings can improve survival. |
| Limited Use Outside High-Risk Groups | Not beneficial for low-risk individuals (e.g., never-smokers) – risk of harm outweighs benefit. |
| Emotional Impact | May cause psychological distress from abnormal findings or ongoing surveillance. |
| Access and Equity | May be less accessible to rural or remote populations, leading to inequities in uptake. |
Key Trial Evidence
| Trial | Country | Outcome |
|---|---|---|
| NLST (2011) | USA | 20% ↓ lung cancer mortality in high-risk smokers (≥30 pack-years) vs chest X-ray. |
| NELSON (2020) | Netherlands/Belgium | 24% ↓ mortality in men; 33–61% ↓ in women (longer follow-up). |
| UKLS | UK | Showed potential cost-effectiveness in high-risk stratified populations. |
Summary for General Practice
- LDCT is most appropriate for asymptomatic adults aged 50–70 with ≥30 pack-years, current smokers or quit <10 years ago.
- Screening is not appropriate for:
- Those with active lung symptoms.
- Life expectancy <5 years.
- Poor performance status or unfit for curative treatment.
SHARED DECISION-MAKING: 3-STEP APPROACH
Step 1: Introduce the Choice
Goal: Ensure the patient understands that lung cancer screening is optional and not mandatory.
Say:
“Because of your age and smoking history, you may be eligible for the National Lung Cancer Screening Program, which uses a low-dose CT scan to detect lung cancer early. Would you like to talk more about whether this might be right for you?”
Key Points to Cover:
- Screening is aimed at people without symptoms.
- Medicare covers the cost if eligible.
- It is done every 2 years if the first scan is normal.
Step 2: Discuss Options: Pros and Cons
Use the NLCSP Decision Tool or a visual aid to guide the conversation.
✅ Benefits:
- Detect cancer before symptoms develop.
- More treatment options and better survival if caught early.
- Peace of mind about lung health.
⚠️ Risks / Downsides:
- False positives → unnecessary further tests or anxiety.
- Small radiation exposure.
- May detect slow-growing cancers that never cause problems (overdiagnosis).
- Doesn’t prevent cancer—only detects it earlier.
You can say:
“This scan might help find lung cancer at a stage where it can be treated more effectively, but there are also risks like false alarms or detecting cancers that may never cause problems.”
Step 3: Explore Preferences and Support Decision
Use open-ended questions and encourage reflection. Involve the patient in weighing their values.
Ask:
- “What matters most to you when it comes to your lung health?”
- “Are you more concerned about finding cancer early or about the risks of unnecessary tests?”
- “Would it help to see a visual decision aid or talk to someone else before deciding?”
Use the Decision Tool:
It consists of two key sections:
1. What is important to you when deciding about screening for lung cancer?
Patients rate the importance (1 = not important, 5 = very important) of:
- Finding lung cancer early, before symptoms.
- Finding lung cancer when more treatment options are available.
- Gaining peace of mind about lung health.
- Having an opportunity to discuss smoking and support to quit.
2. How concerned are you about:
Patients rate their concern (5 = very concerned, 1 = not concerned) regarding:
- Participating in screening.
- Exposure to radiation.
- False positives (e.g. unnecessary follow-up testing).
- Further investigations after CT findings.
How to Interpret the Scores
- More answers toward the right (higher importance/less concern)
- → Likely to favour having screening.
- More answers toward the left (lower importance/high concern)
- → May prefer not to have screening.
DOCUMENTATION FOR GPs
Include in your clinical note:
- Patient’s eligibility (age, pack-year history, smoking status).
- That shared decision-making was undertaken.
- Key benefits/risks discussed.
- Patient’s final decision.