Country context

Australia is one of the richest countries in the world, and in the Asia Pacific region, with an aging society and a growing burden of non-communicable diseases (NCDs), including cancer. This challenge is likely to increase, as the number of Australians over age 65 years is projected to more than double within the next 40 years, and the number of Australians over age 85 is projected to triple. The combination of an aging population, low fertility rate, and increased NCD burden could have a significant impact on the Australian economy, with lung cancer alone predicted to cost it AUD 8.5 billion by 2031.

Despite significant advances in prevention, early detection, and the development and deployment of effective treatments, cancer remains a challenge, and lung cancer, particularly, is the fifth-most diagnosed cancer in Australia and the leading cause of cancer death. In 2022, overall lung cancer incidence was 24.1 cases per 100,000 people, with a mortality rate of 15.6 deaths per 100,000. While there is some gender-based variation in both incidence and mortality, these gaps are smaller, compared to many other Asia Pacific countries, with a lung cancer incidence of 27.1 per 100,000 for men and 21.5 per 100,000 for women, and mortality rates of 18.5 and 13.0 per 100,000, respectively.

Instead, the starkest inequalities are those between Indigenous and non-Indigenous people, and communities living in rural and remote areas compared to those living in metropolitan areas. Aboriginal and Torres Strait Islander people (here referred to as Indigenous Australians) are 1.8 times more likely to die from lung cancer than are non-Indigenous Australians. Meanwhile, patients living in rural or remote areas experience 12 percent lower survival rates and 31 percent higher incidence rates than Australians in metropolitan areas. However, mortality rates for the population as a whole remain high: lung cancer has the lowest five-year survival rate among the five most commonly diagnosed cancers in Australia, at just 20 percent. Indeed, around 42 percent of cases are still diagnosed at stage IV, at which point treatment options are limited, and mortality becomes more likely.

Social determinants of health, including Indigenous status, residence, and income-level, are significant drivers of lung cancer incidence and mortality, as is air pollution, particularly from bushfires, smog, and drought-related dust storms, all of which are exacerbated by climate change. Air pollution from fine particulate matter (PM2.5) alone costs Australia an estimated AUD 6.2 billion annually in lost productivity and years of life lost. Australia has universal health coverage (UHC)—which guarantees free care for all in public hospitals—and a number of relevant government-funded programs, including the Commonwealth Government Pharmaceutical Benefits Scheme (PBS), which provides medicines and treatments for which patients only have to contribute a small co-pay.

However, out-of-pocket expenses for cancer treatment remain extremely high, with one study showing that half of cancer patients face out-of-pocket costs of more than AUD 5,000. In 2023, individual patients were the highest contributors to overall health care spending, second to the government itself, paying AUD 33.7 billion in that year alone. Amid long waiting periods and overly stretched resources in the public sector, many cancer patients are seeking private care and consequently paying significant fees. One crucial strategy to reduce this high spending will be investment in prevention and early detection, which are key to reducing the economic and social impacts of lung cancer.

Assessing policies and programs

Australia’s cancer control strategy is guided by the Australian Cancer Plan, the most recent iteration of which was launched in 2023. The Plan lays out 10-year ambitions, five-year goals, and two-year goals, with the aim of achieving six main objectives. These objectives are: 1) Maximizing cancer prevention and early detection; 2) Enhanced consumer experience; 3) World-class health systems for optimal care; 4) Strong and dynamic foundations; 5) Workforce to transform the delivery of cancer care; and 6) Achieving equity in cancer outcomes for Aboriginal and Torres Strait Islander people, and for other marginalized groups including older adults and LGBTQIA+ people. The Plan highlights the need to train and attract a health care workforce that specializes in addressing cancer, and in particular to recruit more health care workers from underrepresented and marginalized groups, to provide culturally sensitive care. However, the Plan is general, not focused on one specific cancer, and makes no mention of lung cancer. This is a missed opportunity, given the high prevalence and mortality rates of lung cancer in the overall population and among vulnerable groups.

A collection of Optimal Care Pathways is complementary to the Australian Cancer Plan. Each of the most prevalent cancers in Australia, including lung cancer, has a document dedicated to it, and there is then a specific framework on the optimal treatment for Indigenous people and communities. Each Pathway outlines guidelines and standards of care at all phases of the patient journey, from prevention and early diagnosis, to referral, treatment, post-treatment care and management, and end-of-life support. The Pathways are guided by seven “principles”: 1) patient-centered care; 2) safe and quality care; 3) multidisciplinary care; 4) supportive care; 5) care coordination; 6) communication; and 7) research and clinical trials.

Of particular note, the lung cancer Pathway recommends that treatment begin within six weeks of initial specialist referral—a critical issue in Australia, where some studies have found that nearly half of patients wait more than 42 days to begin treatment, and others have found that patients presenting with early-stage lung cancer wait an average of 168 days, undermining the benefits that early diagnosis can bring. Additional notable recommendations include working to establish an advance-care plan in case patients are incapacitated, and the need for all lung cancer care to be led by multidisciplinary teams (MDTs) of medical professionals and specialists from different fields. However, while the Optimal Care Pathways represent a gold standard of cancer care for Australians, they are only guidelines, which are unevenly implemented and without any enforcement mechanism. There is no monitoring system to assess extent and effectiveness of implementation, and hospitals are under no obligation to follow the recommendations offered.

As of June 2024, there is no national screening program for lung cancer, but the government has announced that a screening program offering free low-dose computed tomography (LDCT) screening to high-risk populations every two years will be implemented by 2025. Evidence gathered during the scoping phase for the screening program found that it could improve early diagnosis and save over 12,000 lives. Those meeting the high-risk criteria include individuals between 50 and 70 years of age with a 30-pack year smoking history—assessed by multiplying the number of cigarette packs smoked per day by the number of years of smoking—and vulnerable groups including Indigenous people, those living in remote and rural areas, people with disabilities or mental health conditions, and LGBTQIA+ people. Following diagnosis, Australians with lung cancer are placed in the care of MDTs, bringing together specialists from different fields of medicine. While there are gaps in the coverage and make-up of MDTs, research has found that many teams collaborate via teleconferencing and by referring patients to partner health facilities when they cannot provide a specific form of care or expertise.  

Australia has access to effective and innovative treatments for lung cancer, in part because of a data-sharing initiative among the Australian Therapeutic Goods Association, the U.S. Food and Drug Administration (FDA), and the European Medicines Agency (EMA), which enables rapid approval of drugs already approved in the U.S. and EU. As of 2024, over 90 cancer medications are available and subsidized via the PBS, including systemic therapies such as chemotherapy, and adjunct medicines to reduce the harmful side effects of treatment. A limited course of immunotherapy has also been available via the public health service since 2016, and private health care patients can access unlimited courses of this treatment at their own expense. Critically, next-generation sequencing (NGS) was officially recommended by the Medical Services Advisory Committee (MSAC) in 2022, meaning that NGS will be publicly funded for patients with non-small cell lung carcinoma, the most common form of lung cancer. This will dramatically reduce the lengthiness and physical toll of the diagnostic phase, as NGS panels can test for multiple genetic abnormalities at once and enable the identification of the best treatment for each patient.

While tobacco consumption is typically a key driver of lung cancer in many countries, successive tobacco control legislation introduced in Australia since the 1980s has had a significant impact in reducing overall smoking rates. The Tobacco Advertising Prohibition Act 1992, Tobacco Plain Packaging Act 2011, and Competition and Consumer (Tobacco) Information Standard 2011 limit advertising of tobacco products, mandate graphic and written health warnings on packaging, and ban smoking in indoor public spaces and in cars with minors. In addition, the Public Health (Tobacco and Other Products) legislation passed in December 2023 includes a substantial focus on the control of e-cigarettes and other, newer, tobacco products. Nevertheless, smoking rates remain high in Indigenous communities, and the National Tobacco Strategy 2023–2030 seeks to address this and other upstream drivers of ill health and inequality. The Strategy draws an explicit link between tobacco control and achievement of the SDGs, particularly SDG 3.4 on reduction of NCDs. Notably, the Strategy seeks to reduce the influence of the tobacco industry in the creation and implementation of tobacco-related legislation, which has been a challenge in the past.

Air pollution is a key risk factor for lung cancer and other lung conditions, which collectively represent over 10 percent of Australia’s health burden, making pollution control critical to public health. At the national level, Australia is governed by the National Clean Air Agreement, implemented by the Department of Climate Change, Energy, the Environment, and Water, and complemented by Ambient Air Quality Measures and state-level policies. Notably, the Department of Climate Change collaborates with the Department of Infrastructure, Transport, Regional Development, Communications and the Arts to regulate vehicle and shipping emissions. Despite these various policies and governing bodies, air pollution remains high, and impacts from climate change such as bushfires are exacerbating negative health outcomes. To address these challenges, recent reports have recommended the implementation of centrally coordinated and managed interventions to mitigate air pollution and improve well-being.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

Opportunities ahead

Despite Australia’s commitment to significantly reduce its lung cancer incidence and mortality, challenges remain. In particular, disparities remain stark in access to care, and in knowledge and attitudes toward preventive behaviors. Reducing inequality between Indigenous and non-Indigenous people, and between rural and metropolitan residents, could be crucial to lowering the overall burden of lung cancer. This effort could include establishing lung cancer care facilities more accessible to those in remote areas and investing in community outreach and mobile care centers, including for lung cancer screenings. Additionally, boosting recruitment and retention of specialized health care workers—as outlined in both the Australian Cancer Plan and the Optimal Care Pathways—and increasing the employment of health care workers from marginalized communities could go a long way toward eradicating inequities in care quality and access, reducing the incidence of lung cancer, and lowering its associated socioeconomic costs.

Finally, while the Australian Cancer Plan outlines clear, measurable two- and five-year goals for achieving its overall objectives, it is unclear how the government or other interested stakeholders plan to monitor the progress of the plan, and the Optimal Care Pathways contain no monitoring or evaluation framework at all. Integrating clear, data-driven targets and benchmarks for all lung cancer-related plans and strategies would enable easier assessment of the success of implementation, and assist in identifying gaps to be closed through interim measures and in subsequent plans.