OBJECTIVES:Our goal was to explore and compare risk factors, patterns of management and survival outcomes in Indigenous compared with non-Indigenous Australian patients using the Victorian Lung Cancer Registry (VLCR). STUDY TYPE:A retrospective observational cohort study of the VLCR. SETTING:Data collected from the VLCR between 18 January 2011 and 24 January 2024. PARTICIPANTS:Primary lung cancer patients in the VLCR. MAIN OUTCOME MEASURES:Patient, disease and management characteristics of Indigenous and non-Indigenous Australian patients. Impacts of patient and clinical variables on treatment and survival, measured by multivariable Cox regression and propensity-matched survival analysis. RESULTS:We included 186 Indigenous and 17,439 non-Indigenous Australian patients. Indigenous Australian lung cancer patients were younger in age {median, 62 years (interquartile range [IQR], 55-69 years) vs. median, 71 years (IQR, 63-77 years); p < 0.001}, had lower socio-economic status (lowest quintile, 57 patients [31%] vs. 3274 patients [19%]; p < 0.001), were more likely to be current smokers (118 patients [65%] vs. 5963 patients [35%]; p < 0.001) and had higher levels of respiratory comorbidity (64 patients [34%] vs. 4088 patients [23%]; p < 0.001). There were no statistically significant differences in receipt of guideline-concordant treatment (82 patients [51%] vs. 8036 patients [56%]; p = 0.12) and survival outcomes (median survival, 1.4 vs. 1.5 years; hazard ratio, 1.06 [95% confidence interval, 0.88-1.27]). CONCLUSION:We found lung cancer patients of Indigenous status were more likely to have demographic disadvantage and clinical risk factors that may contribute to discrepancies in management compared with patients of non-Indigenous status. Identifying barriers to healthcare and treatment in the Indigenous Australian population is an important research priority to improve disparities between the two populations.

BACKGROUND:Stage IIIA non-small-cell lung cancer (NSCLC) is a life-limiting disease, and the level of adherence to evidence-based treatment guidelines in the Australian setting is unclear. AIM:To assess the level of adherence to stage IIIA NSCLC treatment guidelines prior to the advent of immunotherapy and highlight factors that may contribute to guideline non-concordance. METHODS:A retrospective cohort study was performed. All patients diagnosed with stage IIIA NSCLC between May 2012 and January 2016 in a Victorian Tertiary Referral Centre were included. Guideline concordant initial treatment (GCIT) was defined according to contemporaneous National Comprehensive Cancer Network (NCCN) recommendations based on tumour resectability. Curative intent treatment was defined as surgery and/or definitive chemoradiotherapy delivered with the aim of disease eradication. RESULTS:Ninety-two patients were included. The mean age of diagnosis was 66 years, and 76.7% had an Eastern Cooperative Oncology Group performance status of 0-1. Curative-intent treatment was delivered in 67.4% of patients, and 62.5% were deemed to have resectable disease of which 58.7% proceeded to surgery. The predominant pre-treatment histological diagnosis was adenocarcinoma (48.3%). Non-operative treatment modalities included platinum-based chemotherapy (64.1%) and radiation (49.4%). One-year survival was 70.5%, while the 5-year survival was significantly lower at 22.2%. Overall, a notable proportion of patients (36.0%) were not treated in accordance with the established guidelines. CONCLUSIONS:While most patients received GCIT, a significant proportion of patients received no or less intensive treatment. This deviation primarily arose from factors such as advanced age, comorbidities and respiratory impairment at baseline.

AIM:Smoking is a chronic relapsing condition that is under-reported in oncology settings. People who report current smoking (CS) and those who report recently quitting smoking (RQ) should receive cessation support when they are diagnosed with cancer. The study aimed to identify whether differences exist in the smoking cessation support given to CS and RQ in oncology and what advice is given regarding the benefits of cessation. METHOD:A survey exploring smoking cessation practices was completed by oncology clinicians (medical, nursing, and allied health) at nine cancer centers in Australia. Data were analyzed using mixed-effects ordinal regression modeling. RESULTS:Across the 177 clinicians completing the survey, the reported provision of smoking cessation care was significantly higher for CS than for RQ in relation to asking about smoking status (odds ratio [OR] 3.03, p = 0.001), advice on the benefits of quitting (OR 2.86, p = 0.001), and advice to call the Quitline (OR 5.08, p < 0.001). Exploratory analyses indicated doctors and nurse specialists were four times more likely to report referring CS to a Quitline compared to RQ (OR 4.38, p = 0.001; OR 4.29, 95%, p = 0.005, respectively). The cessation benefits that clinicians most often cited to their patients was that quitting "can reduce the chance of developing treatment complications and side effects". CONCLUSION:The relative lack of smoking cessation care provided to RQ in oncology suggests that the high risk of smoking relapse is not well-recognized. Greater awareness and training are needed regarding advising RQ about the survival-specific benefits of continuing to not smoke, offering referrals, and offering follow-up support.

INTRODUCTION:Lung cancer accounts for 9% of all cancer diagnoses in Australia with a 5-year survival rate of 26%. Small cell lung cancer (SCLC) is a more aggressive subtype of lung cancer, representing 15% of all lung cancer cases and a 5-year survival of 11.1%. This study aims to assess the extent of guideline concordant treatment (GCT) delivery for SCLC in Victoria, identify patient, clinical, and hospital factors influencing GCT receipt, and evaluate its impact on survival. METHODS:Data were obtained from the Victorian Lung Cancer Registry (VLCR) in Victoria, Australia (n = 1769). Descriptive statistics were used to summarie patient and disease characteristics by treatment type, including GCT, non-GCT, and no/declined treatment. Statistical analyses included multiple logistic regression, Cox regression, and Kaplan-Meier survival estimates. RESULTS:78.1% received GCT, 10.5% received non-GCT, and 11.5% had no treatment. Older age, poor performance status, and advanced cancer stage were associated with a lower likelihood of receiving GCT. Patients who received stage-specific GCT had a 60% lower mortality risk compared to those who received non-GCT treatment. CONCLUSION:This study highlights significant variation in the receipt of guideline concordant treatment for SCLC, with older age, poorer performance status, and advanced cancer stage reducing the likelihood of GCT. Given the survival benefits associated with GCT, addressing barriers to its delivery is essential to improving outcomes for SCLC patients in Victoria.

PURPOSE:Patients who smoke tobacco during and after a cancer diagnosis have poorer health outcomes. Oncology healthcare providers (HCPs) are crucial to providing smoking cessation support. The study examined the characteristics associated with differences in HCPs' smoking cessation practices. METHODS:As part of the Care to Quit trial, a cross-sectional survey exploring smoking cessation practices was completed by HCPs across nine cancer centers in New South Wales and Victoria, Australia. RESULTS:One hundred and seventy-seven HCPs completed the survey. Over half of the HCP respondents reported asking patients their smoking status, but fewer than half advised patients about the benefits of quitting, referred patients to behavioral support such as Quitline, or offered pharmacotherapy medication. All components of the "3A's" model (Ask, Advise, Act) were more likely to be completed by doctors compared to registered nurses (OR: 7.86, 95% CI: 3.64, 16.95, p<0.001), by those with more years of practice (OR: 0.26, 95% CI: 0.07-0.93, p = 0.039), and those who had received smoking cessation training (OR: 3.91, 95% CI: 1.80, 8.48, p = 0.001). Multivariate analyses also identified differences in the amount of cancer-specific advice provided between occupation type (p<0.001) and years of practice (p = 0.021). CONCLUSION:The need for smoking cessation care training in oncology continues to be apparent. Training in prescribing pharmacotherapies (for doctors) or supporting the use of pharmacotherapies (for nurses) is a particular "gap." Differences between the roles and engagement of doctors and nurses in relation to smoking cessation care should be carefully considered when developing site-specific models of cessation care and providing training.

The global incidence of lung cancer is increasing, leading to a rise in the use of Robotic-assisted Thoracic Surgery (RATS) and a demand for more surgeons trained in robotic surgery. With the expanding number of robotic platforms, there is a need to train for a multiplatform environment. Therefore, a literature review was conducted using the PRISMA Scoping Review methodology to examine existing RATS curricula worldwide and identify the learning needs within these programs. This work involves an exploration of the educational experiences of 73 existing thoracic surgical units, revealing common themes such as sequential training and progression through theoretical, simulation-based, and supervised/independent hands-on phases. The most frequently identified gaps include logistical barriers in the simulation phase and insufficient supervised or independent console time for trainees during the hands-on phase of their training. This review has provided insight into the development of the RATS curriculum at the International Medical Robotics Academy, addressing these needs.

BACKGROUND:Previous literature has highlighted health inequality in lung cancer treatment, possibly related to differential healthcare delivery across public and private hospitals. In this study we assessed the association between public and private hospital receipt of guideline-concordant treatment (GCT) and survival. METHODS:A retrospective study of patients in the Victorian Lung Cancer Registry was performed between April 2011 and March 2022. Models were adjusted for propensity score (age, sex, performance status, histology, ethnicity, smoking, hospital location, socioeconomic status, comorbidities, comorbid cancer). Main outcome measures were timeliness of treatment, receipt of GCT, and survival between private and public hospital-admitted patients. FINDINGS:Of 11,396 patients, 9213 (81%) patients had treatment in public hospitals. Compared to private-hospital patients, public-hospital patients experienced substantial treatment delay (median referral-to-treatment interval: 48 vs. 29 days, p < 0.001). After adjusting for propensity score, private-hospital patients were more likely to receive GCT in all stages of non-small-cell lung cancer (NSCLC) except stage III (Stage I: OR 2.77, p < 0.001; Stage II: OR 3.43, p < 0.001; Stage III: 1.06, p = 0.73; Stage IV: OR 2.14, p < 0.001). The private-hospital patients had lower risk of death in NSCLC stages I, II and IV and a near-significant benefit in stage III (Stage I: OR 0.67, p < 0.001; Stage II: OR 0.54, p < 0.001; Stage III: 10.81, p = 0.06; Stage IV: OR 0.79, p < 0.001). INTERPRETATION:Compared to private, the public-hospital patients experienced substantial delay in lung-cancer treatment, lower standard of GCT, and poorer survival rate. This study highlights substantial health inequity and disparity, demanding a need to evaluate, assess, and improve lung cancer treatment in Australian hospitals.

3069 Background: Molecular targeted agents have revolutionized cancer diagnosis and treatment. Intraoperative molecular imaging (IMI) is a novel technique that entails performing real-time, in vivo optical imaging during surgery to ensure cancer clearance. A multicenter clinical trial was conducted using abenacianine, a cathepsin targeted near-infrared (NIR) IMI agent to visualize pulmonary nodules during surgery. The primary objective was to assess the efficacy of abenacianine in localizing pulmonary lesions, evaluating surgical margin, and identifying unsuspected disease. Methods: Participants scheduled to undergo surgery for known or suspected cancer in the lung received abenacianine (0.32 mg/kg intravenous) preoperatively 12 to 36 hours before surgery. During a standard-of-care surgery, the lung underwent IMI and additional disease not identified by conventional methods were identified and analyzed. Efficacy was measured by frequency of clinically significant events (CSEs) defined as localization of lesions not found by standard surgical techniques, identification of additional cancers, identification of positive surgical margins confirmed by histology, and detection of cancerous lymph nodes. Results: 89 participants were included in the study. The mean age was 67 years and 57 (64%) were female. Of 89 participants administered abenacianine who underwent standard of care surgical resection for known or suspected cancer in the lung, 40 (45%) had at least one CSE. Abenacianine with NIR imaging identified lesions that were not found by standard surgical methods in 34 (38%) participants, synchronous and occult cancers that were not found by pre-operative imaging in 2 (2%), margins within 10 mm of the closest staple line in 8 (9%), and lymph nodes determined to be cancerous in 1 (1%) participant. Tumors visualized by IMI with abenacianine included non-small cell lung cancers (adenocarcinoma, squamous cell carcinoma, neuroendocrine tumor) and cancers that metastasized to the lung (breast, colorectal, prostate, thymoma, renal cell, sarcoma). Abenacianine was safe and well tolerated in this study; there were no drug-related serious adverse events. Conclusions: This Phase 2 multicenter study demonstrated that using IMI with abenacianine during standard-of-care lung cancer surgery markedly improved clinical outcomes. Abenacianine localized tumors intraoperatively, identified synchronous and occult lesions, helped assess negative margin status, and identified cancerous lymph nodes enabling a more complete oncologic resection. Clinical trial information: NCT06145048 .

Background and Objective: Approximately 16,000 new cases of lung cancer are diagnosed each year in Australia and Aotearoa New Zealand, and it is the leading cause of cancer death in the region. Unwarranted variation in lung cancer care and outcomes has been described for many years, although clinical quality indicators to facilitate benchmarking across Australasia have not been established. The purpose of this study was to establish clinical quality indicators applicable to lung and other thoracic cancers across Australia and Aotearoa New Zealand. Methods: Following a literature review, a modified three round eDelphi consensus process was completed between October 2022 and June 2023. Participants included clinicians from all relevant disciplines, patient advocates, researchers and other stakeholders, with representatives from all Australian states and territories and Aotearoa New Zealand. Consensus was set at a threshold of 70%, with the first two rounds conducted as online surveys, and the final round held as a hybrid in person and virtual consensus meeting. Results: The literature review identified 422 international thoracic oncology indicators, and a total of 71 indicators were evaluated over the course of the Delphi consensus. Ultimately, 27 clinical quality indicators reached consensus, covering the continuum of thoracic oncologic care from diagnosis to first line treatment. Indicators benchmarking supportive care were poorly represented. Attendant numeric quality standards were developed to facilitate benchmarking. Conclusion: Twenty-seven clinical quality indicators relevant to thoracic oncology care in Australasia were developed. Real world implementation will now be explored utilizing a prospective dataset collected across Australia.

The extent of delivery of evidence-based practice or guideline-concordant treatment is not well established in lung cancer. This study found the measurement and reporting of delivery of guideline-concordant treatment has positive impacts on survival. The creation of a quality indicator reflective of guideline-concordant treatment and the delivery of best evidence-based care merits consideration. Background: Lung cancer in Australia contributes 9% of all new cancer diagnoses and is the leading cause of cancer death and burden. Clinical practice guidelines provide evidence-based treatment recommendations for best practice management. We aimed to determine the extent of delivery of guideline-concordant treatment (GCT) and to identify modifiable variables influencing receipt of GCT and survival. Methods: Data was sourced from the Victorian Lung Cancer Registry (VLCR) in Victoria, Australia. Descriptive statistics were used to summarize patient and disease characteristics according to treatment type: GCT versus non-GCT versus no/declined treatment. Statistical analyses included multiple logistic regression, multiple COX regression and Kaplan-Meier survival estimates. Results: 52% of patients were treated with GCT, 32.8% non-GCT and 15.2% declined or received no treatment. GCT treated patients were younger, never smoked, had no comorbidities, had better performance status, had early stage cancer, were discussed at a multidisciplinary meeting or had treatment at a higher volume hospital. Overall, patients that received GOT had a 24% lower risk of mortality compared to patients that received non-GOT. Conclusion: Modifiable variables impacting likelihood of receiving GOT included age, smoking status and treating hospital characteristics. Several modifiable variables were identified with positive impacts on survival including increased treatment of the elderly, smoking cessation, delivery of GOT, and treatment in higher volume hospitals. The measurement and reporting of delivery of GOT has positive impacts on survival and therefore merits consideration as an evidence-based quality indicator in the reporting of lung cancer quality and safety outcomes.

Early identification and definitive management of lung cancer is the key to improved survival.1,2 Noncalcified pulmonary nodules are often detected on chest computed tomography (CT), particularly in former or current smokers.3 This is observed in both screening and clinical settings. Although the latter may be referred to as incidental findings, they are so frequent as to be expected in a patient older than 50 years of age with a substantial smoking history. The management of incidental nodules requires a different approach to screen-detected nodules, requiring one to consider the context of the chest CT, other comorbidities, and risk factors of the patient.

ImportancePatients with lung cancer have poor physical functioning and quality of life. Despite promising outcomes for those who undertake exercise programs, implementation into practice of previously tested hospital-based programs is rare. ObjectiveTo evaluate a home-based exercise and self-management program for patients after lung resection. Design, Setting, and ParticipantsA randomized clinical trial with assessor blinding was conducted among 116 patients undergoing surgery for non-small cell lung cancer from November 23, 2017, to July 31, 2023, at tertiary hospitals in Australia. Patients were followed up for 12 months postoperatively. InterventionPatients randomized to the intervention group received a postoperative 3-month home-based exercise and self-management program, supported by weekly physiotherapist-led telephone consultations. Patients randomized to the control group received usual care. Main Outcomes and MeasuresThe primary outcome was self-reported physical function (30-item European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire [EORTC QLQ-C30] score) at 3 months. Secondary outcomes included objective measures of physical function and exercise capacity (at 3 and 6 months) and patient-reported outcomes including quality of life (at 3 and 6 months, with some questionnaires completed at 12 months). Analysis was performed on an intent-to-treat basis. ResultsA total of 1370 patients were screened, with 177 eligible and 116 consented (mean [SD] age, 66.4 [9.6] years; 68 women [58.6%]). Of these 116 patients, 58 were randomized to the intervention and 58 to the control. A total of 103 patients (88.8%) completed assessments at 3 months, 95 (81.9%) at 6 months, and 95 (81.9%) at 12 months. There were no statistically significant differences between the intervention and control groups for self-reported physical function (EORTC QLQ-C30 physical functioning domain score) at the 3-month primary end point (mean [SD] score, 77.3 [20.9] vs 76.3 [18.8]; mean difference, 1.0 point [95% CI, -6.0 to 8.0 points]). Patients in the intervention group, compared with the control group, had significantly greater exercise capacity (6-minute walk distance: mean difference, 39.7 m [95% CI, 6.8-72.6 m]), global quality of life (mean difference, 7.1 points [95% CI, 0.4-13.8 points]), and exercise self-efficacy (mean difference, 16.0 points [95% CI, 7.0-24.9 points]) at 3 months as well as greater objectively measured physical function (Short Physical Performance Battery score: mean difference, 0.8 points [95% CI, 0.1-1.6 points]), exercise capacity (6-minute walk distance: mean difference, 50.9 m [95% CI, 6.7-95.1 m]), and exercise self-efficacy (mean difference, 10.1 points [95% CI, 1.9-18.2 points]) at 6 months. One minor adverse event and no serious adverse events occurred. Conclusions and RelevanceIn this randomized clinical trial, a postoperative home-based exercise and self-management program did not improve self-reported physical function in patients with lung cancer. However, it did improve other important clinical outcomes. Implementation of this program into lung cancer care should be considered. Trial Registrationhttp://anzctr.org.au Identifier: ACTRN12617001283369

ImportancePatients with lung cancer have poor physical functioning and quality of life. Despite promising outcomes for those who undertake exercise programs, implementation into practice of previously tested hospital-based programs is rare.ObjectiveTo evaluate a home-based exercise and self-management program for patients after lung resection.Design, Setting, and ParticipantsA randomized clinical trial with assessor blinding was conducted among 116 patients undergoing surgery for non–small cell lung cancer from November 23, 2017, to July 31, 2023, at tertiary hospitals in Australia. Patients were followed up for 12 months postoperatively.InterventionPatients randomized to the intervention group received a postoperative 3-month home-based exercise and self-management program, supported by weekly physiotherapist-led telephone consultations. Patients randomized to the control group received usual care.Main Outcomes and MeasuresThe primary outcome was self-reported physical function (30-item European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire [EORTC QLQ-C30] score) at 3 months. Secondary outcomes included objective measures of physical function and exercise capacity (at 3 and 6 months) and patient-reported outcomes including quality of life (at 3 and 6 months, with some questionnaires completed at 12 months). Analysis was performed on an intent-to-treat basis.ResultsA total of 1370 patients were screened, with 177 eligible and 116 consented (mean [SD] age, 66.4 [9.6] years; 68 women [58.6%]). Of these 116 patients, 58 were randomized to the intervention and 58 to the control. A total of 103 patients (88.8%) completed assessments at 3 months, 95 (81.9%) at 6 months, and 95 (81.9%) at 12 months. There were no statistically significant differences between the intervention and control groups for self-reported physical function (EORTC QLQ-C30 physical functioning domain score) at the 3-month primary end point (mean [SD] score, 77.3 [20.9] vs 76.3 [18.8]; mean difference, 1.0 point [95% CI, −6.0 to 8.0 points]). Patients in the intervention group, compared with the control group, had significantly greater exercise capacity (6-minute walk distance: mean difference, 39.7 m [95% CI, 6.8-72.6 m]), global quality of life (mean difference, 7.1 points [95% CI, 0.4-13.8 points]), and exercise self-efficacy (mean difference, 16.0 points [95% CI, 7.0-24.9 points]) at 3 months as well as greater objectively measured physical function (Short Physical Performance Battery score: mean difference, 0.8 points [95% CI, 0.1-1.6 points]), exercise capacity (6-minute walk distance: mean difference, 50.9 m [95% CI, 6.7-95.1 m]), and exercise self-efficacy (mean difference, 10.1 points [95% CI, 1.9-18.2 points]) at 6 months. One minor adverse event and no serious adverse events occurred.Conclusions and RelevanceIn this randomized clinical trial, a postoperative home-based exercise and self-management program did not improve self-reported physical function in patients with lung cancer. However, it did improve other important clinical outcomes. Implementation of this program into lung cancer care should be considered.Trial Registrationhttp://anzctr.org.au Identifier: ACTRN12617001283369

BACKGROUND:Malignant pleural effusions (MPEs) are common, and a third of them have underlying trapped lung (TL). Management of MPE and TL is suspected to be heterogeneous. Understanding current practices in Australasia is important in guiding policies and future research. AIMS:Electronic survey of Australia-New Zealand respiratory physicians, thoracic surgeons and their respective trainees to determine practice of MPE and TL management. RESULTS:Of the 132 respondents, 56% were respiratory physicians, 23% were surgeons and 20% were trainees. Many respondents defined TL as >25% or any level of incomplete lung expansion; 75% would use large-volume thoracentesis to determine whether TL was present. For patients with TL, indwelling pleural catheters (IPCs) were the preferred treatment irrespective of prognosis. In those without TL, surgical pleurodesis was the most common choice if prognosis was >6 months, whereas IPC was the preferred option if survival was <3 months. Only 5% of respondents considered decortication having a definite role in TL, but 55% would consider it in select cases. Forty-nine per cent of surgeons would not perform decortication when the lung does not fully expand intra-operatively. Perceived advantages of IPCs were minimisation of hospital time, effusion re-intervention and usefulness irrespective of TL status. Perceived disadvantages of IPCs were lack of suitable drainage care, potentially indefinite duration of catheter-in-situ and catheter complications. CONCLUSION:This survey highlights the lack of definition of TL and heterogeneity of MPE management in Australasia, especially for patients with expandable lungs. This survey also identified the main hurdles of IPC use that should be targeted.

Intraoperative fluorescence imaging using indocyanine green (ICG) is an innovative and safe tool in minimally invasive thoracic surgery. It provides real-time imaging capabilities that can enhance surgical precision. We describe several clinical uses of ICG including intersegmental plane identification, thoracic duct injury localisation, anomalous systemic artery identification in pulmonary sequestration, phrenic nerve identification, and sentinel lymph node mapping. Successful visualisation of ICG was achieved to identify intra-thoracic anatomical structures and boundaries, allowing for safe and precise dissection.