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.

A 61-year-old previously healthy man presented to hospital with acute type 1 respiratory failure after five days of coryzal symptoms and a positive coronavirus disease 2019 (COVID-19) rapid antigen test. Within 24 hours, the patient became progressively hypoxic, was rapidly intubated and transferred to Alfred Health in December 2022, a tier one Victorian extracorporeal membrane oxygenation (ECMO) service site, for veno-venous ECMO (Avalon Elite bi-caval dual lumen catheter). The patient was born in Chile and migrated to Australia at 5 years of age. His medical history was significant for mild asthma. The patient was a distant ex-smoker with a less than five pack-year smoking history. At the time of admission, he had received three COVID-19 vaccines (Comirnaty Original; Pfizer–BioNTech). The patient was treated with broad-spectrum antibiotics, antifungals and COVID-19-specific therapies, including baricitinib, remdesivir and dexamethasone. Initial COVID polymerase chain reaction (PCR) analysis identified the Omicron variant with a cycle threshold value of 29.8. In accordance with hospital guidelines, the patient was cleared of isolation precautions on Day 20 with a cycle threshold value of 30.7. Multiple complications occurred during hospitalisation, including deep venous thrombosis, ventilator-associated pneumonia, Pseudomonas aeruginosa bacteraemia, pancreatitis, cytomegalovirus viraemia and localised herpes simplex virus type 1 infection. A failed attempt at de-cannulation occurred two months after presentation, where the patient required re-cannulation within 48 hours due to respiratory distress. The patient remained awake on ECMO and participated in treatment decision discussions and rehabilitation. Lung transplantation assessment and waitlisting occurred four months after the patient started ECMO. Transplantation was delayed due to human leukocyte antigen (HLA) sensitisation following multiple platelet transfusions for bleeding after endoscopic retrograde cholangiopancreatography for investigation of pancreatitis. An HLA single antigen bead Luminex test was positive for 53 Class I HLA antibodies with a peak mean fluorescence intensity of 24 000. After three months, the test was repeated and results had improved to 33 Class I HLA antibodies with a peak mean fluorescence intensity of 15 072. Due to the patient's Chilean heritage, he was tested for Chagas disease (nucleic acid test) and returned a positive result. However, the result was negative on blood smear, indicating a chronic-phase infection. A computed tomography scan was performed at this point and showed evidence of COVID-related pulmonary fibrosis (Box, A). The patient underwent bilateral sequential lung transplantation in June 2023, six months after admission. ECMO de-cannulation occurred the day after transplantation. He was discharged home 20 days post-transplantation with no oxygen requirement. At follow-up six months post-transplantation, the patient was functionally independent with clear lung fields on imaging (Box, B) and normal spirometry. Given the risk of reactivation of Chagas disease post-transplantation, monitoring with clinical and blood film surveillance was performed up until 100 weeks post-transplant. As of November 2024, there has not been reactivation of Chagas disease or allograft dysfunction and the patient continues a routine post-transplant immunosuppression regimen of prednisolone, tacrolimus and mycophenolate. This is the first reported case of lung transplantation as curative treatment for irreversible COVID-19 lung injury in Australia. Although lung transplantation for COVID-19 has been increasingly practised internationally, this indication is not well established in Australia.1, 2 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections continue to result in patients requiring prolonged ventilation for acute respiratory distress syndrome (ARDS) and pulmonary fibrosis.3 In addition to the International Society for Heart and Lung Transplantation 2021 consensus document for the selection of lung transplant candidates,4 an international case series suggested that potential lung transplant candidates with COVID-19 ARDS require two negative COVID-19 PCR results at least 24 hours apart and at least four to six weeks with no signs of recovery despite optimal medical therapy.5 Recovery was defined by improvement in lung compliance, radiography and gas exchange. As seen in the patient (Box, A), post-acute COVID-19 pneumonia can progress to fibrotic lung disease with traction bronchiectasis, interlobular septal thickening, and ground glass with reticulation.6 Short term outcomes of COVID-19 lung transplantation appear promising. Studies have found that lung transplantation for COVID-19 has acceptable one-year outcomes and no significant difference in survival outcomes compared with non-COVID-19 lung transplantation.7, 8 These studies also showed that ECMO treatment pre-transplant resulted in adequate functional status. As experienced with the patient, ECMO may reduce sedation to allow engagement in discussions and participation in physiotherapy to reduce risk of critical illness myopathy.9 Pre-transplant allo-sensitisation creates a barrier to transplant candidacy by limiting available donors.10 Highly sensitised lung transplant candidates are often declined due to increased risk of graft rejection and reduced survival after transplantation.11 Use of erythropoietin and iron supplementation can help moderate blood loss and anaemia without increasing the risk of sensitisation.12 This article demonstrates lung transplantation as a life-saving therapy for irreversible COVID-19 lung injury requiring prolonged ECMO. Further evidence is required to determine long term survival outcomes and best practice principles for lung transplantation in COVID-19 related respiratory failure in Australia. The patient provided written consent for publication. No relevant disclosures. Not commissioned; externally peer reviewed.

Dupilumab has been associated with adverse reactions including symptomatic hypereosinophilia. This study reports the incidence of dupilumab-related eosinophilia and adverse reactions in severe asthma patients at an Australian tertiary centre. https://bit.ly/3JgZ5Ya.

OBJECTIVE:Lung cancer is the leading cause of cancer-related death globally and provides a major disease burden likely to substantially impact quality of life (QoL). Patient-reported outcome measures (PROMs) have been identified as effective methods of evaluating patient QoL. Existing lung cancer-specific PROMs however have uncertain utility and minimal patient involvement in their design and development. This qualitative study aimed to evaluate the patient perspective of existing PROMs and to explore their appropriateness for population-based descriptions of lung cancer-related QoL. METHODS:A descriptive qualitative study was conducted consisting of semi-structured interviews with 14 patients recruited from the Victorian Lung Cancer Registry and Alfred Hospital using purposive sampling. Interviews first explored the factors most important to lung cancer patients QoL, and second, patient's perspectives on the appropriateness of existing PROMs. Thematic analysis was used to develop themes, and content analysis was conducted to determine PROM acceptability. RESULTS:Five novel themes were identified by patients as being important impacts on QoL: Personal attitude toward the disease is important for coping; independence is valued; relationships with family and friends are important; relationships with treating team are meaningful; personal and public awareness of lung cancer is limited. These patient-identified impacts are poorly covered in existing lung cancer-specific PROMs. Patients welcomed and appreciated the opportunity to complete PROMs; however, they identified problems with existing PROMs relevance, tone, and formatting. CONCLUSION:Existing lung cancer PROMs poorly reflect the five themes identified in this study as most important to lung cancer patients QoL. This study reaffirms the need to review existing PROMs to ensure utility and construct validity. Future PROM development must engage key patient-generated themes and evolve to reflect the changing management and therapeutic landscape.

Background: Cancer data registries are central elements of cancer control programs providing critical insights in measures of performance in cancer healthcare delivery. Evidence to practice gaps in cancer care remain substantial. Implementation science (IS) strategies target gaps between generated research evidence and guideline concordance in delivered healthcare. We performed a systematic review of the utilisation and effectiveness of IS strategies reported by cancer registries. Methods: A research protocol and literature search were performed seeking studies incorporating implementation strategies utilised by cancer registries for quality improvement. Searches were undertaken in MEDLINE, Embase, CENTRAL, and the grey literature for randomised trials and observational studies. The "Knowledge to Action" (K2A) framework was used to explore implementation gaps in care delivery. Results: Screening identified 1496 studies, 37 studies identified by title and abstract review, and 9 included for full text review. Studies originated from the United Kingdom, the United States, the Netherlands, and Australia reporting on lung, breast, colo-rectal, and cancer clusters. Registry jurisdictions included 7 national, 4 state, and 4 local registries. Knowledge gap analysis consistently identified monitoring and evaluation of data outcomes in accord with registry primary purpose although limited exploration of the utilisation, translation and re-application of this data. Studies lacked description of strategies describing sustainability of generated knowledge, identification of barriers, knowledge adaptation to local contexts, and the selection, adaptation and implementation of interventions for improvement. Conclusion: Available studies provide limited literature evidence of the effective utilisation of IS strategies reported by cancer registries for healthcare improvement. A substantial opportunity presents to study the engagement of IS in cancer registry data use to close the evidence practice gap and facilitate data driven improvement in cancer healthcare.

Delays in the assessment, management, and treatment of lung cancer patients may adversely impact prognosis and survival. This study is the first to use machine learning techniques to predict the quality and timeliness of care among lung cancer patients, utilising data from the Victorian Lung Cancer Registry (VLCR) between 2011 and 2022, in Victoria, Australia. Predictor variables included demographic, clinical, hospital, and geographical socio-economic indices. Machine learning methods such as random forests, k-nearest neighbour, neural networks, and support vector machines were implemented and evaluated using 20% out-of-sample cross validations via the area under the curve (AUC). Optimal model parameters were selected based on 10-fold cross validation. There were 11,602 patients included in the analysis. Evaluated quality indicators included, primarily, overall proportion achieving “time from referral date to diagnosis date ≤ 28 days” and proportion achieving “time from diagnosis date to first treatment date (any intent) ≤ 14 days”. Results showed that the support vector machine learning methods performed well, followed by nearest neighbour, based on out-of-sample AUCs of 0.89 (in-sample = 0.99) and 0.85 (in-sample = 0.99) for the first indicator, respectively. These models can be implemented in the registry databases to help healthcare workers identify patients who may not meet these indicators prospectively and enable timely interventions.

In Victoria, the second most populous Australian state (population 6.6 million), lung cancer contributed to 9% of new cancers diagnosed, 18.6% of all cancer deaths in 2020 and suffered the lowest survival rate of 17.4% amongst all cancers. Clinical practice guidelines for the treatment of non-small cell lung cancer (NSCLC) by localised, locally-advanced and advanced-stage cancer have been developed to improve evidence-based management and treatment. Provision of guideline-concordant treatment (GCT) is likely to lead to an improvement in patient survival.

The lung cancer Optimal Care Pathway recommends supportive care and palliative care integration throughout its various steps, with early referral to appropriate services improving the quality of life in advanced stage non-small cell lung cancer patients. Using Victorian Lung Cancer Registry data and linked administrative datasets, this retrospective cohort study mapped clinical care pathways of 525 Stage III-IV non-small cell lung cancer patients in Victoria to 11 recommendations in the Optimal Care Pathway, identifying unwarranted variations in clinical care. Supportive care and palliative care delivery were further examined to understand the involvement and timing of specialist care teams. Our findings showed that palliative care utilization is highest at the time of treatment, despite recommendations that it should be provided early after diagnosis to improve patient outcomes and satisfaction. Early supportive care screening was observed in half the cohort and almost three-quarters of the patients had been presented at a multidisciplinary meeting. Multidisciplinary meeting presentations and supportive care provide an opportunity to improve communication about palliative care needs and integration into routine clinical practice, such as at the time of treatment planning.

Lung cancer is a leading cause of cancer-related morbidity and mortality in Australia. Inequities and unwarranted variations in lung cancer care have been repeatedly described and are linked to adverse outcomes. To enable the systemic identification and alleviation of disparities in lung cancer care and outcomes, in 2022 the Lung Cancer Clinical Quality Data Platform (LUCAP) was implemented as a pilot project in two tertiary public hospitals in the Perth metropolitan region, Western Australia.