Beyond treatment volumes: improving equity, outcomes and quality of life in lung cancer care

Lung cancer remains the leading cause of cancer death in New Zealand. Survival is poor because many people are diagnosed with advanced disease. Māori experience substantially higher incidence and mortality than non-Māori. Despite this combination of high mortality, poor survival and pronounced inequity, lung cancer has not always received the policy and public attention accorded to some other cancers. Two papers^1,2 in this issue of the New Zealand Medical Journal bring the scale and consequences of lung cancer treatment into sharper focus.

Gurney et al. quantify the publicly funded treatment delivered to people diagnosed with lung cancer between 2015 and 2021.¹ For each annual cohort of newly diagnosed cases, the public health system provided, during the 2 years after diagnosis, 978 surgical days of lung cancer–specific surgery, 11,027 attendances for radiation therapy and 9,108 dispensings of systemic anti-cancer therapy (SACT). On average patients received 1.5 surgical days in hospital, 11.5 radiation-treatment attendances and 11.8 SACT dispensings. These figures demonstrate the considerable demands that lung cancer already places on the health system. These figures based on 2 years of follow-up should be interpreted alongside the disease’s poor prognosis. Less than half of people diagnosed with lung cancer in New Zealand survive for 1 year, and only a minority survive for 5 years.³ Consequently, many patients undergo substantial investigation and treatment during a very short period of remaining life. The challenge is not simply to provide more treatment, but to ensure that treatment is timely, equitable, evidence based and aligned with what matters to each patient.

Appleton et al. examine another dimension of this burden: severe acute toxicity following SACT.² Using linked national data and a cancer-specific toxicity coding framework, they found that approximately four in five patients receiving systemic therapy experienced at least one recorded toxicity. Infections were especially common, with other frequently recorded toxicities including cardiac arrhythmia, hypotension, anaemia, neutropenia and sepsis. Patients with small cell lung cancer were more likely than those with other tumour types to experience neutropenia, sepsis and electrolyte disturbances. As 87% of the treated cohort received chemotherapy, these findings largely reflect the toxicity associated with cytotoxic treatment during the study period. This pattern may reduce as more patients are treated with immunotherapies. However, the framework provides a valuable means of monitoring toxicity as treatment patterns evolve.

Together, the two papers describe both the volume of care delivered by the public system and the burden that treatment can impose on patients. The goal must surely be to reduce the overall burden of lung cancer on patients and their families as well as the public health system. To do this requires a reduction in the incidence of the disease and improved outcomes through earlier diagnosis and improved treatment. Tobacco smoking is the principal modifiable cause of lung cancer and a major contributor to inequities in incidence and mortality. Sustained tobacco-control policy is essential, including measures that are effective for Māori. The health sector also has a direct responsibility to identify people who smoke, offer evidence-based cessation support and ensure that such support is accessible and culturally safe. Reducing smoking prevalence will deliver benefits well beyond lung cancer, but weakening tobacco-control efforts risks adding substantially to future cancer burden. Earlier diagnosis is the second priority. Patients presenting through the emergency department tend to have more advanced-stage disease, while those presenting through their general practitioners have evidence of being diagnosed earlier and having better survival.⁴ Reducing barriers to accessing general practice and supporting general practitioners to make earlier diagnoses and referrals will improve outcomes. Low-dose computed tomography screening also reduces lung cancer mortality among people at high risk, as demonstrated by the National Lung Screening Trial and the NELSON trial.^5,6 A national lung cancer screening programme should therefore remain an important goal for New Zealand. Its design and implementation must be adequately resourced and developed with Māori to ensure that screening reduces, rather than widens, existing inequities. Screening must also be connected to timely diagnostic assessment, molecular testing and treatment—finding cancer earlier has limited value if subsequent care is delayed or inaccessible.

As the population grows and ages, the number of people diagnosed with lung cancer is expected to increase.¹ At the same time, screening and improved diagnostic pathways should increase the proportion of patients diagnosed at a stage at which curative treatment is possible. Demand cannot therefore be forecast from case numbers alone. Planning must account for stage at diagnosis, tumour type, molecular characteristics, treatment indications and the growing complexity of multimodality care. Surgical capacity will be particularly important if more patients are diagnosed at an earlier stage and are eligible for curative resection. Existing regional and ethnic differences in access to thoracic surgery for non-small cell lung cancer require attention, alongside investment in facilities, specialist workforce and referral pathways. Radiotherapy capacity must similarly accommodate both curative and palliative treatment. Withington and colleagues identified rurality, age, sex and ethnic variation in the receipt of radiotherapy for lung cancer, including lower receipt of curative radiotherapy among some groups of rural Māori.⁷ The development of cancer treatment facilities outside the larger centres already underway may improve access, but infrastructure must be supported by an appropriately trained workforce, robust clinical networks and practical assistance with travel and accommodation.

The greatest uncertainty may lie in forecasting demand for systemic therapy. Lung cancer is not a single disease: non-small cell lung cancer, small cell lung cancer, carcinoid tumours and rarer subtypes have different clinical courses and treatment options. Within non-small cell lung cancer, molecular alterations and genetic markers—such as the epidermal growth factor receptor gene, the reactive oxygen species mutation, the anaplastic lymphoma kinase gene and the protein marker programmed death-ligand 1—determine eligibility for targeted therapies or immunotherapy. As new treatments become available, equitable access depends not only on medicine funding but also on consistent, timely access to high-quality pathological and molecular testing. A postcode lottery in biomarker testing will inevitably produce inequity in treatment. The quality of treatment must be assessed by more than its volume. Appleton et al. show that toxicity is common and sometimes severe.² Routinely linked national data could help monitor adverse outcomes, compare treatment patterns and identify groups at disproportionate risk. Such analyses must be interpreted carefully because administrative data do not capture every toxicity and cannot, by themselves, establish causation. Nevertheless, systematic monitoring offers a practical starting point for improving supportive care, refining treatment selection and reducing avoidable hospitalisation.

Treatment decisions should balance potential gains in survival or symptom control against toxicity, disruption and the patient’s goals. This is especially important in advanced disease, where the marginal benefit of further treatment may be small. The reported use of SACT during the final 30 days of life warrants continued scrutiny as a quality-of-care measure,⁸ although it should never be interpreted without clinical context. The appropriate question is not whether treatment occurred near death, but whether it offered a realistic benefit, reflected an informed patient preference and was supported by high-quality symptom management. Palliative care should be integrated early rather than reserved for the last days of life. In a landmark randomised trial involving patients with metastatic non-small cell lung cancer, early palliative care improved quality of life and mood, reduced aggressive end-of-life care and was associated with longer median survival.⁹ Early palliative care can sit alongside active cancer treatment, helping patients and whānau manage symptoms, clarify priorities and navigate complex choices. When considering the expected increased burden of lung cancer it is important to not only plan for an increase in treatment services but also to remedy the current patchy and under-resourced palliative care services.

The choices facing patients have become more demanding as treatment options and sources of health information have multiplied. Patients may encounter information about chemotherapy, immunotherapy and targeted therapy through news and social media, often without a clear account of applicability, benefit or harm. Care plans and shared decision making can align treatment with patient priorities, strengthen understanding and trust and minimise unwanted treatment.

The two papers in this issue make visible the substantial burden of lung cancer treatment on both patients and the public health system.^1,2 A credible response requires more than just more of the same. It requires a balanced response: sustained tobacco control; equitable, nationally co-ordinated screening and earlier diagnosis; planned investment in surgery, radiotherapy, systemic therapy, pathology and molecular testing; systematic monitoring and reduction of treatment toxicity; and early integration of palliative care. The goal must be not only to extend life, but also to improve its quality and to ensure that the benefits and burdens of care are shared equitably.