The TSANZ and Lung Foundation Australia 2023 landscape survey of lung cancer care across Australia and Aotearoa New Zealand

Unwarranted variations in lung cancer care have been well described in both Australia and Aotearoa New Zealand, with shortfalls in hospital‐based workforce and infrastructure previously demonstrated. A survey of lung cancer clinicians was performed to gain an updated understanding of current workforce and infrastructure.


INTRODUCTION
2][3] Approximately 16,000 new cases of lung cancer are diagnosed in the region annually 1,2 and it is responsible for the highest cancer-related burden of disease. 4elative 5 year survival rates are persistently low at 15%-20%, 5,6 despite significant therapeutic advances.Treatment increasingly involves the utilization of multi-modality therapies, and therefore requires a high degree of collaboration across clinical disciplines; equitable access to diagnostic investigations and treatment is critical to ensure optimal care and outcomes for all patients diagnosed with lung cancer.
Unwarranted variation in lung cancer outcomes reflect inequity in access to, and quality of, care. 7The Optimal Care Pathway (OCP) for lung cancer care delivery 8,9 has been endorsed by government in Australia but never evaluated, whilst development of a similar pathway in Aotearoa New Zealand is ongoing.In the meantime, data consistently demonstrate variation in lung cancer incidence, stage at presentation and outcomes for First Nations populations. 10,11][13] The adequacy of hospital resources to diagnose and treat lung cancer in advanced health systems correlates with 1 year survival. 14A 2021 survey encompassing an estimated 70% Australian lung cancer MDTs identified gaps in hospital-based resources, with fewer than half of lung cancer centres reporting they had a lung cancer nurse specialist (LCNS), and one in four reporting their lung cancer MDT did not have Thoracic Surgery input. 15Addressing variability in these resources is critical to ensure delivery of equitable, guideline-concordant cancer care and is increasingly urgent given the planned implementation of a lung cancer screening program (LCSP) 16,17 in 2025 in Australia; M aoriled pilot screening programs are underway in Aotearoa New Zealand. 18herefore, the purpose of this survey of Australian and New Zealand hospitals was to gain an updated and more comprehensive understanding of current hospital-based lung cancer infrastructure and workforce.

METHODS
An online survey was distributed using Qualtrics (Qualtrics XM, Provo, UT, USA), open for completion between February and June 2023.One response from every institution treating lung cancer in Australia and Aotearoa New Zealand was sought, with the explicit instruction this should preferably be completed by the lead lung cancer clinician (see Appendix A in the Supporting Information).Survey respondents needed to provide the name of their institution, but no personal identifying information.
Survey content was based on the 2021 survey, 15 with some modifications and new questions (see Appendix B in the Supporting Information).Questions included institutional and MDT characteristics, MDT workforce profile and local infrastructure.Survey respondents in Australia were asked about their institution's (perceived) capacity to cope with an increased workload, in anticipation of LCSP implementation.Based on the Australian OCP, 8 core members of the MDT were defined, and waiting time data were consolidated into 'less than two weeks' or 'two weeks or longer'.Case volumes were defined as low ('<100 patients newly diagnosed with lung cancer annually') and high ('≥100 patients newly diagnosed with lung cancer annually').
A master list of all institutions thought to be treating lung cancer was developed based on 2021 survey respondents, Lung Foundation Australia's lung cancer MDT Directory and professional networks.The survey was distributed through professional organizations (Thoracic Society of Australia and New Zealand, Thoracic Oncology Group Australasia and Lung Foundation Australia) and professional networks.If there was no survey response from an institution, attempts were made to contact a clinician via email and/or telephone.A maximum of two reminder emails were sent.
Only one response per institution was analysed.Where duplicate responses were received, any incomplete responses were excluded and direct clarification from the institution was sought where possible.Otherwise, the most recent response was analysed.Statistical analysis was performed in SPSS (v28.0.0.1, IBM).

Institution characteristics
In total there were 116 responses, of which 89 responses from unique institutions were analysed; of these, 87/89 respondents answered all survey questions.There were nine survey respondents from institutions in Aotearoa New Zealand, and the remainder were in Australia: 23 institutions in New South Wales, 21 in Victoria, 15 in Queensland, 12 in Western SUMMARY AT A GLANCE Variation in the quality of lung cancer care may, in part, reflect variation in workforce and infrastructure.This large survey of institutions treating lung cancer in Australia and Aotearoa New Zealand demonstrates persistent shortfalls in workforce and infrastructure, including at MDT.Investment in health infrastructure is required to alleviate these deficiencies.
Australia, 5 in South Australia, 1 in the Australian Capital Territory, 2 in Tasmania and 1 in the Northern Territory.Based on the master list of lung cancer institutions, this suggests responses from 85% (80/94) institutions treating lung cancer in Australia, and 100% of public institutions in Aotearoa New Zealand.No responses were received from any private institutions in Aotearoa New Zealand, although this likely accounts for a very small proportion of lung cancer care. 19,20

MDT characteristics
79/80 Australian institutions and 9/9 institutions in Aotearoa New Zealand reported regularly holding a lung cancer MDT.A high degree of collaboration was evident, with 67/88 (76%) respondents indicating that they had representation from other institutions at their MDT, and 14/88 (16%) of institutions reporting they linked to an MDT hosted by a larger institution.Most institutions reported a hybrid virtual/in person meeting (60/88, 68%), with a further 21/88 (24%) institutions having online-only MDTs and 7/88 (8%) an in-person MDT.Most institutions hold weekly MDT meetings (65/88, 74%), with the remaining holding their MDT fortnightly or monthly.Approximately one third of institutions (32/88, 36%) reported discussing all lung cancer patients at MDT, with 'almost all' or 'most' patients discussed at 52/88 (59%) institutions.Of remaining institutions, all Australian, three reported that a minority of patients were discussed at MDT, and one respondent was uncertain what proportion of patients were discussed.The most common barriers to MDT discussion (with more than one response possible) were identified as: time constraints (48/88, 55%), workforce limitations (17/88, 20%),

Diagnostic infrastructure
Almost all institutions have on site access to lung function testing, Computed Tomography (CT) guided lung biopsy and ultrasound (US) guided biopsy (see Table 2).While most metropolitan institutions also had on site Endobronchial Ultrasound (EBUS) bronchoscopy (89% institutions) and Positron Emission Tomography/Computed Tomography (PET/CT, 70%), only half of non-metropolitan institutions had on site access to these investigations (56% and 52%, respectively).Patients in non-metropolitan areas appear more likely to experience delays when undergoing diagnostic investigations (see Figure 2).At some institutions, external referrals for diagnostic investigations were common despite on-site infrastructure.For example, 18/57 (32%) respondents with on-site PET/CT reported referring externally for PET/CT, and 19/83 (23%) respondents with on-site CT biopsy refer externally for CT biopsy.

Treatment
Most metropolitan institutions have on site access to common treatment modalities (Table 2), however, reduced access to surgery (79% vs. 40%) and stereotactic radiotherapy (SABR: 81% vs. 60%) is evident for nonmetropolitan institutions.Delays in surgical resection following lung cancer diagnosis and staging were reported at both metropolitan and non-metropolitan institutions, with estimated wait times of less than 2 weeks at 20/60 (33%) metropolitan institutions and 5/21 (24%) non-metropolitan institutions.Disparities in access to timely surgery were evident on comparison of public and private institutions: waiting time was less than 2 weeks at 17% (10/59) public institutions compared to 68% (15/22) of private institutions.
Lung cancer nurse specialists are on site at 50% (44/88) institutions, with a median Full Time Equivalent (FTE) of 1.0.However, at 11 of these institutions the LCNS role includes caring for patients across multiple tumour streams, suggesting that the proportion of institutions with a dedicated LCNS on site may be as low as one third (33/88, 37%).Most respondents indicated their institution cares for First Nations and/or Cultural and Linguistically Diverse patients (82/88, 93%), however only 17/88 (19%) institutions have specific support staff embedded within their lung cancer

Service capacity
Respondents in Australia were asked their opinion regarding their institution's capacity to cope with increased demand in the future, given the planned implementation of LCSP.
F I G U R E 3 Australian respondents' perceptions regarding institutional capacity to cope with increased demand following lung cancer screening implementation.
F I G U R E 2 Reported wait times for diagnostic investigation.
Regarding diagnostic services, approximately half of the survey respondents perceived that lung function testing (52%) and SABR (53%) services at their institution have capacity for expansion if needed (see Figure 3 for further detail).Services perceived to have the least capacity include CT biopsy (capacity to expand at 36% institutions), EBUS bronchoscopy (29%) and nodule clinic (24%).Current access to CT biopsy and EBUS was described as 'strained' at 43% and 25% of institutions, respectively, with 35% institutions having no current access to nodule clinics.If centralisation of care in high volume institutions is considered in the future, responses suggest that increased resources will be required to ensure the safety and quality of care.For example, 58% respondents at low volume institutions felt their Thoracic Surgery services had capacity to expand, compared to 32% at high volume institutions (see Appendix C in the Supporting Information); this pattern was replicated for all services evaluated, including CT biopsy (54% (low) vs. 27% (high)), nodule clinic (36% vs. 18%), EBUS bronchoscopy (36% vs. 25%), lung function (74% vs. 42%), PET/CT (58% vs. 41%), SABR (63% vs. 49%) and US biopsy (65% vs. 29%).

DISCUSSION
This comprehensive bi-national survey demonstrates persistent deficiencies and variation in lung cancer workforce and infrastructure across Australia and Aotearoa New Zealand.This includes only one third (36%) of institutions routinely reviewing all patients diagnosed with lung cancer at MDT, only 38% of MDTs fulfilling recommended minimum workforce and only 37% of institutions having a dedicated LCNS.The Australian Optimal Care Pathway recommends that all patients newly diagnosed with lung cancer be discussed at MDT, 8 with benefits including improved equity of outcomes, continuity of care, communication with patients and families, adherence to guideline-based care and more efficient use of resources. 21,22However, survey responses suggest that not all patients newly diagnosed with lung cancer are routinely discussed at MDT, consistent with data from Victoria and Queensland. 23,24The reported barriers to MDT discussion will require resolution at an institutional and local health authority level: time constraints, workforce limitations and inadequate infrastructure.
The quality of MDT decision making may be impaired at institutions where core team members are absent. 25,26For Australian institutions, comparison to 2021 data suggests there have been some improvements in workforce, most notably an increase in the presence of Thoracic Surgery (now 92%, was 77%), and the proportion of MDTs fulfilling core membership (now 41%, compared to 31%, on reinterrogation of 2021 data).In Aotearoa New Zealand, all nine institutions have Thoracic Surgery attending their MDTs, however seven institutions do not have Nuclear Medicine and three do not have Pathology.Appendix C in the Supporting Information summarizes these and other survey findings with comparison by country, estimated annual case volume and institution type.
Survey responses suggest disparities in the accessibility of lung cancer diagnostic investigations and treatment.For example, whilst 65% (41/63) of metropolitan institutions reported all common diagnostic investigations on site (lung function testing, CT biopsy, US biopsy, PET/CT and EBUS bronchoscopy), this was only true for 36% (9/25) of nonmetropolitan institutions.Even when on site, resources may not be sufficient to meet demand, with one in four institutions referring externally for CT biopsy, and one in three referring externally for PET/CT, although this may also reflect patient preference.Regarding treatment, 69% (44/64) of metropolitan institutions have on site access to all relevant specialities, compared to 28% (7/25) of nonmetropolitan institutions.It is not possible to definitively determine if these disparities are driven by geographic location, case volume or public versus private health systems.Disparities affecting non-metropolitan institutions may disproportionately harm Aboriginal and Torres Strait Islander and M aori populations, who are more likely to reside in rural and remote areas. 27,28ung cancer nurse specialists play a critical role in ensuring a timely and coordinated approach to lung cancer diagnosis and treatment. 29,30Despite funding allocated in the 2021-2022 Australian Federal budget, 31 the number of LCNS remains unacceptably low: of Australian institutions, just over half report a LCNS at MDT (now 57%, was 52%) and 44% have a LCNS on site (was 45%).Further, one quarter of these nurses have responsibilities for patients with other cancers, and LCNS numbers appear lower in low case volume and private institutions.In contrast, all nine institutions in Aotearoa New Zealand have a LCNS in attendance at MDT and on site.These mixed findings may reflect changes in sample size, survey methodology and analytical approach and/or uncertainty regarding the LCNS role(s).
Smoking cessation is essential when managing suspected lung cancer 32,33 and yet the majority of institutions (60/88, 68%) have no formal services and are reliant on ad hoc support, with just two institutions (both Australian) reporting they had a smoking cessation lead as part of the MDT.Improvements in smoking cessation services will likely be seen in the future with the implementation of the Australian National Tobacco Strategy 2023-2030 34 and the passing of world-first legislation in Aotearoa New Zealand to reduce smoking prevalence, 35 however, there is an urgent unmet need for this service provision.
Australian clinicians responding to this survey perceive that their institutions will not have capacity to cope with the increased demand that will accompany lung cancer screening.Areas perceived to have the least capacity include CT biopsy, EBUS bronchoscopy and lung nodule clinics.For screening to deliver maximum benefits, all patients with abnormal screening must have timely access to high quality specialist care.Institutions and local health authorities can use these data to inform urgent improvements to current and future lung cancer infrastructure and workforce.
Regular local quality assurance audit, combined with higher-level evaluation as part of a national or regional clinical quality data platform 36 and further longitudinal infrastructure surveys, can be utilized to track these improvements and identify unmet needs.
As with any survey-based approach, there are potential limitations to consider.The intent of some questions, particularly those regarding the proportion of patients discussed at MDT and the LCNS role may have had some ambiguity.Although we requested the lead lung cancer clinician complete the survey for their institution, this was not mandatory; therefore, it is possible that not all respondents had detailed knowledge of all aspects of infrastructure and workforce.Direct comparisons to 2021 data require care, due to slight changes in questions and analytical approach, and the inclusion of institutions in Aotearoa New Zealand.Whilst respondents could remain anonymous, responder bias may have still impacted responses, given that institution name was required.The survey had broad reach yet will not have captured a response from every institution providing lung cancer care, particularly low volume centres; these institutions may have important-and unknown-differences in workforce and infrastructure.Nevertheless, our findings provide worthwhile insights into the current landscape of lung cancer care in the region; future iterations of the survey should focus on maximizing survey reach.
In conclusion, variations in lung cancer infrastructure and workforce in Australia and Aotearoa New Zealand are evident, including variable utilization of MDT, disparities in the accessibility of diagnostic investigations and treatment, and a lack of lung cancer nurse specialists.There have been some improvements since 2021 with better access to Thoracic Surgery and a modest improvement in core MDT workforce.Consistency of purpose, advocacy, collaboration and care coordination through local and national policy change will be required to deliver timely and equitable lung cancer care to all patients.
Table 1 summarizes institution characteristics.