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Aim: This research examines the characteristics and survival outcomes of patients receiving a lung cancer diagnosis after attending the emergency department (ED) of Waikato hospitals in New Zealand., Methods: This retrospective study was based on a comprehensive database of Waikato patients recorded on the Midland Lung Cancer Register from 2011 to 2021. We compared the characteristics of patients with and without emergency presentations within 14 days before their lung cancer diagnosis. The survival of patients with and without ED attendance was compared between Māori and non-Māori. This study also analysed the odds ratios (OR) of presenting via ED before diagnosis and surviving 12 months based on logistic regressions., Results: In total, 2,397 patients were included, with 39.6% attending the ED prior to diagnosis. Māori were 1.27 times more likely than non-Māori to be diagnosed after attending the ED. Other characteristics of patients included being male, being diagnosed with small cell lung cancer and having more advanced-stage disease. Patients attending the ED were less likely to survive 12 months than those without ED visits (OR 0.42), and those with two or more ED visits were even less likely to survive 12 months (OR 0.33)., Conclusion: Patients presenting through the ED have more advanced-stage disease, while those presenting through their general practitioners (GPs) have evidence of being diagnosed earlier and having better survival. Barriers to early diagnoses through attendance with a GP, particularly for Māori and for men, need to be explored., Competing Interests: All authors disclose no competing interests., (© PMA.)

Background: Starting in 2010, the epidermal growth factor receptor (EGFR) kinase inhibitors erlotinib and gefitinib were introduced into routine use in Aotearoa New Zealand (NZ) for treating advanced lung cancer, but their impact in this setting is unknown., Objective: The study described in this protocol aims to understand the effectiveness and safety of these new personalized lung cancer treatments and the contributions made by concomitant medicines and other factors to adverse outcomes in the general NZ patient population. A substudy aimed to validate national electronic health databases as the data source and the methods for determining patient eligibility and identifying outcomes and variables., Methods: This study will include all NZ patients with advanced EGFR mutation-positive lung cancer who were first dispensed erlotinib or gefitinib before October 1, 2020, and followed until death or for at least 1 year. Routinely collected health administrative and clinical data will be collated from national electronic cancer registration, hospital discharge, mortality registration, and pharmaceutical dispensing databases by deterministic data linkage using National Health Index numbers. The primary effectiveness and safety outcomes will be time to treatment discontinuation and serious adverse events, respectively. The primary variable will be high-risk concomitant medicines use with erlotinib or gefitinib. For the validation substudy (n=100), data from clinical records were compared to those from national electronic health databases and analyzed by agreement analysis for categorical data and by paired 2-tailed t tests for numerical data., Results: In the validation substudy, national electronic health databases and clinical records agreed in determining patient eligibility and for identifying serious adverse events, high-risk concomitant medicines use, and other categorical data with overall agreement and κ statistic of >90% and >0.8000, respectively; for example, for the determination of patient eligibility, the comparison of proxy and standard eligibility criteria applied to national electronic health databases and clinical records, respectively, showed overall agreement and κ statistic of 96% and 0.8936, respectively. Dates for estimating time to treatment discontinuation and other numerical variables and outcomes showed small differences, mostly with nonsignificant P values and 95% CIs overlapping with zero difference; for example, for the dates of the first dispensing of erlotinib or gefitinib, national electronic health databases and clinical records differed on average by approximately 4 days with a nonsignificant P value of .33 and 95% CIs overlapping with zero difference. As of May 2024, the main study is ongoing., Conclusions: A protocol is presented for a national whole-of-patient-population retrospective cohort study designed to describe the safety and effectiveness of erlotinib and gefitinib during their first decade of routine use in NZ for treating EGFR mutation-positive lung cancer. The validation substudy demonstrated the feasibility and validity of using national electronic health databases and the methods for determining patient eligibility and identifying the study outcomes and variables proposed in the study protocol., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000998549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368928., International Registered Report Identifier (irrid): DERR1-10.2196/51381., (©Phyu Sin Aye, Joanne Barnes, George Laking, Laird Cameron, Malcolm Anderson, Brendan Luey, Stephen Delany, Dean Harris, Blair McLaren, Elliott Brenman, Jayden Wong, Ross Lawrenson, Michael Arendse, Sandar Tin Tin, Mark Elwood, Philip Hope, Mark James McKeage. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 02.07.2024.)

Background: Māori have three times the mortality from lung cancer compared with non-Māori. The Te Manawa Taki region has a population of 900 000, of whom 30% are Māori. We have little understanding of the factors associated with developing and diagnosing lung cancer and ethnic differences in these characteristics., Aims: To explore the differences in the incidence and characteristics of patients with newly diagnosed lung cancer between Māori and non-Māori., Methods: Patients were identified from the regional register. Incidence rates were calculated based on population data from the 2013 and 2018 censuses. The patient and tumour characteristics of Māori and non-Māori were compared. The analysis used Χ 2 tests and logistic models for categorical variables and Student t tests for continuous variables., Results: A total of 4933 patients were included, with 1575 Māori and 3358 non-Māori. The age-standardised incidence of Māori (236 per 100 000) was 3.3 times higher than that of non-Māori. Māori were 1.3 times more likely to have an advanced stage of disease and 1.97 times more likely to have small cell lung cancer. Māori were more likely to have comorbidities, chronic obstructive pulmonary disease, cardiovascular disease and diabetes. They also had higher levels of social deprivation and tended to be younger, female and current smokers., Conclusions: The findings point to the need to address barriers to early diagnosis and the need for system change including the need to introduce a lung cancer screening focussing on Māori. There is also the need for preventive programmes to address comorbidities that impact lung cancer outcomes as well as a continued emphasis on creating a smoke-free New Zealand., (© 2023 Royal Australasian College of Physicians.)

Introduction: Lung cancer has a poor prognosis that varies internationally when assessed by the two major histological subgroups (non-small cell (NSCLC) and small cell (SCLC))., Method: 236 114 NSCLC and 43 167 SCLC cases diagnosed during 2010-2014 in Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK were included in the analyses. One-year and 3-year age-standardised net survival (NS) was estimated by sex, histological type, stage and country., Results: One-year and 3-year NS was consistently higher for Canada and Norway, and lower for the UK, New Zealand and Ireland, irrespective of stage at diagnosis. Three-year NS for NSCLC ranged from 19.7% for the UK to 27.1% for Canada for men and was consistently higher for women (25.3% in the UK; 35.0% in Canada) partly because men were diagnosed at more advanced stages. International differences in survival for NSCLC were largest for regional stage and smallest at the advanced stage. For SCLC, 3-year NS also showed a clear female advantage with the highest being for Canada (13.8% for women; 9.1% for men) and Norway (12.8% for women; 9.7% for men)., Conclusion: Distribution of stage at diagnosis among lung cancer cases differed by sex, histological subtype and country, which may partly explain observed survival differences. Yet, survival differences were also observed within stages, suggesting that quality of treatment, healthcare system factors and prevalence of comorbid conditions may also influence survival. Other possible explanations include differences in data collection practice, as well as differences in histological verification, staging and coding across jurisdictions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Lung cancer is a major cause of death in New Zealand. In recent years, targeted therapies have improved outcomes., Aim: To determine the uptake of anaplastic lymphoma kinase (ALK) testing, and the prevalence, demographic profile and outcomes of ALK-positive non-small-cell lung cancer (NSCLC), in New Zealand, where no national ALK-testing guidelines or subsidised ALK tyrosine kinase inhibitor (TKI) therapies are available., Methods: A population-based observational study reviewed databases to identify patients presenting with non-squamous NSCLC over 6.5 years in northern New Zealand. We report the proportion tested for ALK gene rearrangements and the results. NSCLC samples tested by fluorescence in situ hybridisation were retested by next generation sequencing and ALK immunohistochemistry. A survival analysis compared ALK-positive patients treated or not treated with ALK TKI therapy., Results: From a total of 3130 patients diagnosed with non-squamous NSCLC, 407 (13%) were tested for ALK gene rearrangements, and patient selection was variable and inequitable. Among those tested, 34 (8.4%) had ALK-positive NSCLC. ALK-positive disease was more prevalent in younger versus older patients, non-smokers versus smokers and in Māori, Pacific or Asian ethnic groups than in New Zealand Europeans. Fluorescence in situ hybridisation, ALK immunohistochemistry and next generation sequencing showed broad concordance for detecting ALK-positive disease under local testing conditions. Among patients with ALK-positive metastatic NSCLC, those treated with ALK TKI survived markedly longer than those not treated with ALK TKI (median overall survival 5.12 vs 0.55 years)., Conclusion: Lung cancer outcomes in New Zealand may be improved by providing national guidelines and funding policy for ALK testing and access to subsidised ALK TKI therapy., (© 2019 Royal Australasian College of Physicians.)

Background: Since 2013, clinical practice guidelines recommend EGFR mutation testing of non-squamous NSCLC to select advanced-stage patients for first-line treatment using EGFR-TKIs., Objective: We aimed to determine population-based trends in the real-world uptake and impact in routine practice of these recently updated testing guidelines., Patients and Methods: A population-based observational study was conducted of notifications to the New Zealand Cancer Registry of patients eligible for EGFR testing diagnosed in northern New Zealand between January 2010 and April 2014. The main study variable was EGFR mutation testing. Main outcome measures (overall survival and dispensing of EGFR-TKIs) were extracted from prospectively archived electronic databases until October 2015., Results: The population-based cohort of 1857 patients had an average age of 70 years. Most had adenocarcinoma and metastatic disease at diagnosis. EGFR testing was undertaken in 500 patients (27%) with mutations detected in 109 patients (22%). EGFR testing increased during the period of study from <5% to 67% of patients (P < 0.0001). Full uptake of testing by all eligible patients was limited by a lack of availability of specimens for testing and variable testing referral practices. The proportion of patients treated with EGFR-TKIs decreased during the same time period, both among untested patients (from 12.2% to 2.8% (P < 0.0001)) and in the population as a whole (from 13.7% to 10.6% (P < 0.05)). EGFR testing was associated with prolonged overall survival (Adjusted HR = 0.76 (95% CI, 0.65-0.89) Log-rank P < 0.0001) due at least in part to the much longer overall survival achieved by mutation-positive patients, of whom 79% received EGFR-TKIs. Compared to untested EGFR-TKI-treated patients, mutation-positive EGFR-TKI-treated patients received EGFR-TKIs for longer, and survived longer both from the start of EGFR-TKI treatment and date of their diagnosis., Conclusions: In this real world setting, high uptake of EGFR testing was achieved and associated with major changes in EGFR-TKI prescribing and improved health outcomes. Modifiable factors determined testing uptake. Study registration ACTRN12615000998549.

Introduction: Low dose spiral computed tomography (CT) is a sensitive screening tool for lung cancer that is currently being evaluated in both non-randomised studies and randomised controlled trials., Methods: We conducted a quantitative decision analysis using a Markov model to determine whether, in the Australian setting, offering spiral CT screening for lung cancer to high risk individuals would be cost-effective compared with current practice. This exploratory analysis was undertaken predominantly from the perspective of the government as third-party funder. In the base-case analysis, the costs and health outcomes (life-years saved and quality-adjusted life years) were calculated in a hypothetical cohort of 10,000 male current smokers for two alternatives: (1) screen for lung cancer with annual CT for 5 years starting at age 60 year and treat those diagnosed with cancer or (2) no screening and treat only those who present with symptomatic cancer., Results: For male smokers aged 60-64 years, with an annual incidence of lung cancer of 552 per 100,000, the incremental cost-effectiveness ratio was 57,325 dollars per life-year saved and 105,090 dollars per QALY saved. For females aged 60-64 years with the same annual incidence of lung cancer, the cost-effectiveness ratio was 51,001 dollars per life-year saved and 88,583 dollars per QALY saved. The model was used to examine the relationship between efficacy in terms of the expected reduction in lung cancer mortality at 7 years and cost-effectiveness. In the base-case analysis lung cancer mortality was reduced by 27% and all cause mortality by 2.1%. Changes in the estimated proportion of stage I cancers detected by screening had the greatest impact on the efficacy of the intervention and the cost-effectiveness. The results were also sensitive to assumptions about the test performance characteristics of CT scanning, the proportion of lung cancer cases overdiagnosed by screening, intervention rates for benign disease, the discount rate, the cost of CT, the quality of life in individuals with early stage screen-detected cancer and disutility associated with false positive diagnoses. Given current knowledge and practice, even under favourable assumptions, reductions in lung cancer mortality of less than 20% are unlikely to be cost-effective, using a value of 50,000 dollars per life-year saved as the threshold to define a "cost-effective" intervention., Conclusion: The most feasible scenario under which CT screening for lung cancer could be cost-effective would be if very high-risk individuals are targeted and screening is either highly effective or CT screening costs fall substantially.

Objective: Lung cancer is a substantial public health problem in Western countries. Evidence from previous controlled trials of chest radiography and sputum cytology does not support lung cancer screening, but computed tomography (CT) screening has recently emerged as a more sensitive screening tool. For the present article, the available observational studies of low-dose helical CT screening for lung cancer were reviewed., Methodology: An evidence-based review of all published observational studies of low-dose helical CT screening for lung cancer, identified by an extensive search of Medline, was conducted., Results: Eight observational studies of CT screening for lung cancer were identified. Relative to chest radiography, low-dose helical CT is a sensitive screening tool and can detect a high proportion of small lung cancers at an early and resectable stage. The yield of sputum cytology in addition to CT screening appears to be relatively low. To date, 5-year lung cancer survival of all individuals participating in baseline screening has not been reported for any of the studies., Conclusions: Although these preliminary studies are very promising, it remains to be proven that the early detection and treatment of lung cancer will lead to a reduction in mortality. This issue will be addressed by randomized controlled trials. In the interim, the long-term follow up of these observational studies could provide further insights.