Luc Te Marvelde

Background: The state of Victoria, Australia, had significant lockdowns to prevent spread of COVID‐19. Aim: To describe its impact on lung cancer incidence, stage at diagnosis, treatment utilisation and timeliness of care in Victoria, Australia. Methods: Population‐wide Victorian Cancer Registry data (1982–2019) were used to predict expected number of lung cancer diagnoses in 2020 and 2021, which were compared with observed diagnoses. Data from the Victorian Lung Cancer Registry were used to study changes in stage and treatment (receipt, guideline concordance and timeliness) comparing the pre‐COVID period (1 January 2019–31 March 2020) with the COVID era (1 Apr 2020–31 Dec 2021). Results: In the COVID era, 298 (95% CI 217–379) fewer Victorians were diagnosed with lung cancer than expected. Comparing the COVID era with the pre‐COVID period, no differences were detected in clinical stage at diagnosis, proportion receiving treatment, guideline concordance and timeliness measures. Conclusions: Compared to the expected number of diagnoses, 5% fewer lung cancer diagnoses were observed in 2020 and 2021 combined. Although the healthcare system in Victoria had many disruptions following COVID restrictions, no major negative impacts on treatment utilisation or timeliness were observed.

Objective: To identify factors contributing to the known increased age‐standardised incidence and mortality rates for lung cancer for Aboriginal and Torres Strait Islander people in Victoria, Australia. Study Type: Retrospective, population‐based, case–control study using Victorian Cancer Registry (VCR) data and linked health administrative datasets. Setting and Participants: Self‐identified Aboriginal and Torres Strait Islander people (respectfully referred to hereon as Aboriginal) and non‐Aboriginal people (aged > 18 years) diagnosed with lung cancer from 1 January 2008 to 31 December 2022. Main Outcome Measures: Clinical, pathological, demographic, socio‐economic factors and biomarkers (programmed cell death‐ligand 1 [PD‐L1], anaplastic lymphoma kinase [ ALK ] and c‐ros oncogene [ ROS1 ]) were assessed. Endpoints were all‐cause and lung cancer‐specific mortality. Survival analyses were conducted using Cox regression. Results: Aboriginal people ( N = 512) were younger ( p < 0.001), more likely to live outside a major city ( p < 0.001) and in areas of greatest disadvantage ( p < 0.001) than non‐Aboriginal people ( N = 43,468). More Aboriginal females had small cell lung cancer compared with non‐Aboriginal females (17% vs. 10%), more Aboriginal males had adenocarcinomas (41% vs. 36%) and squamous cell carcinomas (26% vs. 20%), compared with non‐Aboriginal males. There were no differences in the proportions of PD‐L1‐positive disease nor ALK or ROS1 gene rearrangements. A higher risk of all‐cause mortality (hazard ratio, 1.12; 95% CI, 1.01–1.24; p = 0.03) for Aboriginal people after stratification for age, sex and lung cancer subtype was identified. Conclusion: This study identified that Aboriginal people were younger, more likely to be living outside of major cities and in areas of greatest inequity than non‐Aboriginal people, which is an ongoing manifestation of colonisation. Aboriginal people diagnosed with lung cancer had an increased all‐cause mortality compared with non‐Aboriginal people.

Background: International variation in lung cancer survival may be partly explained by variation in stage-specific treatment use, but relevant comparative evidence is sparse. As part of the International Cancer Benchmarking Partnership, we examined use of chemotherapy and radiotherapy in population-based cancer registry data. Methods: Linked population-based data sources were used to describe use and time to first treatment for either chemotherapy or radiotherapy in patients with lung cancer diagnosed in study periods during 2012–2017 in 16 jurisdictions of Australia, Canada, the UK and Norway. Results: There was large variation in the proportions of patients with lung cancer receiving chemotherapy (ranging from 23% in Northern Ireland to 45% in Norway) and radiotherapy (ranging from 32% in England to 48% in New South Wales and 50% in Newfoundland and Labrador). Across jurisdictions, chemotherapy use decreased steeply with increasing age, regardless of stage at diagnosis. For radiotherapy use, in stage 1–3 cancer three patterns were observed: (a) steep decrease with increasing age (UK jurisdictions, Saskatchewan-Manitoba); (b) a relatively flat pattern (Norway, Alberta, British Columbia, Atlantic Canada, New South Wales) and (c) increasing use with increasing age (Ontario). Time to radiotherapy initiation was longer in the UK jurisdictions than elsewhere; time to chemotherapy was longer in the UK and Canadian jurisdictions except Ontario. Discussion: Use of chemotherapy and radiotherapy in patients with lung cancer varied substantially between jurisdictions during the mid-2010s within age-stage strata. Reasons for these variations are unclear. Differences in non-surgical treatment use are plausibly associated with international variation in lung cancer survival.

Bar charts showing significantly more Aboriginal females live in areas of greatest socioeconomic disadvantage and outside the greater metropolitan area

Analysis of co-variates for Aboriginal females and females from TCGA

Immune-biology data for Aboriginal females and females from TCGA with breast cancer

Background: Despite access to universal health care, Aboriginal and Torres Strait Islander females (hereafter respectfully referred to as Aboriginal) in Australia have higher breast cancer incidence and mortality rates. We investigated the factors contributing to these survival disparities. Methods: Aboriginal females (n = 395; 0.7%) and non-Aboriginal females (n = 57,618; 99.3%) with breast cancer were identified from Victoria, Australia. Clinical, pathologic, demographic, and socioeconomic variables were analyzed. Endpoints were all-cause and breast cancer–specific mortality. HRs were estimated using Cox regression. Stromal tumor–infiltrating lymphocytes were evaluated from a subset of Aboriginal females and compared with females in The Cancer Genome Atlas. Results: Registry data revealed that Aboriginal females were younger (P < 0.001), had more advanced stage disease (P = 0.007), and were more likely to live in nonmetropolitan areas (P < 0.001) and in areas of greater disadvantage (P < 0.001) compared with other females at diagnosis. Age-adjusted multivariate analysis revealed a higher all-cause mortality risk (HR 1.27; 95% confidence interval, 1–1.61) for Aboriginal females, but this risk diminished for breast cancer–specific mortality and after adjustment for stage and grade. Breast cancers from Aboriginal females had significantly reduced stromal tumor–infiltrating lymphocytes in the luminal and triple-negative subtypes compared with The Cancer Genome Atlas. Conclusions: Mortality for females with breast cancer was influenced by socioeconomic, geographic, and clinical factors. Notably, Aboriginal females with tumor features typically associated with favorable outcomes experienced poorer outcomes. The reduced immune infiltrate warrants further investigation. Impact: These findings highlight the need to address socioeconomic inequities and ensure culturally safe cancer care. Further research should explore biological and environmental factors influencing outcomes for Australian Aboriginal females.

Background: Breast cancer survival in Australia varies according to socio‐economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.Methods: Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.Results: Five‐year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio‐economic quintile) of living in inner‐regional areas compared with major cities. About half of the socio‐economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner‐regional survival advantage was not due to differences in prognostic factors.Conclusions: Part of the socio‐economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio‐economic disparities as well as the observed inner‐regional survival advantage.

Purpose: Despite the benefits of palliative care (PC) in pancreatic cancer, little is known about patients who access PC. This observational study examines the characteristics of patients with pancreatic cancer at their first episode of PC. Methods: First-time, specialist PC episodes captured through the Palliative Care Outcomes Collaboration (PCOC), in Victoria, Australia between 2014 and 2020, for pancreatic cancer, were identified. Multivariable logistic regression analyses examined the impact of patient- and service-level characteristics on symptom burden (measured through patient-reported outcome measures and clinician-rated scores) at first PC episode. Results: Of 2890 eligible episodes, 45% began when the patient was deteriorating and 32% ended in death. High fatigue and appetite-related distress were most common. Generally, increasing age, higher performance status and more recent year of diagnosis predicted lower symptom burden. No significant differences were noted between symptom burden of regional/remote versus major city dwellers; however, only 11% of episodes recorded the patient as a regional/remote resident. A greater proportion of first episodes for non-English-speaking patients began when the patient was unstable, deteriorating or terminal, ended in death and were more likely to be associated with high family/carer problems. Community PC setting predicted high symptom burden, with the exception of pain. Conclusion: A large proportion of first-time specialist PC episodes in pancreatic cancer begin at a deteriorating phase and end in death, suggesting late access to PC. Timely referrals to community-based specialist PC, access in regional/remote areas, as well as development of culturally diverse support systems require further investigation.

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