What a Brisbane South PHN pilot is teaching general practice about lung cancer risk, screening and digital tools
Lung cancer is a leading cause of cancer death in Australia and has the lowest survival rate of the top 5 most common cancers in Australia. Early detection through targeted screening offers the best chance of improving the survival rate. Without having complete and correct health information data recorded for patients, general practices are less able to effectively support national health screening efforts like the National Lung Cancer Screening Program.
To support general practice engagement with the Australian Government’s National Lung Cancer Screening Program (NLCSP), Brisbane South PHN ran a localised lung cancer screening pilot with 19 general practices. The focus was on helping the practice teams strengthen the patient data quality and build confidence using clinical software and reporting tools (including national databases and integrated screening tools) to identify patients who may be at higher risk of lung cancer invite them for assessment and refer the patient for further investigation where it was appropriate to do so.
What did the Brisbane South PHN lung cancer screening pilot find?
Over 6 months, the 19 participating practices recorded 68 new lung cancer diagnoses among patients who underwent imaging following GP assessment and referral.
Of those 68 diagnosed cases, the pilot analysis found over two-thirds (74%) were in patients who were considered high-risk but did not meet current NLCSP eligibility criteria. Of significance, almost half of those diagnoses (29 out of 68) were in patients recorded as never-smokers, or where smoking status was not recorded.
These patients were identified by the practice as high-risk, assessed by their GP as needing further investigation and were referred through usual clinical pathways based on individual risk factors and presentation.
Overall, the pilot suggests that when practices clean up key data fields and use available reporting tools, they may be better placed to identify patients who warrant a conversation about risk, eligibility and next steps.
About the PHN-led model: building screening capability through digital uplift of general practice teams
The pilot aimed to strengthen participating practices’ screening capability through tailored education and support to use existing digital tools, including clinical information systems (Best Practice and MedicalDirector), Primary Sense reports and custom-built screening dashboards.
A bespoke lung cancer screening dashboard was developed to provide practices with real-time visibility of eligible and high-risk patients, screening status, and diagnosis. The data for this dashboard was derived from Primary Sense, a clinical audit and data extraction tool used by PHN’s to support population health and general practice initiatives. In addition, clinic staff were provided education on compiling and analysing reports within both Best Practice and MedicalDirector to identify varying cohorts of high-risk patients. Education was also provided on using the Primary Sense ‘Lung Cancer Screening’ report, to identify high-risk patients and proactively recall them for screening.
Practices were provided this supported through webinars, face-to-face visits and regular check-ins. Each participating practice completed three webinars and three in-practice education sessions.
An education dinner also brought practice teams together with guest speakers. Dr Michelle Murphy, Director of Respiratory and Sleep Medicine at Princess Alexandra Hospital, walked through what happens after referral, including hospital workflows and multidisciplinary team involvement. Dr Peter Adkins, GP Clinical Advisor to Brisbane South PHN, discussed common barriers to diagnosis in general practice and the importance of consistent clinical coding.
Overall, practices reported greater confidence in identifying their high-risk patients, clearer understanding of the NLCSP, and improved proficiency in using digital information systems such as Primary Sense and their clinical information system.
‘I’ve learnt so much about the national lung cancer screening program … not to mention I know how to use my system better,’ said one practice manager who participated in the program.
The diagnostic yield was particularly notable: 1 diagnosis for every 4 scans (25%), indicating highly targeted and clinically appropriate referrals were achieved with clinicians identifying higher probability cases.
Pilot reveals broader impact of effective patient data collection and reporting screening beyond lung cancer diagnosis
In addition to lung cancer diagnoses, participating practices reported clinically significant incidental findings on imaging such as emphysema, coronary artery disease, ground-glass opacities and osteopenia. These incidental findings highlight the broader preventive value of targeted imaging and the potential for improved chronic disease management.
In one such example, a GP reflected ‘If it wasn’t for your pilot, that patient never would have known they had emphysema.’
Brisbane South PHN Digital Health and Capability Program Manager Jenaya Price said the approach highlights how everyday practice software and patient data tools can support more systematic case-finding and patient follow-up across a range of screening and prevention activities.
‘The pilot showed how digital clinical tools support improved patient care and health outcomes through risk stratification and earlier identification, when general practice teams are supported to use them well,’ she said.
Key takeaways (for NLCSP readiness and beyond)
Julie Hall-Brown, Senior Digital Health Program Coordinator at Brisbane South PHN and pilot lead, said the work was designed to fit within the realities of busy practices.
‘Understandably, time constraints in general practices with competing priorities and a full schedule can be a limiting factor in creating meaningful change overall to the health system. However, despite these big challenges, the 19 practices who completed the lung cancer screening pilot showed dedication to the aims of the pilot and were pivotal to the success of the outcomes.’ she said.
The pilot has allowed participating practices to:
strengthen early detection across diverse populations
improve proactive identification and diagnosis of all high‑risk individuals
enhance data quality within their practices
improve digital capability within their practice and subsequent workflows.
The pilot’s findings align with the National Lung Cancer Screening Program in identifying and diagnosing high-risk patients. However, results from the PHN-led pilot add a unique perspective by revealing:
a significant proportion of lung cancers in high-risk individuals can occur outside current NLCSP eligibility criteria
high diagnostic yield when general practice is supported with practical tools and education
persistent gaps in smoking history documentation, with 12 diagnoses in patients with no recorded smoking status
strong general practitioner and nursing engagement when support is local, hands‑on, and tailored.
These insights confirm the important role of primary care in early detection of lung cancer. Results from the pilot underline the value of complete risk-factor documentation and confident use of practice systems to support case-finding and follow-up. They may also have implications for national policy, helping to inform ongoing discussions about risk stratification as the NLCSP is implemented and refined over time.
Support for your general practice
Brisbane South PHN’s Digital Health team supports general practices with integrating digital health software solutions and with understanding and interpreting their patient cohort data for proactive screening and preventative healthcare. Contact [email protected] to request tailored support for your general practice.
Funding disclaimer
Brisbane South PHN acknowledges their funding partner for the pilot, AstraZeneca. Industry partnership is governed by Brisbane South PHN’s Industry Partnership Policy, and the partner has no control or input into the content, tone, emphasis, allocation of funds or selection of participants. Brisbane South PHN does not endorse or promote any partner’s product or service. Brisbane South PHN does not share or provide practice level data to the funder.