The past six decades have seen remarkable improvements in health outcomes for people with cystic fibrosis, which was once a fatal disease of infants and young children. However, although life expectancy for people with cystic fibrosis has increased substantially, the disease continues to limit survival and quality of life, and results in a large burden of care for people with cystic fibrosis and their families. Furthermore, epidemiological studies in the past two decades have shown that cystic fibrosis occurs and is more frequent than was previously thought in populations of non-European descent, and the disease is now recognised in many regions of the world. The Lancet Respiratory Medicine Commission on the future of cystic fibrosis care was established at a time of great change in the clinical care of people with the disease, with a growing population of adult patients, widespread genetic testing supporting the diagnosis of cystic fibrosis, and the development of therapies targeting defects in the cystic fibrosis transmembrane conductance regulator (CFTR), which are likely to affect the natural trajectory of the disease. The aim of the Commission was to bring to the attention of patients, health-care professionals, researchers, funders, service providers, and policy makers the various challenges associated with the changing landscape of cystic fibrosis care and the opportunities available for progress, providing a blueprint for the future of cystic fibrosis care. The discovery of the CFTR gene in the late 1980s triggered a surge of basic research that enhanced understanding of the pathophysiology and the genotype-phenotype relationships of this clinically variable disease. Until recently, available treatments could only control symptoms and restrict the complications of cystic fibrosis, but advances in CFTR modulator therapies to address the basic defect of cystic fibrosis have been remarkable and the field is evolving rapidly. However, CFTR modulators approved for use to date are highly expensive, which has prompted questions about the affordability of new treatments and served to emphasise the considerable gap in health outcomes for patients with cystic fibrosis between high-income countries, and low-income and middle-income countries (LMICs). Advances in clinical care have been multifaceted and include earlier diagnosis through the implementation of newborn screening programmes, formalised airway clearance therapy, and reduced malnutrition through the use of effective pancreatic enzyme replacement and a high-energy, high-protein diet. Centre-based care has become the norm in high-income countries, allowing patients to benefit from the skills of expert members of multidisciplinary teams. Pharmacological interventions to address respiratory manifestations now include drugs that target airway mucus and airway surface liquid hydration, and antimicrobial therapies such as antibiotic eradication treatment in early-stage infections and protocols for maintenance therapy of chronic infections. Despite the recent breakthrough with CFTR modulators for cystic fibrosis, the development of novel mucolytic, anti-inflammatory, and anti-infective therapies is likely to remain important, especially for patients with more advanced stages of lung disease. As the median age of patients with cystic fibrosis increases, with a rapid increase in the population of adults living with the disease, complications of cystic fibrosis are becoming increasingly common. Steps need to be taken to ensure that enough highly qualified professionals are present in cystic fibrosis centres to meet the needs of ageing patients, and new technologies need to be adopted to support communication between patients and health-care providers. In considering the future of cystic fibrosis care, the Commission focused on five key areas, which are discussed in this report: the changing epidemiology of cystic fibrosis (section 1); future challenges of clinical care and its delivery (section 2); the building of cystic fibrosis care globally (section 3); novel therapeutics (section 4); and patient engagement (section 5). In panel 1, we summarise key messages of the Commission. The challenges faced by all stakeholders in building and developing cystic fibrosis care globally are substantial, but many opportunities exist for improved care and health outcomes for patients in countries with established cystic fibrosis care programmes, and in LMICs where integrated multidisciplinary care is not available and resources are lacking at present. A concerted effort is needed to ensure that all patients with cystic fibrosis have access to high-quality health care in the future.

Alder Hey Children's Hospital Liverpool UK

Charité Universitätsmedizin Berlin Berlin Institute of Health Berlin Germany

CS Mott Children's Hospital Ann Arbor MI USA

Cystic Fibrosis Centre IRCCS Istituto Giannina Gaslini Genoa Italy

Cystic Fibrosis Centre University Hospital Leuven Leuven Belgium

Cystic Fibrosis Clinic British Columbia Children's Hospital Vancouver BC Canada

Cystic Fibrosis Trust London UK

Department of Biology and Medical Genetics 2nd Faculty of Medicine Motol University Hospital Charles University Prague Czech Republic

Department of Medical Microbiology 2nd Faculty of Medicine Motol University Hospital Charles University Prague Czech Republic

Department of Thoracic Medicine The Prince Charles Hospital Brisbane QLD Australia

Division of Paediatric Pulmonology and MRC Unit for Child and Adolescent Health University of Cape Town Cape Town South Africa

Division of Respiratory Medicine Department of Paediatrics Translational Medicine Research Program The Hospital for Sick Children University of Toronto Toronto ON Canada

European Medicines Agency Amsterdam Netherlands

German Center for Lung Research Berlin Germany

Hadassah Medical Centre Jerusalem Israel

Hôpital Cochin Assistance Publique Hôpitaux de Paris Paris France

Hospital de Pediatria Juan P Garrahan Buenos Aires Argentina

Jessa Ziekenhuis Holsbeek Belgium

Johns Hopkins University Baltimore MD USA

Lee Kong Chian School of Medicine Nanyang Technological University Singapore

National Heart and Lung Institute Imperial College London UK

Post Graduate Institute of Medical Education and Research Chandigarh India

QIMR Berghofer Medical Research Institute Brisbane QLD Australia

Queen's University of Belfast Belfast UK

Red Cross War Memorial Children's Hospital Cape Town South Africa

Research Center for Medical Genetics Moscow Russia

Royal Brompton and Harefield NHS Foundation Trust London UK

Royal Prince Alfred Hospital Sydney NSW Australia

School of Medicine St Vincent's University Hospital Dublin Ireland

Seattle Children's Research Institute Seattle WA USA

St Michael's Hospital Toronto ON Canada

Starship Children's Hospital Auckland New Zealand

Université Paris Descartes Institut Cochin Paris France

Universities of Giessen and Marburg Lung Center German Center of Lung Research Justus Liebig University Giessen Giessen Germany

University College Dublin School of Medicine Dublin Ireland

University of Alabama at Birmingham Birmingham AL USA

University of Auckland Auckland New Zealand

University of Liverpool Liverpool UK

University of Michigan Ann Arbor MI USA

University of Toronto Toronto ON Canada

University of Washington Seattle WA USA

University of Wisconsin Madison WI USA

Woolcock Institute of Medical Research Sydney NSW Australia

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