Lung Cancer Awareness Month: how GPs can contribute to earlier diagnosis of lung cancer

29 November 2019

Dr Richard Roope, RCGP and Cancer Research UK Clinical Champion for Cancer

November is lung cancer awareness month. In the UK, there are 47,235 cases of lung cancer annually (2014-16 average), making it the third most numerous cancer (13%). With 35,349 deaths per year (2015-17 average), it is the commonest cause of cancer death (21%). Lung cancer has more cases diagnosed at a late stage than any other cancer.

Lung cancer survival by stage at diagnosis

Outcomes for people with lung cancer in the UK have been improving, however, they remain behind those in similar countries.  How can we improve our outcomes? As for all cancers, earlier diagnosis will make an important contribution.

Lung cancer survival across comparison countries

Although haemoptysis is associated with lung cancer, it is only present in 20% of cases. In comparison, cough is present in 65%. Therefore, diagnosing lung cancer can be challenging because cough is also the commonest symptom seen in primary care.1  When cough is combined with other symptoms in people aged 40 years and over, the positive predictive value for lung cancer increases

Around 20% of lung cancer patients have a normal chest X-ray

This underpins the NG12 NICE Guidance recommendations that people aged 40 or over who have a history of smoking or asbestos exposure and one listed symptom (cough, fatigue, shortness of breath, chest pain, weight loss, appetite loss) or those who have never smoked and have two of these listed symptoms should have a chest X-ray within two weeks. 

In addition, anyone aged 40 or over with any of the following symptoms: persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should have a chest X-ray within two weeks. Presentation with haemoptysis is managed slightly differently – and all over 40s with unexplained haemoptysis should be referred directly on a suspected cancer referral pathway.

It is important to appreciate that around 20% of lung cancer patients have a normal chest X-ray. Be aware of the possibility of false negative results and ensure safety netting is in place. Safety netting can include a review agreed with people at increased risk of cancer, and/or raising the vital importance of patients initiating an appointment sooner if they develop new or worsening symptoms.

 Fewer deaths from lung cancer when more chest X-rays were taken

To facilitate timelier referral of suspected lung cancer GPs need to know that there is a very low threshold for ordering chest X-rays. Research from Leeds presented at the 2019 RCGP conference showed there were more lung cancer diagnoses at an earlier stage and fewer deaths from lung cancer when more chest X-rays were taken. Perceived barriers by healthcare professionals to undertaking more chest X-rays include cost and radiation exposure. However, both are minimal and should not be a barrier to arranging chest X-rays.

As frontline clinicians, we can really make a difference to our patients outcomes if their lung cancer is diagnosed at an earlier stage.

Cancer is one of the RCGP's five-year enduring priorities. Working with Cancer Research UK, we have produced and Primary Care Cancer Toolkit to support GPs and their teams to improve early diagnosis, prevention and screening of cancer by effective use of information from research, national audits and innovate cancer care in general practice. 

References: 

  1. Hamilton W, Peters TJ, Round A, et al  What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study Thorax 2005;60:1059-1065

 

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