Dr Michael Peake outlines the difficulties with early recognition of disease and highlights recommendations in the NICE guidelines for GPs on identification and referral

Lung cancer is one of the commonest forms of cancer in the developed world. Despite a modest fall in the incidence in males in recent years, it still accounts for 1 in 7 of all new cancer cases in the UK, which amounts to over 37,000 cases per year.1 In contrast to men, the incidence of lung cancer in women is steadily increasing and the male to female ratio is now 3:2.2 The median age at diagnosis is 71 years for men and 72 years for women with approximately 85% of cases being found in individuals over the age of 60 years.1 Lung cancer is uncommon below the age of 40 years.1

Although the majority of cases of lung cancer occur in smokers or ex-smokers, up to 15% occur in individuals who have never smoked—in absolute terms, this is over 4000 such incidences each year in the UK.

There is wide geographical variation in incidence across the UK; some of the highest rates are seen in Scotland and Northern England, where there is a strong relationship to socioeconomic deprivation.1

For the majority of patients, the long-term prognosis is poor and there were 33,465 deaths from lung cancer in the UK in 2005—around one every 15 minutes. This exceeds by far deaths from breast cancer (12,509) and from colorectal cancer (16,092). Lung cancer is now a more common cause of death than breast cancer in women in most parts of the UK.1

Prevention

Changes in the epidemiology of smoking and cessation strategies have significantly lowered the rates of lung cancer in the UK but there is a long way to go. It is vital that patients and healthcare workers understand that stopping smoking at almost any age has benefits for health and that persuading a large number of middle-aged patients to quit would have a major impact on the incidence of lung cancer.

Primary care staff should take every opportunity to persuade patients to stop smoking and need to have a clear strategy on how to deal with patients who seek help to quit. NICE published its guideline on Brief interventions and referral for smoking cessation in primary care and other settings in 20063 and further guidance has recently been issued.4

Late diagnosis

In contrast to many other types of cancer, there has been only a small improvement in overall survival for lung cancer patients over the past 20 years.5 The major reason for the poor prognosis is the fact that almost 80% of patients have locally advanced or metastatic disease by the time they are diagnosed in secondary care.2 In addition, the survival and treatment rates for UK patients are significantly below those for most other countries in the developed world.5 There is evidence for colorectal and breast cancer patients in the UK, which shows they have later-stage disease at the time of diagnosis and this is likely also to be true for lung cancer. There is emerging evidence that delays in referral from primary care play a part in this.6,7

Early recognition of lung cancer patients

Despite lung cancer being a common disease, an individual GP is only likely, on average, to see one or two new cases each year.8 When viewed in the context of the many hundreds of patients he or she will see with cough, breathlessness, chest pain, and so on, the difficulties of diagnosis faced in primary care are obvious. However, GPs should not be afraid to refer patients—in order to achieve the goal of earlier diagnosis it is inevitable that a significant proportion of patients will turn out not to have lung cancer.

In 2005, NICE published its evidence-based guideline on The diagnosis and treatment of lung cancer,9,10 and later that year its guideline on Referral for suspected cancer.11,12 The guidance can be distilled into four golden rules, which are explained below.

1. High-risk groups—it is important that GPs are alert to whether the patient is in a high-risk group.

Indicators of this are:9–12

  • age over 50 years—however, although less common, lung cancer does occur in patients well under 50 years1
  • smoker or ex-smoker—around half of newly-diagnosed cases of lung cancer occur in people who had previously given up smoking,1 but based on an estimate of 37,000 new cases per year in the UK, 1 in 7 cases of lung cancer occur in those who have never smoked
  • presence of chronic obstructive pulmonary disease (COPD)—increases risk two-fold to four-fold, independent of smoking history13
  • previous history of head and neck, bladder or renal cancers
  • other factors such as exposure to asbestos, or living in a high radon exposure area.
  • although there is a slight excess risk of lung cancer in patients with a family history of the disease, this association is weak.14

2. Trigger symptoms and signs—the GP must recognise the trigger symptoms and signs of lung cancer.

Box 1 summarises the NICE guidance on the need for referral for chest X-ray or specialist care, but it is important to remember that many lung cancer patients have other co-morbidities, especially COPD, so it may be a change in existing symptoms, such as cough or dyspnoea, that one needs to be alert to, not just new ones. Fatigue is also a very common feature of lung cancer.12

3. Chest X-ray—clinicians in primary care should set a low threshold for requesting chest X-rays and should not be afraid to repeat the film in a few months if symptoms persist.

More than 90% of patients with symptoms of lung cancer will have an abnormal chest X-ray,15 but it is important to remember that a normal chest X-ray does not exclude a diagnosis of lung cancer. If there is still a high index of clinical suspicion of lung cancer, the patient should be referred.9–12

4. Specialist lung cancer clinics—patients with suspected lung cancer should be referred directly to the local lung cancer multidisciplinary team’s (MDT) rapid access lung cancer clinic.

Specialist lung cancer referral clinics started to appear in the 1990s but have become standard now in almost all parts of the UK. The NICE guideline on The diagnosis and treatment of lung cancer recommends that they should be used where possible.9,10 The 2-week referral rule for patients suspected of having lung cancer is now universal16 and many patients are identified automatically from abnormal chest X-ray reports in hospital trusts. One of the reasons why lung cancer outcomes have been poor in the past is that many patients were never referred to see a specialist. The lung cancer specialist MDTs are now well established and, in general, deliver a high standard of care.

Involving the whole primary care team

The opportunity and responsibility for identifying lung cancer patients early in primary care should not rest entirely in the hands of the GP. Patients see many other professionals, including nurses, receptionists, physiotherapists, and pharmacists. Nurses running asthma/COPD clinics are in a particularly key position to identify these patients and the issues identified in this article are of equal relevance for them. Patients often go to their local chemist for repeated purchases of cough medicines, and pharmacists are in a good position to identify patients and advise them to go and see their GP to ask whether a chest X-ray may be required.

Box 1: Summary of NICE guidance on referral of patients with suspected

lung cancer

1. An urgent referral for chest X-ray should be made in patients presenting with:

  • haemoptysis
  • any of the following unexplained persistent (i.e. lasting more than 3 weeks) symptoms and signs:
      • cough with or without any other features
      • chest and/or shoulder pain
      • dyspnoea
      • weight loss
      • chest signs (e.g. pleural effusion)
      • hoarseness
      • finger clubbing
      • features suggestive of metastases from a lung cancer (for example, brain, bone, skin, or liver)
      • cervical/supraclavicular lymphadenopathy

2. An urgent specialist referral should be made for any of the following:

  • persistent haemoptysis in smokers or ex-smokers aged 40 or over (although a chest X-ray should still be carried out as part of the referral process)
  • if a chest X-ray or chest computed tomography is suggestive of lung cancer (including pleural effusion and slowly resolving consolidation)

3. Immediate referral should be considered for the following:

  • signs of superior vena caval obstruction (swelling of the face and/or neck with fixed elevation of jugular venous pressure)
  • stridor
Adapted from: National Institute for Health and Care Excellence (NICE) (2005) CG 24 The diagnosis and treatment of lung cancer. Available from www.nice.org.uk

Conclusions

Late diagnosis is the major reason why the outcomes for lung cancer patients are so poor. This is probably a greater factor in the UK than in some other developed countries and is likely to be part of the explanation for the comparatively worse survival statistics. Delays in primary care are part of the problem. Patients identified with early stage disease have a significantly better prognosis, with up to 75% 5-year survival rates in stage I non-small cell lung cancer.17 Many patients have fairly advanced disease before they present even to primary care, but vigilance by all healthcare professionals working in the community and appropriate referral to specialist lung cancer MDTs could make a significant impact.

  1. Cancer Research UK 2007. CancerStats: Lung Cancer and Smoking. http://info.cancerresearchuk.org/cancerstats/types/lung/
  2. The Information Centre for Health & Social Care (2007) National Lung Cancer Audit; Second annual report. http://www.ic.nhs.uk
  3. National Institute for Health and Care Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. NICE Public Health Intervention Guidance No. 1. London: NICE, 2006.
  4. National Institute for Health and Care Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. Public health guidance 10. London: NICE, 2008.
  5. Berrino F, De Angelis R, Sant M et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995–99: results of the EUROCARE-4 study. Lancet Oncol 2007; 8 (9): 773–783.
  6. Koyi H, Hillerdal G, Brandén E. Patient’s and doctors’ delays in the diagnosis of chest tumours. Lung Cancer 2002; 35 (1): 53–57.
  7. Bowen E, Rayner C. Patient and GP led delays in the recognition of symptoms suggestive of lung cancer. Lung Cancer 2002; 37 (2): 227–228.
  8. Scottish Executive, NHS Scotland. Scottish referral guidelines for suspected cancer. Edinburgh: Scottish Executive, NHS Scotland, 2002.
  9. National Institute for Clinical Excellence. The diagnosis and treatment of lung cancer. Clinical Guideline 24. London: NICE, 2005.
  10. National Collaborating Centre for Acute Care. Lung cancer: the diagnosis and treatment of lung cancer. London: NICE, 2005.s
  11. National Institute for Health and Care Excellence. Referral for suspected cancer. Clinical Guideline 27. London: NICE, 2005.
  12. National Collaborating Centre for Primary Care. Referral guidelines for suspected cancer in adults and children. London: NICE, 2005.
  13. Purdue M, Gold L, Järvholm B et al. Impaired lung function and lung cancer incidence in a cohort of Swedish construction workers. Thorax 2007; 62 (1): 51–56.
  14. Nitadori J, Inoue M, Iwasaki M et al. Association between lung cancer incidence and family history of lung cancer: data from a large-scale population-based cohort study, the JPHC study. Chest 2006; 130 (4): 968–975.
  15. Stapley S, Sharp D, Hamilton W. Negative chest X-rays in primary care patients with lung cancer. Br J Gen Pract 2006; 56 (529): 570–573.
  16. DH. HSC 1999/25. Cancer waiting times achieving the two week target. London: DH, 1999.
  17. Groome P, Bolejack V, Crowley J et al. The IASLC lung cancer staging project: Validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumours. J Thorac Oncol 2007; 2 (8): 694–705.G