Lung cancer campaign: Information for GPs

There are around 34,900 [1] new cases of lung cancer in England each year and more than 28,100 [1] people die from it. Although the survival rates are rising slowly, the improvement has been slower than for other common cancers.

Survival rates in Britain are worse than those in some comparative European countries and it was estimated that around *1,300 deaths from lung cancer could be avoided in England each year if survival rates matched the best in Europe [2]. The poor survival seen with lung cancer in Britain compared with Europe is thought to be predominantly due to larger numbers of patients being diagnosed with late stage disease, when the cancer is already locally advanced or has spread, therefore  excluding them from potentially curative surgery. Early diagnosis is one of the key ways to improve survival rates, alongside improved access to diagnostics and optimal treatment.

When diagnosed at its earliest stage, around 73% of patients with non small cell lung cancer and around 56% of patients with small cell lung cancer will survive their disease for at least one year after diagnosis [3]. But around 70% of lung cancer patients in England are diagnosed at a late stage [4].

References

1. Source: Office for National Statistics   http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--42--2011/sty-lung-cancer.html

2.  Source: British Journal of Cancer (2009) 101, S115–S124.  doi:10.1038/sj.bjc.6605401 www.bjcancer.com.
Published online 3 December 2009  http://www.nature.com/bjc/journal/v101/n2s/full/6605401a.html

3. Source: Walters, S et al. Lung cancer survival and stage at diagnosis in  Australia, Canada, Denmark, Norway, Sweden and the United Kingdom: a  population-based study, 2004-2007. Thorax 2013.

4. Source: National Lung Cancer Audit Report 2012.

The Be Clear on Cancer campaign is part of Improving Outcomes – a strategy for cancer. This outlines the ambition to prevent 5,000 deaths per year by 2014/2015, which would bring survival in England up to the average for Europe. In line with the NHS Outcomes Framework, the CCG Outcomes Indicator Set 2014/15 highlights cancer survival as a key area for improvement under indicator 1: preventing people from dying prematurely.

A significant amount of work has been undertaken across all areas of activity on lung cancer in recent years, including building the information base and gathering data on lung cancer; refreshing the NICE guidance for suspected lung cancers; and learning from a range of activities to raise awareness of the signs and symptoms of lung cancer at a national, regional and local level.

With the highest number of avoidable deaths each year, bowel cancer was selected as the first Be Clear on Cancer campaign to be tested regionally and rolled out nationally. The Department of Health then looked at lung cancer to see if this success could be replicated for other cancer types which account for a significant number of avoidable deaths each year and where there is most scope for improvement in outcomes.

Whilst survival rates for the more common cancers have improved significantly in recent years, England’s survival rates still lag behind the European average. Only 24% of lung cancer patients are diagnosed via the two week wait referral system - 39% of them present as emergencies (this compares to 24% across all cancers [1]). This may result in poorer outcomes for patients, as they are more likely to be diagnosed at a late stage by the time they present. Increased diagnosis by primary care can reduce emergency admissions and improve the prognosis for many lung cancer patients - the aim is to get people with appropriate symptoms to present earlier and, where appropriate, referred on promptly for investigation.

Read more about the Be Clear on Cancer Campaign

References

1. Source: Routes to Diagnosis http://www.ncin.org.uk/publications/routes_to_diagnosis

We need to sustain this campaign to continue to drive behaviour change. Sean Duffy, National Clinical Director for Cancer at NHS England, explains: “I am delighted that results suggest that hundreds of patients received potentially life-saving surgery following the first national campaign for lung cancer. Be Clear on Cancer, alongside continued work to improve access to diagnostics and treatments, is helping to move things in the right direction for lung cancer. However, we still have a long way to go to match the best in Europe and must keep focused on how we can improve the outcomes for all cancer patients.”

The first national lung cancer campaign ran in 2012, and when comparing the campaign period with the same time the previous year, the results show:

• A statistically significant increase of 9.1% in the number of lung cancer cases diagnosed in patients first seen for lung cancer during the months surrounding the Be Clear on Cancer lung cancer campaign. This equates to around 700 people.
• There was a statistically significant increase of 3.6 percentage points for the proportion of Non Small Cell Lung Cancers (including carcinoid tumours) diagnosed at an early stage (stage I and II). This is approximately 400 more people. There was also a significant decrease in the proportion of people diagnosed at a late stage.
• A statistically significant increase of 2.3 percentage points for the proportion of patients receiving surgical resection as a first definitive treatment - around 300 additional patients receiving potentially life-saving treatments [1].

References

1. Source: National Lung Cancer Audit. Data provided by HSCIC

Adverts ran on TV, radio and in the press from 10 March until the end of April 2014 highlighting the symptom of a persistent three-week cough in line with NICE guidelines. The campaign’s key message to the public was: “ 'Been coughing for three weeks? Tell your doctor'.”

As this was a ‘reminder’ campaign, the advertising was less intense than previous lung cancer campaigns. As an indication, for the first national lung cancer campaign, which ran from May to July in 2012, 92% of the target audience were likely to have seen the TV advert 12 times. This time, 90% were likely to have seen the advert 10.8 times.

The campaign is aimed at men and women from lower socioeconomic groups over the age of 50 and their key influencers, such as friends and family.

Although the adverts don’t mention age, Public Health England has targeted the channels for promoting the campaign to primarily reach the over 50s.

Most recent statistics from the first national campaign show that from May to July 2012, the age group with the largest percentage increase in number of patients presenting to their GP with a cough was for those aged 50 to 59 (up nearly 83% on the same time in 2011) [1].

References

1. Be Clear on Cancer national lung cancer  awareness campaign evaluation – impact on patients attending GP appointments. Produced by Mayden, February 2014 for NHS IQ

More than 90% of patients with lung cancer are symptomatic at diagnosis, with cough being the most common presenting symptom [1]. Weight loss is an indicator of systemic disease and is the second most prevalent symptom of lung cancer. Dyspnoea develops early in up to 60% of patients and is usually associated with increasing cough and sputum.

There are other symptoms of lung cancer too however, when developing the campaign for the general public, it was important to lead with one clear symptom that they would be able to easily understand and identify. The symptom of a persistent cough for three or more weeks also reflects the NICE guidelines.

A persistent cough could be related to other things, e.g. a viral cough, asthma or COPD, so your clinical judgement is key to assessing and referring patients appropriately.

The Be Clear on Cancer information leaflet also lists some other symptoms of lung cancer, as well as the risk factors associated with the disease, and the case studies included emphasise that smokers shouldn't put a persistent cough or  change in cough down to 'just a smoker's cough'. The adverts and leaflet also highlight that symptoms might not be cancer, but may be a sign of something else that needs treatment. The leaflet features a series of questions that the doctor might ask and highlights that the GP ‘may suggest a chest X-ray’.

References

1. Source: Beckles M A et al;  Initial Evaluation of the Patient With Lung Cancer; Chest.  2003;123(1_suppl):97S-104S. doi:10.1378/chest.123.1_suppl.97S

During the first national lung cancer campaign, more people with a persistent cough went to their GP than during the same time in the previous year. When looking at the period May - July 2012 compared with May - July 2011, the number of patients aged 50+ presenting with a persistent cough went up 64% - the equivalent to around 3.1 additional visits per practice per week [1].

References

1. Source: Be Clear on Cancer national lung  cancer awareness campaign evaluation – impact on patients attending GP  appointments. Produced by Mayden, February 2014 for NHS IQ

Lung cancer is more common in older age, with 97% of people diagnosed in England aged over 50 [1]. Tobacco is by far the biggest cause of lung  cancer – smoking causes more than eight in 10 lung cancers in the UK. People who  smoke, used to smoke, or are exposed to second-hand smoke have an increased  chance of developing the disease [2].

But it’s important to remember that an estimated 17% of lung cancers in the UK are caused by factors other than being a current or past smoker.

References

1.  Source: Office for National Statistics http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--42--2011/sty-lung-cancer.html

2. Parkin DM. Tobacco-attributable cancer burden in the UK in 2010. Br J Cancer  2011;105(S2):S6-S13.

We know that smoking causes almost 90% of lung cancer deaths and that living with someone who smokes increases risk of lung cancer in non-smokers by about a quarter.

When developing the Be Clear on Cancer message, it was important not to be seen as negative or nagging – we need to be supportive and encourage earlier presentation. We know from qualitative research and anecdotal information on existing lung cancer awareness projects that including a stop smoking message, or highlighting that this affects mainly those who smoke, can act as a barrier to early presentation. Smokers may feel they will be chastised and therefore delay going to see their GP and non smokers don’t see it as relevant to them.

More about smoking statistics

Be Clear on Cancer case studies are used to highlight that smokers shouldn’t put a persistent cough or change in cough down to ‘just a smoker’s cough’.  Information leaflets highlight the risk factors, including a stop smoking message.

Chest X-ray is a key diagnostic test for the detection of lung cancer. One chest X-ray is the equivalent of 3 days of natural background radiation.

Early diagnosis of cancer is a very high priority for the Government. That is why Improving Outcomes: A Strategy for Cancer, which was published in January 2011, emphasises improved GP access to diagnostic tests.

The Strategy is backed by over £750 million, including over £450 million to support early diagnosis of cancer. This includes  better GP access to key diagnostic tests including MRI, non-obstetric ultrasound scan, chest x-ray, and flexible sigmodoiscopy to support the diagnosis of a number of cancers. The Department of Health also produced guidance on direct referral by GPs for these diagnostic tests in April 2012: ‘Direct access to diagnostic tests for cancer: best practice  referral pathways for general practitioners’.

Patients urgently referred for suspected cancer by their GP still have a right to be seen within two weeks under the NHS Constitution. In Q4 2012-13, 95.7% of patients in England urgently referred for suspected cancer by their GP were seen by a specialist within the two-week specified period. For suspected lung cancer, 97.2% were seen within two weeks in England were seen within the two-week specified period [1].

References

1. Provider based Cancer Waiting Times http://www.england.nhs.uk/statistics/2013/05/31/provider-based-cancer-waiting-times-q4-2012-13-published-2/

Dr Trevor Rogers, Consultant Physician, Doncaster Royal Infirmary, advises that 'the chest X-ray remains the main tool for diagnosing lung cancer and is very sensitive' (false negative rate is a few percent) [1].

An urgent two week wait referral should be made irrespective of chest X-ray result where there is a high clinical suspicion of lung cancer, i.e. persistent  haemoptysis in smokers / ex-smokers over 40 years old. It is reasonable to offer patients an urgent two week wait referral while awaiting the result. It is worth pointing out that all three of these factors should be present; if they aren’t and the chest X-ray does not indicate cancer, lung cancer is unlikely and a less urgent referral should be considered.

If an X-ray result is normal you should still refer urgently any patient older than 50 with persistent symptoms.

References

1. Source: Clare de Normanville, Angela Tod et al. Early detection of lung cancer: Information for General Practitioners

During the first national lung cancer campaign when TV adverts ran from May to July 2012, more patients were referred for a chest x-ray by a GP during the first month of the campaign (May), compared to the month before (April) – up  20%.

There was an 8% rise in GP- referred CT scans per working day in May 2012, compared with April 2012 [1].

References

1. NHS England. Diagnostic Imaging Dataset http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostic-imaging-dataset/

The Be Clear on Cancer materials promote the potential benefits of early presentation and reassure people that the symptom is unlikely to be cancer, but that it’s best to get it checked. The tone is balanced, practical and reassuring.

Research has shown that the campaigns are seen as targeted, sensible, easy to understand and action-orientated by the public. Overall, Be Clear on Cancer is viewed as a valuable campaign which ‘tells us what to do’ and normalises seeing a GP with worrying symptoms.

Results from previous lung cancer activities indicate that Be Clear on Cancer is changing levels of public awareness and behaviour. There are also early indications that clinical outcomes are improving too:

There are some statistically significant initial findings following the first national lung campaign in 2012:

• There was an increase in unprompted public awareness of a persistent/prolonged cough (from 12% pre-campaign to 15%  post-campaign). When given a list of possible symptoms and asked how much of a  warning sign of lung cancer each was, a cough for 3 weeks or more was the symptom that saw the largest increase – up 15 percentage points (18% - 33%) [1]
• There was an increase of 32% in two-week-wait referrals for suspected lung cancer in the campaign months compared with the previous year, with the majority of additional referrals in the over 50s [2]
• More patients were referred for a chest X-ray by a GP during the first month of  the campaign compared to the month before– up 20% [3]
• Around 700 more people were diagnosed with lung cancer when compared with the same period in the previous year. Approximately 400 more people had their cancer diagnosed at an early stage and around 300 additional patients had surgery as a first treatment of diagnosed lung cancer [4].

However, despite these promising results, there is still a great deal of potential to improve lung cancer survival in England, and for this reason, Public Health England is running the lung cancer campaign again.

References

1. TNS-BMRB report for the national lung cancer campaign 2012. Produced for Public Health England

2. National lung cancer awareness campaign: Analysis of urgent GP referrals. An analysis looking at the impact of the national lung cancer awareness campaign on the number of urgent GP referrals for suspected lung cancer. Produced by Trent Cancer Registry, July 2012

3. NHS England. Diagnostic Imaging Dataset http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostic-imaging-dataset/

4. National Lung Cancer Audit. Data provided by HSCIC

The national picture of lung cancer mortality shows us the variation across the UK.

You can find out more about the statistics in your local area using the Public Health England's GP Practice Profiles or Cancer e-Atlas.

Learn more about lung cancer statistics

Learn more about GP practice and local data

GPs have a pivotal role as the gatekeepers to investigation and referral, but the task is a difficult one as the number of new  diagnoses encountered each year is typically very small. To put it into perspective, approximately 5% of all primary care consultations are for cough and 1.5% of the population consult with their GP for fatigue each year. However, a GP would typically expect to encounter a new lung cancer approximately once every 8 months [1]. Recognising new symptoms can be particularly difficult in the presence of co-existing respiratory disease (such as chronic obstructive pulmonary disease).

We hope you will see an increase in the number of people presenting with a persistent three week cough during the campaign period. Continue to use your clinical judgement and refer for a chest x-ray as appropriate. The average cost for a plain film X-ray is £30 and radiation exposure for a single chest X-ray is equivalent to three days of normal background radiation.

We are expecting to see a significant increase in referrals and NHS Improving Quality is working with Strategic Clinical Networks to help them be prepared for any increase.

As a GP:
Talk about the campaign. People that may have previously ignored or found excuses for their signs and symptoms may be prompted by this campaign to present at your surgery. However they may still be fearful and we know that they sometimes don’t find it easy to communicate their symptoms effectively and may worry about wasting the GP’s time. Even if the patient doesn’t have cancer, it’s a great opportunity to discuss prevention or lifestyle changes, such as smoking cessation.

Take a look at the refreshed guidelines and research. The NICE guidance for suspected lung cancers was updated in  2011. There is also a wealth of other information to support you, including:

• Cancer decision support tools, including lung cancer risk assessment tools (RATs) and QCancer;

• BMJ learning online education tools – ‘Suspected lung cancer: when you should refer’ and ‘Tackling late diagnosis of cancer’

• ‘Direct access to diagnostic tests for cancer: best practice referral pathways for general practitioners’.

Work with your GP lead. Your CCG may have a GP cancer lead, who can give you further information relating to your area. If you would like the details of the GP lead in your area, contact partnerships@phe.gov.uk with ‘GP lead query’ in the subject line. Many GPs have found it useful to work more closely with secondary care clinicians to make  improvements in the patient pathway too.

Get extra CPD points and test your knowledge about the early diagnosis of lung cancer. A BMJ Learning module has also been developed in association with NICE: 'Suspected lung cancer: when you should refer'. It aims to help you to be familiar with the typical presenting features of lung cancer; identify unusual presentations of lung cancer; and know when to refer patients with suspected lung cancer. A further module on ‘Tackling late diagnosis of cancer - in association with the  Department of Health’ is also accredited and available on BMJ Learning. A quiz from Cancer Research UK and Doctors.net.uk features 10 questions that let you test your knowledge on diagnosing lung and bowel cancer. In addition to the quiz, there are other tools, information and guidance to support you. Doctors.net.uk is open to all GPs - if you’re not a member already it’s quick and easy to sign up.

Encourage your colleagues to support the campaign. Practice nurses, receptionists and practice managers, all have an important part to play in helping this campaign be a success. We know that one of the perceived barriers to early presentation is the challenge of booking an appointment. We have provided some questions and answers specifically for nurses and practice teams on this site and are making additional materials available to your practice teams to support them and prepare them for the campaign, including planning for increases in the number of people visiting their GP.

More information for practice teams

​References

1. William Hamilton and Deborah Sharp:Diagnosis of lung cancer in primary care: a structured review; Family  Practice volume 21; issue 6; pp 605-611

2. W Hamilton, T Peters, A Round and D Sharp; What are the clinical  features of lung cancer before the diagnosis is made? A population based case-control study; Thorax. Dec 2005; 60(12): 1059–1065. Published online  October 14, 2005.

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For more information, or if you have any queries, please contact partnerships@phe.gov.uk.

Be Clear on Cancer is a cancer awareness campaign led by Public Health England, working in partnership with the Department of  Health and NHS England. This page contains links to documents that we hope you find useful. Please note however that the views or opinions expressed within those links are not necessarily those of Cancer Research UK.