Supporting the earlier diagnosis of lung cancer

Summary

Lung cancer is the 3rd most common cancer in the UK and the most common cause of cancer death [1]. Early diagnosis is key to improving outcomes, but this can be challenging for lung cancer. Read below for information and tips for health professionals to support the timely recognition of lung cancer in primary care. 

Download our Lung Cancer Insight guides for GPs and health professionals:

Lung Cancer Insight guide for GPs in England and Wales 
Lung Cancer Insight guide for GPs in Scotland
Lung Cancer Insight guide for GPs in Northern Ireland

Earlier diagnosis of lung cancer can improve patient outcomes

Most people are diagnosed with lung cancer at stage 4 where outcomes are poor. Only around 5 in 100 people diagnosed with lung cancer at stage 4 in England will survive their disease for 5 years or more [1].

 

 

 

A third of people diagnosed with lung cancer in England with a known route to diagnosis are diagnosed via emergency presentation, where more than two-thirds (68%) are diagnosed with stage 4 lung cancer [2]. However, in primary care, the proportion of early-stage lung cancer diagnoses is higher [3]. Timely recognition and referral of lung cancer by primary care professionals is therefore vital to improve outcomes for people affected by cancer.

Find the latest lung cancer statistics here. 

Be aware of patient groups at risk of lung cancer

Find out more about lung cancer risks on our webpage 
 

Smoking

Over 70% of lung cancer cases in the UK are caused by smoking [4]. Healthcare professionals have an essential role to play by supporting people to access smoking cessation services. Ask your patients about other forms of smoking tobacco (eg bidis, shisha, pipes etc.) often used by ethnic minority groups which can also increase lung cancer risk [5]. Record your patients smoking history accurately as the risk of lung cancer does remain after smoking cessation.  

Be aware of the stigma associated with smoking and lung cancer, which may affect help-seeking behaviours in these groups [6,7]. It is important to remember that deprivation is strongly linked to lung cancer diagnosis [1] with higher rates of smoking in more deprived groups [8]. 

Screening

The UK National Screening Committee recommend lung screening for people aged 55 – 74 with a history of smoking [9]. Find out about targeted lung cancer screening on our webpage for health professionals.

Family history 

Asking about family history of lung cancer could support a future lung cancer diagnosis. The risk of lung cancer increases significantly if a sibling or parent has been diagnosed with lung cancer, independent of whether an individual has ever smoked [18]. 

Lung cancer in those who have never smoked

Lung cancer in people who have never smoked is typically defined as someone who has smoked <100 cigarettes in their lifetime [10] Estimates vary, but every year in England, over 1,600 people who have never smoked are diagnosed with lung cancer [11]. Research into lung cancer in never smokers highlights several potential challenges to earlier diagnosis [12-15]: 

  • People who have never smoked may not perceive themselves as at risk from lung cancer. 
  • There may be less urgency to seek help as symptoms are often attributed to an illness. 
  • Lower levels of perceived risk of lung cancer may prevent people from pushing for investigations or referral. 
  • Presentation of symptoms can vary; often there may be fewer, less-severe symptoms in never smokers. 
  • False reassurance from an initial presentation can prevent future re-presentation if symptoms are not resolved. 

As lung cancer referral guidelines focus on smoking status, clinicians end up relying on gut feeling, patient health or advocacy to inform their decision making [16]. Remain vigilant to signs and symptoms of lung cancer even in people who have never smoked. Consider other risk factors such as second-hand smoke, occupational exposures or air pollution [17]. Where clinically appropriate, consider investigations for people regardless of their smoking history. 

Recognition and referral of suspected lung cancer

Referral guidelines

The guidance for suspected lung cancer referral can be found below:

NICE NG12 guidelines for lung cancer in England and Wales
Scottish Referral Guidelines for lung cancer
NICaN Northern Ireland
 
Key considerations from the referral guidance
  • Symptoms of lung cancer include cough, shortness of breath and chest/shoulder pain.
  • Unexplained haemoptysis warrants urgent referral.
  • Chest x-ray should be offered as a first line investigation for people with lung cancer symptoms.
  • A normal chest x-ray result does not exclude lung cancer. Consider a repeat chest x-ray, direct access CT or referral for those with persistent symptoms.
  • Be aware of non-specific symptoms, such as fatigue, weight loss and appetite loss.
  • Consider further investigation for those with recurrent or persistent chest infections.

 

Most lung cancer symptoms are non-specific and can be misattributed to other conditions. For example, people with asthma and COPD may not seek help for a persistent cough even if it has changed or worsened.[6,7].  

For some lung cancer symptoms, health professionals are likely to explore other avenues before considering lung cancer, which can delay diagnosis. Research suggests that lung cancer patients who experienced shortness of breath were more likely to be prescribed antibiotics or inhaled medications [19] and that a significant proportion of patients presenting with dyspnoea (86%) or haemoptysis (50%) did not receive prompt chest imaging despite being eligible in clinical guidance [20]. 

Non-specific symptom pathways are being introduced across the UK and can be a useful referral route for patients who do not fit clearly into a single referral pathway. Check what your local pathway looks like, including referral criteria. 

Ensure you are familiar with the guidelines, particularly around vague or non-specific symptoms to recognise the early signs of lung cancer. Clinical decision support (CDS) tools, used alongside guidelines and clinical judgment, may support decision-making when patients present with non-specific symptoms. 

Diagnostic tools 

Chest x-ray 

Chest x-rays are relatively cheap, safe and accessible, but over 20% of cancers may be missed, highlighting the importance of safety netting people with a negative chest x-ray [21]. If clinical suspicion persists following a negative chest x-ray, you can consider further investigations or refer people on a non-specific symptom pathway. 

Computerised tomography (CT) 

CT scans are more sensitive than chest x-rays in detecting lung cancer, If available, CT scans should be considered where patients have a normal chest x-ray, but clinical symptoms and risk factors continue to cause concern. 

Blood tests

Thrombocytosis is a risk marker for certain types of cancer, including lung cancer, in adults [22]. Therefore, a full blood count may be a useful investigation in people presenting with potential lung cancer symptoms.

How to safety net patients with suspected lung cancer

Given the challenges that health professionals face in recognising and managing suspected lung cancer, safety netting patients with signs and symptoms of lung cancer is vital to improve patient outcomes.

Top tips for safety netting patients with signs and symptoms of lung cancer:

  • If clinical concern persists following investigation, repeating tests or booking in follow-ups will ensure that people have continuity of care.
  • Ensure that your safety netting communication is clear and specific so that people feel empowered to return if their concerns persist. Provide a time frame for re-presentation if symptoms don’t improve.
  • Check patient understanding on next steps to ensure that there is no miscommunication.
  • Implement practice-wide safety netting systems that all staff are aware of (including locums and admin staff) to reduce the chance of a patient being lost during follow up.  

Our safety netting webpage offers more information and downloadable resources. 

References

  1. Cancer Research UK. Lung cancer statistics 
  2. Cancer Research UK. Early diagnosis hub
  3. Koo, M.M. et al., 2020. The Lancet Oncology.
  4. Cancer Research UK (2018). Lung cancer risk. 
  5. Cancer Research UK (2021). Shisha, betel leaf, paan and other tobacco. 
  6. McCutchan, G. et al., 2019. BMJ Open.(link is external) 
  7. McCutchan, G. et al., 2020. British Journal of Cancer(link is external). 
  8. Office for National Statistics (ONS), 2023. Deprivation and the impact on smoking prevalence, England and Wales: 2017 to 2021 
  9. Cancer Research UK. Lung Health Checks 
  10. Couraud, S. et al., 2012. European Journal of Cancer.(link is external) 
  11. Calculated by the Cancer Intelligence team at CRUK, Nov 2023. Based on National Lung Cancer Audit data for 2017-19+21. Based on lung cancer patients with a recorded smoking status; some patients without a recorded smoking status may also be never-smokers. 
  12. Os, S. et al., 2021. Psycho-Oncology.(link is external) 
  13. Walabyeki, J. et al., 2017. PLoS One.(link is external) 
  14. Black, G.B. et al., 2022. Psycho-Oncology.(link is external) 
  15. Grover, H. et al., 2022. Thorax.(link is external) 
  16. Black, G.B. et al., 2024. Medical Decision Making.  
  17. Bhopal, A. et al., 2019. Journal of the Royal Society of Medicine 
  18. Coté, M. et al., 2012. Eur J Cancer(link is external) 
  19. Wickramasinghe, B. et al., 2023. Cancer Epidemiology.(link is external) 
  20. Koo, M.M. et al., 2023. Thorax.(link is external) 
  21. Bradley, S.H. et al., 2019. British Journal of General Practice.(link is external) 
  22. Bailey, S.E. et al., 2017. British Journal of General Practice.(link is external) 

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