A framework for improving early diagnosis in symptomatic lung cancer

On 8th March 2023, Roy Castle Lung Cancer Foundation hosted a workshop to identify ways to improve the early diagnosis of lung cancer in symptomatic patients.

Executive Summary

The existing evidence identifies four key objectives for improving early diagnosis of symptomatic lung cancer:

• To develop improved processes that result in earlier diagnosis of symptomatic lung cancer
• To increase awareness of symptoms and motivation for appropriate help-seeking in the general public
• To ensure better access to diagnostic tests and assessment
• To equitably and sustainably increase the number of diagnostic tests (chest X-ray and CT) in people with symptoms that may represent lung cancer

Multiple barriers exist to achieving these objectives both for patients with the common symptoms of lung cancer and the healthcare system. These relate to awareness of symptoms that may indicate lung cancer, lack of prompt and easy access to healthcare assessment and underuse of imaging in those at risk.

Specific issues are:

• Lack of awareness about the common symptoms of lung cancer
• Inconsistent understanding by patients and clinicians that patients in apparently low risk groups such as never smokers (where risk if poorly understood), can get lung cancer and constitute a substantial proportion of cases
• Public and patient fears over being dismissed, judged, or criticised for misuse of the healthcare service
• Patient worry that symptoms are not worthy of investigation
• Lack of easy access by patients and carers to healthcare assessment
• Attribution of common symptoms of lung cancer to common respiratory illnesses,
• such as respiratory tract infection
• Lack of primary care access to timely CXR and reporto Variation in the threshold of primary care clinicians to investigate the common
• symptoms of lung cancer
• False reassurance following a normal CXR
• Lack of robust safety netting after a normal CXR
• Lack of clear guidance on which patients require further investigation following a normal CXR

Potential solutions to these challenges include:

• Public education & symptom awareness campaigns
• Engagement with primary care clinicians to support timely investigation
• Alternative routes to CXR and/or CT for people with the common symptoms of lung cancer including self-referral CXR and a cancer symptom concern hotline
• Training and support for non-medically qualified clinicians in primary care to request CXRs
• Publishing CXR rates by GP practice and administrative units (e.g. Primary Care Networks and Integrated Care Systems)
• Digital clinical decision support tools for general practice
• Proactive safety netting systems following a normal CXR (e.g. telephone call, text message or follow up actions guided by clinical algorithms
• Specific guidance for which patients to refer on the suspected lung cancer pathway or for CT imaging following a normal CXR
• GP direct access to CT for patients with a suspicion of lung cancer following a normal CXR.