24th October 2019

Chest X-rays miss lung cancer in almost a quarter of cases

View all Early detection

A review by research scientists at the universities of Leeds and Exeter has revealed that an early opportunity to diagnose lung cancer is being missed due to the use of chest X-rays rather than more sensitive testing methods such as CT scans.  

The study, published in the British Journal of General Practice, shows that X-rays can miss up to 23% of patients with the disease. The authors say this may be a factor behind UK lung cancer survival rates being lower than in similar European countries.

The research team drew on data from 21 previous studies, involving more than 1,000 patients. They concluded that the lung cancer detection rate for X-rays was between 77% and 80%.

The current recommendation by the National Institute for Health and Care Excellence (NICE) is that GPs in England and Wales should order an X-ray in the first instance if they suspect the patient might have lung cancer.

Paula Chadwick, chief executive of Roy Castle Lung Cancer Foundation, comments:

“We always want the very best for all people affected by lung cancer. We know that early diagnosis is key to ensuring patients can be offered treatment with curative intent or at the very least having the best options to help them live better for longer. So, naturally, we are concerned when we see evidence that some cases of lung cancer may be missed on chest X-rays. 

We urgently call for the NHS to carefully consider the evidence within this study and to look hard at revising procedures to ensure that every patient has an equal chance of being diagnosed as early as possible.

The consequences of missed opportunities

Nicky Peel, of south Wales, is living with late stage lung cancer, having been diagnosed in 2017.

In 2015, finding she had difficulty breathing in the night, she was sent for a chest X-ray, but nothing showed up. Her lung cancer was only spotted after her GP referred her to the A&E department of her local hospital, suspecting she might have a blood clot on the lung.

Nicky is living with late stage lung cancer

Nicky’s experience was one of the reasons she chose to take part in our ‘Like Me’ awareness campaign.

I had no classic symptoms. In 2015, I began to wake in the night with the feeling of not being able to get breath. I had palpitations, so they were checking for any heart conditions. I did have chest x-rays but nothing showed up on the x-rays. This went on for well over a year, back and forth to the doctor. They basically put it down to being a women of a certain age, so perimenopause.

It took Nicky over a year to be diagnosed

Often, younger patients such as Nicky and the others who took part in the ‘Like Me’ campaign, are at odds with the ‘typical lung cancer patient’ (frequently perceived as being an older man with a history of smoking). This can be a barrier to early diagnosis, as can over-reliance on X-rays.

The current state of play

Currently, a chest X-ray is usually the first test used to diagnose lung cancer. Most lung tumours appear on X-rays as a white-grey mass.

However, chest X-rays cannot give a definitive diagnosis because they often cannot distinguish between cancer and other conditions, such as a lung abscess (a collection of pus that forms in the lungs).

If a chest X-ray suggests you may have lung cancer, you should be referred to a specialist in chest conditions.

A specialist can arrange more tests to investigate whether you have lung cancer and, if you do, what type it is and how much it’s spread.

The authors of the study suggest that CT (computed tomography) scanning should be considered as a replacement first-line test. However, a chest X-ray costs the NHS around £25 while a CT scan is significantly more expensive and takes longer, particularly given recent findings that Britain has far fewer scanners or staff to operate them than other European countries.

X-ray has been with us for a long time but surprisingly, there has been very little research into how accurate it is for diagnosing lung cancer. If chest X-ray were a novel technology, it is debatable whether the available evidence would be deemed sufficient to support its implementation as a diagnostic test for lung cancer.

Researchers from Leeds and Exeter Universities

In our own pilot studies into better early diagnosis, the Lung Health Checks we ran in Nottingham, anyone identified as being at significant risk was offered a low-dosage CT scan straightaway, rather than having a chest X-ray first. These scans have detected several cases of lung cancer, at both early and late stages, as well as other serious diseases. As a result, lives have been saved.

Bill Simpson was one of those able to undergo curative surgery as a result of being scanned through taking part in our Lung Health Check pilot project.

Bill’s lung cancer was diagnosed early through our lung health check

“If I hadn’t have gone for that scan, I could have been dead in a year’s time. Instead, my doctor has now said it’s given me ten more years of my life”.

NHS England has now rolled out 14 similar lung health check pilot schemes in ten locations across the country.

Under current plans, these lung health checks are available to people aged 55 to 74 with a smoking history. This is because your risk of lung cancer increases as you get older. The average age of a lung cancer patient is 72.

However, lung cancer can affect anyone, of any age and so if you have any concerns or are experiencing potential lung cancer symptoms, we urge you to go to your doctor.

Our charity has always been committed to improving early detection.  We recognise that, although they are a significant step forward to improve the early detection of lung cancer, lung health checks will not benefit everyone.

As the only UK charity dedicated to helping anyone affected by lung cancer, we remain committed to finding early detection techniques which can benefit everyone.

For more information, go to www.roycastle.org/about-lung-cancer/getting-diagnosed/lung-cancer-tests/