Recognising Lung Cancer in Primary Care

Abstract

Significant advances in the management of both early and advanced stage lung cancer have not yet led to the scale of improved outcomes which have been achieved in other cancers over the last 40 years. Diagnosis of lung cancer at the earliest stage of disease is strongly associated with improved survival. Therefore, although recent advances in oncology may herald breakthroughs in effective treatment, achieving early diagnosis will remain crucial to obtaining optimal outcomes. This is challenging, as most lung cancer symptoms are non-specific or are common respiratory symptoms which usually represent benign disease. Identification of patients at risk of lung cancer who require further investigation is an important responsibility for general practitioners (GPs). Diagnosis has historically relied upon plain chest X-ray (CXR), organised in response to symptoms. The sensitivity of this modality, however, compares unfavourably with that of computed tomography (CT). In some jurisdictions screening high-risk individuals with low dose CT (LDCT) is now recommended. However uptake remains low and the eligibility for screening programmes is restricted. Therefore, even if screening is widely adopted, most patients will continue to be diagnosed after presenting with symptoms. Achieving early diagnosis requires GPs to maintain an appropriate level of suspicion and readiness to investigate in high-risk patients or those with non-resolving symptoms. This article discusses the early detection of lung cancer from a primary care perspective. We outline risk factors and epidemiology, the role of screening and offer guidance on the recognition of symptomatic presentation and the investigation and referral of suspected lung cancer.

Keywords: CT chest; Cancer diagnosis; Chest X-ray; GP; General practitioner; Lung cancer; Lung cancer screening; Oncology; Primary care.

Fig. 1

Positive predictive values (%) for lung cancer for individual risk markers, and for pairs of risk markers in combination (against a background risk of 0.18%). (1) The top row (bold) gives the PPV for an individual feature. The cells along the diagonal relate to the PPV when the same feature has been reported twice. Other cells show the PPV when a patient has two different features. (2) The top figure in each cell is the PPV. It has only been calculated when a minimum of ten cases had the feature or combination of features. The two other figures are the 95% CIs for the PPV. These have not been calculated when any cell in the 2 × 2 table was below 10. (3) The yellow shading is when the PPV is above 1%. The amber shading is when the PPV is above 2%. The red shading is for PPVs above 5.0%. Reprinted by permission from Springer Nature Customer Service Centre GmbH: Springer Nature. Ref. [54]