Key learning points

  • Lung cancer diagnosis can be difficult due to non-specific symptoms or symptoms presenting with a background of long-term respiratory symptoms, thus late presentation and poor prognosis is often associated with this disease
  • Guidelines and decision support tools are available to aid GPs in quantifying and assessing the risk of lung cancer in their patients 
  • Trials have demonstrated lung cancer screening within high-risk populations is associated with reduced mortality 
  • Primary care has an important role in identifying and screening for lung cancer in high-risk groups  

Introduction

Lung cancer continues to pose a significant public health burden both in the UK and internationally. The smoking epidemic of the 20th century has led to high incidence rates, which have only recently begun to reduce in parallel with rates of smoking.1,2 Reducing smoking within the patient population via the best available pharmacological methods and treatments should remain a high priority.

Lung cancer has typically been associated with very late presentation and poor prognosis. Indeed, there is a degree of nihilism about lung cancer that has been difficult to overcome.3 However, new treatments are starting to make a significant difference, particularly in early stage lung tumours and we are beginning to see some genuine progress. Advances in targeted treatments and refined radiotherapy techniques have significantly improved the prospects of longer-term survival.4 Early recognition of lung cancer is critical as early stage disease can have 5-year survival rates of over 70%.5

Diagnosis

The problem with diagnosing lung cancer in primary care is that symptoms are often non-specific and occur on a background of long-term respiratory symptoms including chronic cough, especially in patients who smoke. Importantly, non-smokers also get lung cancer – 10-20% of lung cancers are in people who don’t smoke, and it’s important to look for other risk factors, such as exposure to asbestos, regardless of smoking status.6,7 We need to be aware that many patients will defer presenting with lung cancer symptoms due to its non-specific nature.8 Patients may also deny symptoms or feel that nothing can be done. Therefore, it is vital for GPs to be alert of these mechanisms and to be astute in recognising changes in long-standing respiratory symptoms, which may signify malignant change.

Public awareness of lung cancer

Nowadays, there is increasingly greater public discourse about lung cancer and several campaigns have launched, such as ‘Be Clear on Cancer’, encouraging people to present to their doctor if they have been coughing for more than 3 weeks or getting out of breath for things that they used to be able to do.3,9 Although increases in presentation to primary care were demonstrated following public awareness campaigns, there were no statistically significant improvements demonstrated in overall lung cancer survival.10

Decision support tools 

High-quality guidelines that outline typical symptoms associated with lung cancer are now available to aid GPs in their decision-making process. There are a number of ‘red flag’ symptoms which most GPs will be alert to – these include haemoptysis, change in a longstanding cough and weight loss. However, it is important to understand that the changes to be looking for are often quite subtle – for example, a patient who has been complaining of a cough for the last 10 years but new symptoms arise such as weight loss or coughing up blood. The focus should be on high risk patients; sometimes decision support tools such as CAPER and QCancer can help – for example, the CAPER scoring system can attach a risk to the combination of two symptoms (e.g. change in cough + weight loss).11,12

Screening 

Evidence from randomised control trials, including the most recent NELSON trial, has demonstrated that lung cancer screening is associated with reduced mortality in high-risk groups (24% in men and 33% in women).13 However, challenges remain in identification of individuals who should be screened. The information required to assess risk factors sits within primary care, for example past medical history or smoking history. At present, a number of lung cancer screening pilot schemes have been established, particularly in England.14 Further evidence is still required to consolidate the best screening approach. Regardless of the approach adopted, primary care will play a crucial role in implementing such practice. 

Future directions 

Moving forward, GPs should be included in government and public health efforts to raise awareness of lung cancer and combat negative perceptions surrounding this disease. This is crucial to ensure patients present with their symptoms as early as possible.

Secondly, GPs need to be astute about respiratory symptoms, especially spotting subtle changes in symptoms that may indicate an underlying malignancy. This can be especially challenging in patients the GP has been seeing for many years with chronic respiratory symptoms.

Guidelines should be used to help with decision-making; those produced by NICE and SIGN are based on best available evidence and are a useful adjunct in deciding who to refer.15,16 Our current models of lung cancer risk assessment must be carefully reviewed and updated. In the event of new screening procedures, primary care should have a key role in identifying at-risk populations and providing information to those who have been invited to screening. 

Lung cancer remains a devastating illness but change is on the horizon with the availability of new treatments, better strategies for early symptom-based diagnosis and the prospect of screening in the near future. It is important that GPs embrace these changes and ensure that we play our part in improving outcomes for this disease.

Dr David Weller, Professor of general practice, University of Edinburgh, Scotland

This project was initiated and funded by Teva Respiratory. Teva have had no influence over content. Topics and content have been selected and written by independent experts.

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