Your early lung cancer diagnosis could save a life

In the three months leading up to a diagnosis, a patient will often see their GP four or more times before the cancer is diagnosed.

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How many times have you suspected lung cancer as a potential source of new or changed symptoms in a patient?

You may only see a case of lung cancer once or twice a year but when you do, having the knowledge of an evidence-based, stepwise approach to investigation and referral may help save a life.

Commissioned by Cancer Australia, Lung Foundation Australia has developed an accredited, scenario-based eLearning course, A Systematic Approach to Investigating Symptoms of Lung Cancer. The training is designed to help you recognise lung cancer in symptomatic patients and to apply the recommendations of Cancer Australia’s updated resource Investigating symptoms of lung cancer: a guide for all health professionals (the Guide).

Lung cancer remains the nation’s most common cause of cancer death, with over 13,000 Australians expected to be diagnosed each year. Compared to other cancers, people with lung cancer are much more likely to be diagnosed at an advanced, incurable stage^[i]. Nationally, only 18% of lung cancers are diagnosed at Stages 1 or 2 with five-year survival being 68% and 32% respectively^[ii].

Diagnostic delays in lung cancer are multi-factorial but are contributed to by  the presence of non-specific symptoms, such as cough and chest pain^{[iii] [iv]}, which overlap with those seen in other conditions such as chronic obstructive pulmonary disease (COPD), chronic heart failure and coronary heart disease^[v]. Studies show that the most frequently reported barriers to early presentation and diagnosis of lung cancer, highlighted by patients and carers, relate to poor relationships between GPs and patients, a lack of access to services and care, and a lack of awareness of symptoms and treatment options^[vi].

We also know that stigma is a barrier to people accessing early support for their symptoms and as health professionals, we all play a key role in fighting this stigma to ensure that patients access the treatment they deserve. This is particularly important for health professionals in the primary care setting, as in the three months leading up to a diagnosis, a person with lung cancer will often see their GP four or more times before lung cancer is diagnosed^[vii].

Understanding risk factors

Lung cancer can be diagnosed in people of all backgrounds and ages, including those who have never smoked or who have quit. Consider modifiable factors such as:

• environmental exposures such as passive smoking and air pollution
• occupational exposures including asbestos, diesel exhaust, silica and radon (including underground workers in poorly ventilated environments)
• tobacco smoking

There are also personal factors that come into play such as increasing age, a family history of cancer, a personal history of previous primary cancer and/or prior lung disease. While smoking is the largest single cause of lung cancer (about 90% in males, 35% in females^[viii]), people who have never smoked can also be diagnosed.  In fact, around one in four lung cancers in women and one in seven lung cancers in men are attributable to factors other than smoking, including occupational exposures and genetic factors ^{[ix] [x] [xi]}.

Indigenous and remote Australians 

Aboriginal and Torres Strait Islander people are twice as likely to be diagnosed with lung cancer, almost twice as likely to die from the disease and less likely to survive five years after a diagnosis, compared with non-Indigenous Australians^[xii]. Indigenous Australians may also experience language, cultural and access barriers to optimal cancer care and treatment, thereby negatively impacting their prognosis. Incidence and mortality of lung cancer also increases with remoteness and is higher for patients living in lower socioeconomic areas.^[xiii]  

Investigating symptoms and signs of lung cancer

Many unexplained, persistent symptoms and signs can indicate lung cancer. This is particularly important if symptoms last more than three weeks, or less in patients with known risk factors or with more than one symptom or sign.

Symptoms to look for include:

• persistent or unexplained haemoptysis
• a new or changed cough
• chest or shoulder pain
• shortness of breath
• hoarse voice
• persistent or recurrent chest infections
• fatigue
• weight loss / loss of appetite

Signs to look for include:

• abnormal chest signs
• finger clubbing
• cervical and/or supraclavicular lymphadenopathy
• superior vena caval obstruction
• features suggestive of metastasis (e.g. brain, bone, liver or skin)
• pleural effusion
• thrombocytosis

It is important to remember that many of these symptoms and signs overlap with those of other conditions. Keeping lung cancer front of mind, and applying an evidence-based, stepwise approach to investigation and referral, will help you exclude lung cancer as a potential cause of symptoms.  

Optimal imaging modalities for lung cancer

As a first step in those without recent previous imaging, a chest X-ray should be requested to assess for the presence of nodules, unexplained consolidation and/or other suspicious signs of lung cancer. It is critically important that results are reviewed promptly and provided to the patient (within one week). This allows for timely onward referral through the diagnostic pathway, if necessary.

If lung cancer is suspected, urgent referral for a chest CT scan (delivered with contrast unless contraindicated) should occur. The latest edition of the Guide (May 2020) also recommends concurrent referral (within 2 weeks) to a specialist linked to a lung cancer multi-disciplinary team (MDT). Again, this allows for rapid diagnostic work up with the objective to reduce treatment delays.

An urgent chest CT scan may replace chest X-ray as a first step if there is a high clinical suspicion of lung cancer, arising from the presence of concerning symptoms or signs such as persistent or unexplained haemoptysis, or signs of superior vena caval obstruction. Any incidental imaging findings suggestive of lung cancer would also warrant this pathway.

The Guide also notes:

• Chest CT scans should be offered when there is a strong clinical suspicion of lung cancer. They should be delivered with contrast unless contra-indicated
• Low-dose CT (LDCT) scans have a lower radiation dose compared to conventional chest CT scans, provide good clinical information and are more sensitive than chest X-ray in the diagnosis of lung cancer^[xiv]
• There is ongoing national and international research into the role of LDCT screening for lung cancer in asymptomatic people. For more information on the potential role of screening for asymptomatic patients, visit Cancer Australia’s lung cancer screening enquiry information centre

Refer patients for best management

All patients with suspected lung cancer should be referred to a specialist with expertise in lung cancer who is affiliated with a lung cancer multidisciplinary team.  Multidisciplinary care is an integrated, evidence-based approach which sees medical and allied health care professionals consider all relevant treatment options and collaboratively develop an individual treatment and care plan. Each MDT member has varying responsibilities, with all playing a role in providing supportive and palliative care^[xv]. Multidisciplinary care for lung cancer patients is well supported by the literature and is associated with: 

• Improved survival^{[xvi] [xvii]}, quality of life and reduced hospitalisation at the end of life^[xviii]
• Reduced time to treatment after diagnosis and improved patient satisfaction^{[xix] [xx] [xxi] [xxii]}
• Increased likelihood of patients receiving guideline-adherent care ^{[xxiii], [xxiv] [xxv] [xxvi]}and curative treatment ^{[xxvii] [xxviii] [xxix] [xxx]} 
• More frequent referrals to specialist supportive and palliative care and increased opportunities for clinical trial participation^[xxxi]
• Improved cancer treatment planning, documentation of patient preferences and more accurate and complete pre-operative staging ^{[xxxii] [xxxiii] [xxxiv]} 

Lung Foundation Australia’s online MDT directory provides useful information about MDTs including contact details where known. The directory is updated annually.

Accredited training and education for health professionals

Lung Foundation Australia and a multidisciplinary group of lung cancer experts, have developed a free, accredited eLearning course, A Systematic Approach to Investigating Symptoms of Lung Cancer. Through scenario-based learning, this self-paced training aims to increase your confidence in recognising lung cancer in symptomatic patients and support an evidence-based, practical, systematic approach to referral and diagnosis. Focusing in particular on the primary care setting, this course is free for all health professionals. Enrol here.  

Professor Kwun Fong is a thoracic and sleep physician at The Prince Charles Hospital and chair of the Lung Cancer Clinical Advisory Group.

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[i] Australian Institute of Health and Welfare 2021. Cancer data in Australia. Cat. no. CAN 122. Canberra: AIHW. Accessed September 2021; https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia

[ii] Australian Institute of Health and Welfare 2021. Cancer data in Australia. Cat. no. CAN 122. Canberra: AIHW. Accessed June 2021; https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/data

[iii] Weller DP, Peake MD and Field JK. Presentation of lung cancer in primary care. NPJ primary care respiratory medicine. 2019;29(1):21. 

[iv] Bradley SH, Kennedy MPT and Neal RD. Recognising Lung Cancer in Primary Care. Advances in therapy. 2019;36(1):19-30. 

[v] Smith SM, Campbell NC, MacLeod U, et al. Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study. Thorax. 2009;64(6):523-31. 

[vi] Cassim, S., Chepulis, L., Keenan, R. et al. Patient and carer perceived barriers to early presentation and diagnosis of lung cancer: a systematic review. BMC Cancer 19, 25 (2019). https://doi.org/10.1186/s12885-018-5169-9

[vii] Purdie S, Creighton N, White KM, Baker D, Ewald D, Lee CK, Lyon A, Man J, Michail D, Miller AA, Tan L, Currow D, Young JM. Pathways to diagnosis of non-small cell lung cancer: a descriptive cohort study. NPJ Prim Care Respir Med. 2019 Feb 8;29(1):2. doi: 10.1038/s41533-018-0113-7. PMID: 30737397; PMCID: PMC6368611

[viii] Australian Institute of Health and Welfare & Cancer Australia 2011. Lung cancer in Australia: an overview. Cancer series no. 64. Cat. no. CAN 58. Canberra: AIHW.  

[ix] Whiteman D, Webb P, Green A, Neale R, Fritschi L, Bain C et al. Cancers in Australia in 2010 attributable to modifiable factors: summary and conclusions. Australian and New Zealand Journal of Public Health. 2015;39(5):477-484.

[x] Hoy R, Brims F. Occupational lung diseases in Australia. MJA. 2017;207(10):443-448.

[xi] Malhotra J, Malvezzi M, Negri E, La Vecchia C, Boffetta P. Risk factors for lung cancer worldwide. European Respiratory Journal. 2016;48(3):889-902.

[xii] Australian Institute of Health and Welfare 2018. Cancer in Aboriginal & Torres Strait Islander people of Australia. Cat. no. CAN 109 Accessed June 2021; https://www.aihw.gov.au/reports/cancer/cancer-in-indigenous-australians 

[xiii] Australian Institute of Health and Welfare 2020. Cancer data in Australia. Cat. no. CAN 122. Canberra: AIHW. Accessed January 2021 

[xiv] Cancer Australia: Investigating symptoms of lung cancer: a guide for all health professionals.
https://www.canceraustralia.gov.au/sites/default/files/publications/investigating-symptoms-lung-cancer-guide-all-health-professionals/pdf/investigating_symptoms_of_lung_cancer_-_the_guide.pdf

[xv] Olver I, Keefe D, Herrstedt J, et al. Supportive care in cancer—a MASCC perspective. Supportive Care in Cancer. 2020; 

[xvi] Osarogiagbon RU, Phelps G, McFarlane J and Bankole O. Causes and consequences of deviation from multidisciplinary care in thoracic oncology. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2011;6(3):510-6.  

[xvii] Stone E, Rankin N, Kerr S, et al. Does presentation at multidisciplinary team meetings improve lung cancer survival? Findings from a consecutive cohort study. Lung cancer. 2018;124:199-204.  

[xviii] Taplin SH, Weaver S, Salas E, et al. Reviewing cancer care team effectiveness. Journal of oncology practice. 2015;11(3):239-46.  

[xix] Coory M, Gkolia P, Yang IA, et al. Systematic review of multidisciplinary teams in the management of lung cancer. Lung cancer. 2008;60(1):14-21.  

[xx] Osarogiagbon RU, Phelps G, McFarlane J and Bankole O. Causes and consequences of deviation from multidisciplinary care in thoracic oncology. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2011;6(3):510-6.

[xxi] Freeman RK, Van Woerkom JM, Vyverberg A and Ascioti AJ. The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with lung cancer. European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery. 2010;38(1):1-5.  

[xxii] Prades J, Remue E, van Hoof E and Borras JM. Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes. Health policy.2015;119(4):464-74. 

[xxiii] Taplin SH, Weaver S, Salas E, et al. Reviewing cancer care team effectiveness. Journal of oncology practice. 2015;11(3):239-46.  

[xxiv] Boxer MM, Vinod SK, Shafiq J and Duggan KJ. Do multidisciplinary team meetings makea difference in the management of lung cancer? Cancer. 2011;117(22):5112-20.

[xxv] Onukwugha E, Petrelli NJ, Castro KM, et al. ReCAP: Impact of Multidisciplinary Care onProcesses of Cancer Care: A Multi-Institutional Study. Journal of oncology practice.2016;12(2):155-6; e7-68.

[xxvi] Freeman RK, Ascioti AJ, Dake M and Mahidhara RS. The Effects of a Multidisciplinary Care Conference on the Quality and Cost of Care for Lung Cancer Patients. The Annals of thoracic surgery. 2015;100(5):1834-8; discussion 8.

[xxvii] Coory M, Gkolia P, Yang IA, et al. Systematic review of multidisciplinary teams in the management of lung cancer. Lung cancer. 2008;60(1):14-21.  

[xxviii] Boxer MM, Vinod SK, Shafiq J and Duggan KJ. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer. 2011;117(22):5112-20.

[xxix] Onukwugha E, Petrelli NJ, Castro KM, et al. ReCAP: Impact of Multidisciplinary Care onProcesses of Cancer Care: A Multi-Institutional Study. Journal of oncology practice.2016;12(2):155-6; e7-68.

[xxx] Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer treatment reviews. 2016;42:56-72

[xxxi] Freeman RK, Ascioti AJ, Dake M and Mahidhara RS. The Effects of a Multidisciplinary Care Conference on the Quality and Cost of Care for Lung Cancer Patients. The Annals of thoracic surgery. 2015;100(5):1834-8; discussion 8.

[xxxii] Prades J, Remue E, van Hoof E and Borras JM. Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes. Health policy.2015;119(4):464-74.

[xxxiii] Freeman RK, Ascioti AJ, Dake M and Mahidhara RS. The Effects of a Multidisciplinary Care Conference on the Quality and Cost of Care for Lung Cancer Patients. The Annals of thoracic surgery. 2015;100(5):1834-8; discussion 8.

[xxxiv] Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer treatment reviews. 2016;42:56-72