Lung Cancer
Figure 1: The National Awareness and Early Diagnosis Initiative Pathway49
Low public awareness and/or negative beliefs about cancer
Difficulty accessing primary care
Late presentation to a GP
Delays in primary care
Late presentation to hospital services Delays in secondary care
More advanced disease at diagnosis
Low uptake of screening
Emergency presentation
randomised controlled trials currently under way seeking to definitively answer this question.27–29
There are several other methods currently under investigation for use as screening tests for lung cancer, including narrow-band and autofluorescence bronchoscopy. One observational study looked at the use of bronchoscopy along with CT as a primary tool in screening.20,30 Volunteer current and former smokers underwent sputum induction for quantitative cytometry and CT before being offered autofluorescence bronchoscopy. Five hundred and sixty-one subjects were enrolled in the study, with 378 undergoing bronchoscopy. Fourteen primary lung cancers were identified, of which four (29%) were CT occult and only detected by autofluorescence bronchoscopy. All of these CT occult cancers were squamous cell carcinomas. Because of the observational nature of the study, the significance of the use of this approach on mortality is unknown.
Poor survival rates
Biological tools, such as testing serum for tumour-associated antibodies, detection of gene-promoter hypermethylation in sputum samples, exhaled breath volatile organic compounds and detection of novel proteins in serum or sputum, are also in development.31
Avoidable deaths
Unfortunately, none of these is currently ready for use in clinical practice and no form of screening for lung cancer can be recommended.
Figure 2: Poster Used on Billboards
Symptom Recognition and Reporting Interest has now switched to looking at whether lung cancer can be diagnosed earlier in its natural history by focusing on promoting symptom recognition and reporting. Ninety per cent of patients are symptomatic at the time of diagnosis,32 symptoms.33–35
often experiencing multiple
Much work has focused on investigating this, with reported median delays from onset of symptoms to presenting to healthcare ranging from seven to 31 days.35–39
Many of those presenting will have been symptomatic for many months, with reported delays to healthcare of up to two years.33
symptoms generally appears to be poor.35,37,40,41
Public knowledge of lung cancer Patients often develop
symptoms but are unaware that they could be related to a sinister cause: it appears that between 50 and 75% of lung cancer patients may not be aware of the significance of their symptoms.35,37
Only when
including serial CTs, positron-emission tomography–CT (PET–CT) and percutaneous biopsy. Only 9.6% of these participants were subsequently proved to have lung cancer. Even higher rates of benign nodule identification have been quoted in other studies20–23 and up to 20% of invasive procedures following CT screening are for benign disease.20,21,23
An additional concern is overdiagnosis, such that patients receive treatment for slowly growing tumours that may never have caused them any problems in their lifetime, a phenomenon that is already recognised in other screening programmes.24,25
In particular, systemic symptoms such as lethargy and weight loss seem to be associated with longer delays, whereas haemoptysis tends to prompt a more rapid response.33,39
further symptoms develop, or their general health deteriorates will they seek advice.33,35
It has also been noted that even those deemed to be at risk of lung cancer, predominantly current and ex-smokers, do not always perceive themselves to be at risk.35,41
Even when patients recognise a Several studies have calculated
tumour volume doubling times for screen-detected cancers. These have shown that many of the screen-identified tumours are slow-growing, with doubling times well in excess of the 40–70 days calculated from epidemiological data of non-screen-identified cancers.26
Currently, there is insufficient evidence to recommend low-dose CT as a screening test for lung cancer, although there are several
28
change in their health, there are many barriers to presentation. Themes that have been identified include fear of wasting the doctor’s time, feeling unworthy of treatment (particularly in relation to being a smoker), being unsure as to whether the symptom/change experienced is ‘normal’, putting the symptom down to being part of the ageing process, minimising symptoms, stoicism and the and associating the symptom with a known, pre-existing, condition.40,41
Delays have also been identified once patients present to their primary care team, with many patients having to present on more than one occasion before onward referral/further investigation. This is despite clear advice in the British National Institute for Clinical Excellence (NICE) guidelines in terms of chest X-ray referral.42
The EUROPEAN ONCOLOGY
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