Diagnosis of Lung Cancer – Improving Survival Rates
delay from first presentation to referral to a respiratory specialist has been reported to range from a mean of 3438 >175).37,36,39,43,44
Bowen and Raynor’s study37
to 73 days (range 0 to also showed that of the
76% of patients who first consulted their own family doctor, only one-third were referred following their initial consultation, with a further third referred by another doctor in the practice, suggesting a second consultation. A Danish study looked at potential reasons for the delay in onward referral of symptomatic patients and identified several contributing factors. In patients with co-morbid diseases, symptoms were often ascribed to this rather than potential lung cancer.45
public awareness campaign launched comprising leaflets, advertising on bus banners and billboards (see Figure 2), local media events and bus stops that were fitted with sound chips to make them ‘cough’ and in so doing drew attention to the campaign posters.
Chest X-rays reported as normal were associated with a longer delay, with primary care teams being falsely reassured. Twenty-five per cent of lung cancer diagnoses in the UK are made during an acute admission, despite the patient having presented previously to their primary healthcare team with a symptom that could be indicative of lung cancer.46
Improving the early diagnosis of lung cancer in Britain has become a government priority, with the formation of the National Awareness and Early Detection Initiative (NAEDI), an important component of the 2007 cancer-reform strategy.47
This hypothesises that delays lead to
more advanced disease at diagnosis with associated poor one- and five-year survival rates and potentially avoidable deaths. Abdel- Rehman et al. calculated that if UK survival rates were similar to those in Europe, nearly 1,000 deaths per year within five years of the diagnosis of lung cancer, could be avoided.48
The NAEDI pathway
highlights many areas that could be targeted in order to try to promote earlier diagnosis (see Figure 1).49
One such strategy is to use social marketing techniques to raise awareness of lung cancer symptoms and to encourage a more timely presentation to healthcare services. Social marketing uses commercial marketing techniques to change individual and organisational behaviours and policies.50
This project used a mass media campaign combined with general practice education to raise awareness of the symptoms of oral and colorectal cancer. Awareness of symptoms was improved and, in those presenting who were aware of the campaign, presentation was more timely in 60%.
Similar approaches have already been used in other cancers, an example of which is the West of Scotland Cancer Awareness Project (WoSCAP).51
An initial social marketing pilot has been carried out in lung cancer in Doncaster, the largest metropolitan borough in the UK, which has a high rate of lung cancer52,53
and a high rate of social deprivation. The
social marketing campaign and primary care education programme were initially designed as a way of addressing a recognised health inequality. Six areas, covered by 11 general practice surgeries, with the highest lung cancer risk were identified. In these areas, brief intervention training was undertaken with the general practitioners, practice nurses and local pharmacists. Following this, there was a
1.
World Health Organisation, The global burden of disease: 2004 update. 2008. Geneva: WHO Press,
www.who.int/ healthinfo/global_burden_disease/2004_report_update/en /
index.html (accessed 28 June 2010).
2. 3.
Quinn M, Babb P, Brock A, et al., Cancer Trends in England and Wales 1950–1999. SMPS No 66. Office of National Statistics, The Stationery Office, London. 2001. Sant M, Allemani C, Santaquilani M, et al.; EUROCARE
Victoria L Athey is a Clinical Research Fellow in the Department of Respiratory Medicine at the University of Sheffield. She is based at Doncaster Royal Infirmary and her research area of interest is the use of social marketing strategies to promote earlier diagnosis of lung cancer. She graduated from St George’s Hospital Medical School in London and is undertaking her respiratory training in Sheffield.
Angela M Tod is a Principal Research Fellow in the Centre for Health and Social Care Research at Sheffield Hallam University. Her expertise is in exploring patient experience of illness, qualitative research and health services. Dr Tod’s research has been used in stand-alone qualitative studies and mixed-method studies, including clinical trials. Her main interest is in public health research, including health inequalities and service access. Dr Tod has worked with members of the National Lung Cancer Forum for Nurses (NLCFN) to develop research into care for patients with lung cancer and mesothelioma and their carers, and has been involved in research into early detection and diagnosis of lung cancer.
Rupert Suckling is Deputy Director of Public Health at NHS Doncaster. He is responsible for the public health input into commissioning at NHS Doncaster, including both strategic and practice-based commissioning, and he has specific public health roles for mental health, prisons, harm reduction and cancer. His work in cancer includes the Early Lung Cancer Intervention in Doncaster social marketing project, which was adopted by the Yorkshire & Humber Social Marketing programme. He is a member of the National Awareness and Early Diagnosis Initiative steering group. Dr Suckling trained in general medicine, psychiatry and public health as he followed the path from addressing the physical to the mental, and finally to the social causes of ill-health.
Trevor Rogers is a Consultant Respiratory Physician and is Director of Research and Development at Doncaster and Bassetlaw NHS Foundation Trust. He is also Secretary of the UK Respiratory Specialist Advisory Committee (SAC). His area of research mainly concerns how symptoms and primary care interventions affect the presentation of lung cancer. He was network lead clinician for lung cancer from 2001 until 2006, during which time he created the network group. He belongs to the subgroup of the National Cancer Research Institute (NCRI) concerned with screening and early diagnosis of lung cancer. His early research interest was the pulmonary circulation, leading to an MD from the University of Sheffield. He graduated from the University of Bristol in 1985.
This project increased awareness of the importance of seeking medical advice for a prolonged cough and resulted in a statistically significant increase in chest X-ray referrals. Lung cancer diagnosis rates were also increased, although this was not statistically significant. No stage shift was evident, but the numbers at different lung cancer stages were too small for subgroup analysis.53,54
If the responses to this campaign could be replicated on a larger scale, and people could be encouraged to present earlier with their symptoms, their disease should be identifiable in a more timely fashion. In turn, this will hopefully increase the number of patients suitable for curative treatment as well as influencing the numbers receiving active treatment (chemotherapy and/or radiotherapy). Both actions should lead to improved survival of patients with lung cancer. n
working group, EUROCARE-4 Survival of cancer patients diagnosed in 1995–1999. Results and Commentary, Eur J Cancer, 2009;45:931–91.
4.
SEER Cancer Statistics Review 1975-2006 Section 15: lung and bronchus. National Cancer Institute,
www.seer.
cancer.gov/csr/1975_2006/results_merged/sect_15_lung_ bronchus.pdf (accessed 28 June 2010).
5. Cancer Research UK, Lung cancer and smoking statistics:
Key facts,
http://info.cancerresearchuk.org/cancerstats/ types/lung/
index.htm (accessed 28 June 2010).
6. 7.
Brett GZ, The value of lung cancer detection by 6-monthly chest radiographs, Thorax, 1968;23:414–20.
Berlin NI, Buncher CR, Fontana RS, et al., The National Cancer Institute Cooperative Early Cancer Detection program. Results of the initial screen (prevalence). Early lung cancer detection: Introduction, Am Rev Respir Dis,
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