Dr Anthony Cunliffe and Dr Richard Simcock share 10 top tips for primary care on the diagnosis and management of patients with lung cancer
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Lung cancer is the third most common cancer in the UK and the second most common in both men and women; there are around 130 new cases every day. Since the 1990s incidence in men has decreased by around one-third, whereas rates in women have increased by more than one-quarter (29%).1 Unfortunately, most patients are diagnosed at a late stage meaning that outcomes are poor; lung cancer is the most common cause of cancer death in the UK. Despite the risk increasing with age, lung cancer is one of the leading causes of premature death in many areas. People from more deprived areas have a greater risk of developing lung cancer and dying from the disease.1,2
1. Diagnose Early
The average 5-year survival rate of people diagnosed with lung cancer is less than 10%,1 with just over one-third of people surviving more than 1 year.3 The stage at diagnosis is vital, with the 5-year survival rate increasing to over 30% if a person is diagnosed early.1 Unfortunately, many people are diagnosed at a late stage by emergency presentation, increasing the likelihood of poor outcomes. Interestingly, GP-managed referrals account for the highest percentage of people diagnosed at an early stage, showing that primary care plays an important role in the earlier diagnosis of this cancer.1 However, lung cancer can be an ‘easily missed’ disease, which means that a possible diagnosis should be considered in all higher-risk patients with a new respiratory symptom or atypical non-respiratory symptom, and in non-smokers with suspicious symptoms.4
2. Investigate in Primary Care
Primary care physicians have a vital role in improving outcomes for patients with lung cancer. A low threshold for chest X-ray in all symptomatic patients is important and robust information should be given on radiology request forms to enable more useful reports. Patients with chronic obstructive pulmonary disease (COPD) are at a four-fold increased risk; therefore, it may be important to have an even lower threshold for testing in this group.5 Up to 23% of initial chest X-rays may be reported as normal or show indeterminate findings, so if there is ongoing concern patients should undergo further urgent investigations, namely a computed tomography (CT) scan, or be referred on an urgent suspected cancer pathway.4,6 A full blood count may be useful; a persistent thrombocytosis potentially indicates an underlying cancer.7
3. Ask About Vague and Atypical Symptoms
Alongside common symptoms of lung cancer, such as haemoptysis, cough, recurrent chest infections, and shortness of breath, ask patients about more vague symptoms, for example, weight loss, appetite loss, and fatigue, as well as atypical symptoms like shoulder pain.6 A thorough examination is important, looking for abnormal chest signs, clubbing, and supraclavicular or persistent cervical lymphadenopathy.
4. Check Lung Health
There is no national screening programme for lung cancer, but there is increasing evidence that targeting health checks to high-risk individuals can lead to more cancers being diagnosed at an earlier stage. Second-round results from a community-based lung cancer screening pilot in Manchester funded by Macmillan Cancer Support found that, of 1194 high-risk individuals who received low-dose CT scans, 19 cases were diagnosed. The majority (79%) were early stage and 70% were offered potentially curative treatment.8 NHS England is now running further pilots, with primary care being an essential partner in identifying those at risk.9
5. Support Patients to Make Treatment Decisions
Currently, only a small percentage of patients are amenable to potentially curative surgical resection at diagnosis. In 2017, 18% of patients with non-small-cell lung cancer (NSCLC) received surgery.3 The number of patients with lung cancer who undergo surgery is increasing, but the overall low figures contribute to poor survival rates. Patients who are medically unfit for the physical challenge of surgery may be able to receive highly focused radiotherapy, that is, stereotactic radiosurgery or stereotactic ablative radiotherapy. A far greater number of people are offered palliative radiotherapy and chemotherapy. Rates of chemotherapy in patients with good performance status, that is, those who are ambulatory and not in bed or a chair for more than 50% of waking hours, are around 65% in the UK.3 Once diagnosed, patients should have access to GPs for support and help in making decisions about treatment.
6. Know About ‘Personalised’ Medicine
For decades, lung cancer has been classified as either NSCLC or small-cell lung cancer. Modern therapies have now evolved around genomic changes in the tumour and available palliative treatments, particularly immunotherapies, will depend on the molecular subtype of the cancer. Most patients will face the potential disappointment that they do not fit the strict evidence-based selection criteria used by NICE and the Cancer Drugs Fund to access newer drug treatments. For example, only around 5% of patients with NSCLC have a cancer with an anaplastic lymphoma kinase mutation and are therefore eligible for treatment with the new drug crizotinib, which may extend life by an average of 3 months.10,11 NICE now recognises that NSCLC may be categorised and treated according to different molecular subtypes: PD-L1 high or low; ALK positive; ROS-1 positive; and EGFR-TK positive.12 The numbers of patients in each of these subsets may be small.
Analysing for these mutations may require sequential biopsies, but may also permit access to novel treatment with what is increasingly referred to as ‘personalised’ medicine.
7. Be Aware of Immunotherapy and its Side-effects
Oncological immunotherapy harnesses a person’s immune system to target malignant cells. Either alone or in combination with conventional treatments, immunotherapy can significantly improve patient outcomes in NSCLC and other cancers. These therapies are often better tolerated than conventional treatments, and have a different toxicity profile. The toxicities of immunotherapy often mimic autoimmune disease, including reactions such as colitis, hepatitis, endocrinopathies, and skin toxicities. GPs should be aware of these newer treatments and their potential for improved outcomes, but also their different side-effects. These side-effects are highlighted in a toxicity risk assessment tool produced by the UK Oncology Nursing Society in partnership with Macmillan Cancer Support.13
8. Involve Palliative Care Services Early
Despite the excitement about novel therapies, it is still sadly the case that the majority of patients with lung cancer will die of their disease. Early involvement of palliative care should always be considered and trials have shown that these services can improve quality of life and may even improve overall survival.14 NICE recommends that all patients with lung cancer should have access to a clinical nurse specialist (CNS).15,16 However, not every patient has access to specialist nursing support in hospital: the 2018 National Lung Cancer Audit found that 30% had no access to a CNS.3 Support from a CNS in primary care will always be necessary.
Short-course radiotherapy may be useful for pain and haemoptysis. Patients with persistent pleural effusion may regain some independence and reduced hospital visits with permanent indwelling pleural drains or after a talc pleurodesis procedure. Pleurodesis obliterates the pleural space to prevent recurrent effusion. Installation of talc as an irritant into the pleural space causes fibrosis.17
In adults with bone metastases, denosumab may be recommended as an option for preventing skeletal-related events, for example, pathological fracture, spinal cord compression, or surgery to bone.18
9. Consider Non-drug Interventions for Breathlessness
NICE recommends consideration of non-drug interventions based on psychosocial support, breathing control, and coping strategies for people with breathlessness. These may be delivered by a nurse, physiotherapist, or occupational therapist with expertise.15 Opioids, such as codeine or morphine, can help to reduce cough.15 Patients with troublesome hoarseness due to recurrent laryngeal nerve palsy may benefit from review by an ear, nose, and throat specialist for advice and intervention.15
10. Reduce Risk Through Smoking Cessation
Of lung cancer cases in the UK, 79% are preventable. Most cases are caused by smoking, followed by ionising radiation, workplace exposure, and air pollution.1 Primary care teams have an essential role to play in helping patients to reduce their risk by giving up smoking.19 This is important even for people who already have a diagnosis, because smoking cessation around the time of diagnosis leads to significantly better survival. Patients undergoing investigations who are not diagnosed with cancer provide primary care teams with a perfect opportunity for a ‘teachable moment’ to reduce their future risk.20
Dr Anthony Cunliffe
Joint National Lead Macmillan GP Adviser; Macmillan GP Adviser London; Joint Clinical Chair, South East London Cancer Alliance
Dr Richard Simcock
Macmillan Consultant Medical Advisor and Oncologist