Lung Cancer In Primary Care Research Articles

The Clinical Value of Pre-Diagnostic Thrombocytosis for the Detection of Lung Cancer in Primary Care.

Thrombocytosis is a risk marker for lung cancer in primary care. We investigated whether thrombocytosis presents pre-diagnostically for all the histological subtypes of lung cancer and its association with the stage at diagnosis. A matched cohort study used English electronic primary care data linked to the national cancer registry. Patients diagnosed with lung cancer aged ≥40 years with no prior history of malignancy were matched by age, sex, and general practice to five controls without lung cancer. Multivariable logistic regression models quantified the incidence of pre-diagnostic thrombocytosis and advanced-stage diagnoses, adjusting for COPD diagnosis, smoking status, and anti-platelet drug prescriptions. A total of 9504 cases were matched to 45,647 controls, consisting of 3260 (34%) adenocarcinomas (ADC), 2020 (21%) squamous cell carcinomas (SCC), 70 (<1%) large-cell carcinomas (LCC), and 1089 (12%) small-cell lung cancers (SCLC). The patients with lung cancer were 8.9 (95% CI 8.0-9.9) times more likely to exhibit pre-diagnostic thrombocytosis than the controls. The odds ratios were highest for the comparison between SCC and ADC (1.8, 95% CI 1.5-2.1). Thrombocytosis is associated with advanced-stage ADC and SCC but presented equally for early- and advanced-stage SCLC. Pre-diagnostic thrombocytosis may aid in the detection of all the histological subtypes in primary care.

Impact of the COVID-19 Outbreak-Delayed Referral of Colorectal and Lung Cancer in Primary Care: A National Retrospective Cohort Study.

The Coronavirus disease 2019 (COVID-19) outbreak impacted health care. We investigated its impact on the time to referral and diagnosis for symptomatic cancer patients in The Netherlands. We performed a national retrospective cohort study utilizing primary care records linked to The Netherlands Cancer Registry. For patients with symptomatic colorectal, lung, breast, or melanoma cancer, we manually explored free and coded texts to determine the durations of the primary care (IPC) and secondary care (ISC) diagnostic intervals during the first COVID-19 wave and pre-COVID-19. We found that the median IPC duration increased for colorectal cancer from 5 days (Interquartile Range (IQR) 1-29 days) pre-COVID-19 to 44 days (IQR 6-230, p < 0.01) during the first COVID-19 wave, and for lung cancer, the duration increased from 15 days (IQR) 3-47) to 41 days (IQR 7-102, p < 0.01). For breast cancer and melanoma, the change in IPC duration was negligible. The median ISC duration only increased for breast cancer, from 3 (IQR 2-7) to 6 days (IQR 3-9, p < 0.01). For colorectal cancer, lung cancer, and melanoma, the median ISC durations were 17.5 (IQR (9-52), 18 (IQR 7-40), and 9 (IQR 3-44) days, respectively, similar to pre-COVID-19 results. In conclusion, for colorectal and lung cancer, the time to primary care referral was substantially prolonged during the first COVID-19 wave. In such crises, targeted primary care support is needed to maintain effective cancer diagnosis.

Treating lung cancer in primary care

Treating lung cancer in primary care

Lung Cancer Pre-Diagnostic Pathways from First Presentation to Specialist Referral.

Background: Lung cancer is often diagnosed at a late stage with high associated mortality. Timely diagnosis depends on timely referral to a respiratory specialist; however, in Canada, little is known about how patients move through primary care to get to a respiratory specialist. Accordingly, we aimed to identify and describe lung cancer pre-diagnostic pathways in primary care from first presentation to referral. Methods: In this retrospective cohort study, patients with primary lung cancer were recruited using consecutive sampling (n = 50) from a lung cancer center in Montréal, Québec. Data on healthcare service utilization in primary care were collected from chart reviews and structured patient interviews and analyzed using latent class analysis to identify groups of patients with similar pre-diagnostic pathways. Each group was described based on patient- and tumor-related characteristics and the sequence of utilization activities. Results: 68% of the patients followed a pathway where family physician (FP) visits were dominant (“FP-centric”) and 32% followed a pathway where walk-in clinic and emergency department (ED) visits were dominant (“ED-centric”). Time to referral in the FP group was double that of the ED group (45 days (IQR: 12–111) vs. 22 (IQR: 5–69)) with more advanced disease (65% vs. 50%). In the FP group, 29% of the patients saw their FP three times or more before being referred and 41% had an ED visit. Conclusions: Our findings may reflect the challenge of diagnosing lung cancer in primary care, missed opportunities for earlier diagnosis, and a lack of integration between primary and specialist care.

Sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms: a systematic review.

Despite increasing use of computed tomography (CT), chest X-ray remains the first-line investigation for suspected lung cancer in primary care in the UK. No systematic review evidence exists as to the sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms. To estimate the sensitivity of chest X-ray for detecting lung cancer in symptomatic people. A systematic review was conducted to determine the sensitivity of chest X-ray for the detection of lung cancer. Databases including MEDLINE, EMBASE, and the Cochrane Library were searched; a grey literature search was also performed. A total of 21 studies met the eligibility criteria. Almost all were of poor quality. Only one study had the diagnostic accuracy of chest X-ray as its primary objective. Most articles were case studies with a high risk of bias. Several were drawn from non-representative groups, for example, specific presentations, histological subtypes, or comorbidities. Only three studies had a low risk of bias. Two primary care studies reported sensitivities of 76.8% (95% confidence interval [CI] = 64.5 to 84.2%) and 79.3% (95% CI = 67.6 to 91.0%). One secondary care study reported a sensitivity of 79.7% (95% CI = 72.7 to 86.8%). Though there is a paucity of evidence, the highest-quality studies suggest that the sensitivity of chest X-ray for symptomatic lung cancer is only 77% to 80%. GPs should consider if further investigation is necessary in high-risk patients who have had a negative chest X-ray.

Recognising Lung Cancer in Primary Care.

Significant advances in the management of both early and advanced stage lung cancer have not yet led to the scale of improved outcomes which have been achieved in other cancers over the last 40 years. Diagnosis of lung cancer at the earliest stage of disease is strongly associated with improved survival. Therefore, although recent advances in oncology may herald breakthroughs in effective treatment, achieving early diagnosis will remain crucial to obtaining optimal outcomes. This is challenging, as most lung cancer symptoms are non-specific or are common respiratory symptoms which usually represent benign disease. Identification of patients at risk of lung cancer who require further investigation is an important responsibility for general practitioners (GPs). Diagnosis has historically relied upon plain chest X-ray (CXR), organised in response to symptoms. The sensitivity of this modality, however, compares unfavourably with that of computed tomography (CT). In some jurisdictions screening high-risk individuals with low dose CT (LDCT) is now recommended. However uptake remains low and the eligibility for screening programmes is restricted. Therefore, even if screening is widely adopted, most patients will continue to be diagnosed after presenting with symptoms. Achieving early diagnosis requires GPs to maintain an appropriate level of suspicion and readiness to investigate in high-risk patients or those with non-resolving symptoms. This article discusses the early detection of lung cancer from a primary care perspective. We outline risk factors and epidemiology, the role of screening and offer guidance on the recognition of symptomatic presentation and the investigation and referral of suspected lung cancer.

Clinical features of patients with non-metastatic lung cancer in primary care: a case-control study.

BackgroundLung cancer (LC) kills more people than any other cancer globally, mainly due to the late stage of diagnosis.AimTo identify and quantify the prediagnostic features of non-metastatic lung cancer (nMLC) and to compare the clinical features in GPs’ chest X-ray referral letters with the clinical features (expressed as diagnostic codes) in medical records.Design & settingA population-based case-control study was conducted using diagnostic codes from national and regional healthcare databases in Sweden.MethodIn total, 373 patients diagnosed with LC in 2011 (of which 132 had nMLC) and 1472 controls were selected from the Swedish Cancer Register (SCR) and regional healthcare database, respectively. Diagnostic codes registered in medical records from primary care consultations in the year before LC diagnosis were collected from the regional healthcare database. Odds ratios (OR) were calculated for variables associated with nMLC. The GPs’ referral letters for chest X- ray were retrieved from the regional repository for radiology.ResultsClinical features with the highest OR were vitamin B12 deficiency anaemia (OR 6.7, 95% confidence interval [CI] = 1.6 to 27.9), dyspnoea (OR 5.0, 95% CI = 2.0 to 12.7), and chronic bronchitis (OR 5.0, 95% CI = 1.3 to 18.6). Clinical features that were GPs’ reasons for requesting chest X-ray were almost three times more frequent in referral letters compared to the corresponding diagnostic codes in the medical records.ConclusionPatients with nMLC could not be identified by symptoms. The clinical features in referral letters for X-ray were more frequent than corresponding diagnostic codes from medical records.

92 Predictors of early death from lung cancer in primary care

92 Predictors of early death from lung cancer in primary care

Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports

Most lung cancers present symptomatically, but the pathway to diagnosis in primary care can be complex and is poorly understood. Significant event audit (SEA) is a quality improvement technique widely used in UK general practice. To gain insights into the diagnostic process for lung cancer, drawn from analysis of SEA documents. Qualitative analysis of SEAs from 92 general practices in the North of England Cancer Network. Participating practices were provided with a standardised electronic template and asked to undertake a significant event audit related to the most recent diagnosis of lung cancer in the practice, even if that patient had since died. Reported accounts for 132 diagnoses were analysed using a modified framework approach. Most SEAs demonstrated timely recognition and referral. Where this had taken longer, there were often reasonable explanations, including: chest X-rays reported as normal or with benign findings; patient-mediated factors, such as delay in re-presenting or declining earlier referral; and presentation complicated by comorbidity. Some opportunities for earlier referral were also found. Lessons drawn from these events included limitations of chest X-ray as a diagnostic tool, the need for vigilance in patients with existing morbidity, and the importance of 'safety-netting'. Qualitative synthesis of SEAs offered considerable value in understanding circumstances surrounding the diagnostic process for lung cancer in primary care. The most common presentation was with cough or other symptoms indicative of infection, and it is by understanding more about these patients in particular that most can be gained.

Identifying patients with suspected lung cancer in primary care: derivation and validation of an algorithm

Lung cancer has one of the lowest survival outcomes of any cancer because more then two-thirds of patients are diagnosed when curative treatment is not possible. The challenge is to help earlier diagnosis of lung cancer and hence improve prognosis. To derive and validate an algorithm incorporating information on symptoms, to estimate the absolute risk of having lung cancer Cohort study of 375 UK QResearch® general practices for development, and 189 for validation. Selected patients were aged 30-84 years and free of lung cancer at baseline and haemoptysis, loss of appetite, or weight loss in previous 12 months. Primary outcome was incident diagnosis of lung cancer recorded in the next 2 years. Risk factors examined were: haemoptysis, appetite loss, weight loss, cough, dyspnoea, tiredness, hoarseness, smoking, body mass index, deprivation score, family history of lung cancer, other cancers, asthma, chronic obstructive airways disease, pneumonia, asbestos exposure, and anaemia. Cox proportional hazards models with age as the underlying time variable were used to develop separate risk equations in males and females. Measures of calibration and discrimination assessed performance in the validation cohort. There were 3785 incident cases of lung cancer arising from 4 289 282 person-years in the derivation cohort. Independent predictors were haemoptysis, appetite loss, weight loss, cough, body mass index, deprivation score, smoking status, chronic obstructive airways disease, anaemia, and prior cancer (females only). On validation, the algorithms explained 72% of the variation. The receiver operating characteristic (ROC) statistics were 0.92 for both females and males. The D statistic was 3.25 for females and 3.29 for males. The 10% of patients with the highest predicted risks included 77% of all lung cancers diagnosed over the subsequent 2 years. The algorithm has good discrimination and calibration and could potentially be used to identify those at highest risk of lung cancer, to facilitate early referral and investigation.

How to manage lung cancer in primary care

Edin Lakasing and Melanie Tester present an overview of the pathology of lung cancer and how to manage the symptoms of treatment.

Diagnosis of lung cancer in primary care: a structured review

Lung cancer has the highest cancer incidence and mortality in the UK. Despite this, an individual GP encounters only one new presentation approximately every 8 months, so gains relatively little experience of its diagnosis. This is partly addressed by referral guidelines which aim to help GPs in selection of patients for chest X-ray or referral for specialist investigation. The purpose of this study was to review the primary care presenting features of lung cancer, in the light of the UK Referral Guidelines for Suspected Cancer. A structured literature review was carried out. Little research has been undertaken in primary care, and the predictive values for most symptoms are unknown. Approximate likelihood ratios could be calculated for six symptoms or signs: haemoptysis 13; fatigue 5.7; cough 5.3; finger clubbing 3.9; weight loss 2.9; and dyspnoea 1.5-5.7, but none of these figures derived from single primary care studies. Three recommendations for urgent investigation of possible lung cancer in the UK Referral Guidelines are questioned: for unexplained dyspnoea, hoarseness or cervical lymphadenopathy. For all these presentations, other serious diagnoses are more likely. The UK Guidelines for referral of suspected lung cancer have a weak evidence base.