Advanced Lung Cancer Missed in Primary Care

Liam Davenport

October 16, 2014

Thirty percent of lung cancer patients die early in the United Kingdom, although they visit their primary care physician more often in the 3 months before their death than other lung cancer patients, a new study has shown.

The findings come from an analysis of more than 20,000 lung cancer cases, published online October 13 in Thorax.

The researcher team, led by Emma O'Dowd, MD, from the University of Nottingham, says that the findings indicate that there are missed opportunities to identify lung cancer patients earlier in the disease process.

Primary care physicians need support to identify these missed patients because they might see only one new case each year, said Michael Peake, MD, from Glenfield Hospital in Leicester and clinical lead for the UK National Cancer Intelligence Network, who wrote an accompanying editorial.

"I don't know how many patients with cough a primary care physician sees each year — hundreds and hundreds and hundreds," Dr Peake said. "They need a lot more support to try to flag things."

Consultations Highest Among Patients Who Die Early

For the study, Dr O'Dowd and her colleagues searched the UK Health Improvement Network database for all cases of lung cancer diagnosed from 2000 to 2013. They compared the proportion of patients diagnosed less than 30 days before death, less than 90 days before death, and after death with the proportion of patients who survived more than 90 days after diagnosis. The researchers also calculated rates of standardized chest x-ray and consultation for each practice.

The analysis involved 20,142 lung cancer cases from 444 general practices. Of these, 1071 (5%) had a death-certificate-only diagnosis, 2036 (10%) died 1 to 30 days after diagnosis, and 2976 (15%) died 31 to 90 days after diagnosis.

Factors independently associated with early death from lung cancer on logistic regression analysis were being male (odds ratio [OR], 1.17), being a current smoker (OR, 1.43), being older (≥80 years vs 65 - 69 years; OR, 1.80), being socially deprived (OR, 1.16), and living in a rural rather than urban area (OR, 1.22).

Crucially, patients who died early consulted their primary care physician more often than other patients (median, 5 vs 4 consultations).

"We showed that those who are older, those who are more socially deprived, current smokers, and those from rural areas...were the ones who were most likely to die, which perhaps isn't a great surprise. It's probably what we would have thought," Dr O'Dowd noted.

"The thing we were surprised about was that actually these patients were interacting with primary care," she explained. "It does suggest, certainly, that there are potentially missed opportunities to identify them earlier in the disease process."

A Mixed Picture of Chest X-ray Use

On multivariate analysis, the likelihood of early death was lower in patients who had a chest x-ray in primary care. However, patients registered at practices with a high x-ray rate were 41% more likely to die early than those registered at practices least likely to perform a chest x-ray, an anomaly the researchers believe might be due to ascertainment bias.

"We know that the chest x-ray is a very good initial investigation in patients with symptoms," Dr O'Dowd said. However, "it's not very good in completely asymptomatic patients, which is why it's not a very good screening tool."

She emphasized that patients who fit the profile of being at risk for lung cancer should have a chest x-ray early on.

Dr Peake said he agrees: "I think they should have a very low threshold for x-rays, and we ought to probably be looking at access to CT scans as well."

At present, CT scanning for lung cancer is being examined in clinical trials in the United Kingdom, where there is no public access to this technology. In contrast, in the United States, some centers advertise such screening to the general public.

"What we want to look into is what the people are consulting with," Dr O'Dowd noted. "Clearly, if someone comes in with something that we don't know is associated with lung cancer, we don't necessarily expect a primary care physician to be automatically thinking about that," Dr O'Dowd noted. "It may be that they are coming in with something that is very nonspecific."

Better Tools and Better Access

The study was prompted by the finding that the United Kingdom has poor cancer survival rates. The proportion of patients diagnosed with lung cancer at the earliest stage in the United Kingdom is 12% to 14%; in contrast, it is around 20% in countries such as Sweden and Canada, Dr Peake reported.

In addition, there are huge disparities in 1-year survival rates across the country, he noted, citing a previous study of survival rates in what were formerly designated primary care trusts (PCTs). "In some PCTs, the proportion who were alive at a year was 44.0%, and the worst PCT was 14.5%," said Dr Peake. "That's almost three times as many people alive at 1 year in one PCT as another."

To improve the diagnosis of early lung cancer, Dr Peake suggested easier access to care. For example, he said, patients should be able to obtain a chest x-ray from a pharmacist, practice nurse, or National Health Service walk-in center.

"What we ideally want to do is get patients presenting with the earliest-stage disease, when we know we've got a 70% 1-year survival," Dr O'Dowd said. "If we can get patients at the very early stage, they can do quite well. But by picking them up at the most advanced stage, we are down to 30% 1-year survival."

This aim has been put into practice in Leeds, United Kingdom. "They have open access...where anybody over 50 who reports with a cough and who has not had an x-ray in the previous 3 months can walk in and have an x-ray," Dr Peake explained.

Although the findings have not yet been published, "they've shown that the proportion of people surviving with early-stage disease with lung cancer has increased," he reported. "The proportion of people first coming into secondary care as an emergency, which is high, has dropped. The number of people who are getting potentially curative treatment has increased, and this has led to an improvement in the proportion of people who are alive at a year."

Dr Peake said he believes that public understanding of lung cancer also needs to be addressed. "We need to educate the public what the symptoms of lung cancer are, and that it's worth being detected early, because the whole perception is that if you are diagnosed it's a death sentence and nothing can be done."

In 2012, a 2-month public education campaign in the United Kingdom involving advertisements on television and in other media urged people with a cough lasting more than 3 weeks to visit their doctor. The project, part of Public Health England's Be Clear On Cancer campaign, was supported by Cancer Research UK, NHS England, and the Department of Health. It was reported by BBC News to be a great success, leading to an estimated 700 extra patients being diagnosed with lung cancer around the time of the campaign. However, there has been no repeat of that or any similar campaign since.

The study was supported by the Roy Castle Lung Cancer Foundation. Dr O'Dowd and Dr Peake have disclosed no relevant financial relationships.

Thorax. Published online October 13, 2014. Abstract, Editorial

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