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Frequent GP visits linked to late lung cancer diagnosis

GPs must have better risk tools and access to appropriate tests for lung cancer, conclude the authors of a study that found patients who died early of the disease consulted their GP more frequently prior to diagnosis.

The team – whose study is published today in Thorax – found patients who died within three months of diagnosis had consulted their GP a median of five times, compared with four times for patients who survived beyond three months.

Patients who died early were also less likely to have had a chest X-ray in primary care than others.

GP experts said the study reflected how difficult lung cancer is to diagnose in primary care, especially in deprived areas dealing with complex patients - and called for more funding to give them better resources to investigate patients earlier.

The study included 20,142 cases of lung cancer diagnosed between 2000 and 2013, which were identified in The Health Improvement Network database, and compared patients who died within 90 days of diagnosis with those who survived more than 90 days.

It showed men and current smokers were 17% and 43% more likely to die early than women and non-smokers, while people aged 80 or older were 80% more likely than people aged 65-69 to die within three months.

People with lowest socieconomic status, in the bottom quintile of Townend scores, were 16% more likely than the most affluent (top quintile) to die early, while living in a rural area upped the risk by 22%, compared with living in an urban environment.

While the odds of an early death were lower among those who had had a chest X-ray carried out in primary care, patients registered at a practice with high referral rates for chest X-rays were 41% more likely to die early than those from practices with low referral rates.

The Nottingham University researchers, led by Dr Emma O’Dowd, concluded: ‘We need to promote better use of risk assessment tools, and use software prompts to help GPs to identify and investigate in a timely manner those at risk.

‘This has potential to increase the proportion of patients who are diagnosed at an early stage and are, therefore, suitable for treatment with curative intent.’

Dr Richard Roope, RCGP cancer lead, said lung cancer was difficult to pick up in primary care - and called for better funding and technology for those working under particularly challenging conditions.

Dr Roope said: ‘Lung cancer is notoriously difficult to diagnose in primary care, especially as a key symptom is coughing, which is present with numerous other conditions that GPs see every day.

‘Taking into account the global picture, GPs across the UK are doing very well considering the meagre resources available to us; funding for general practice is at an all-time low, we have a chronic shortage of doctors, and access to CT scanners, that would help in the diagnosis of lung cancer, is very limited in UK primary care.’

He added: ‘Instead of criticising GPs, we need to invest in general practice to allow us to employ more GPs and support staff and to give GPs more access to technology that could ultimately save our patients’ lives.’

Dr Rupert Jones, clinical research fellow at the University of Plymouth and respiratory lead at NHS Northern, Eastern and Western Devon CCG, said it was important for patients to be investigated early for lung cancer, but said patients in deprived areas tended to be more likely to refuse investigations.

Dr Jones said: ‘Deprivation is a major risk factor for lung cancer and poor prognosis – which does seem to be related to them not getting treatment early. I work in a practice in a very deprived area and it is very clear patients with social deprivation have a range of barriers that prevent them receiving care at the right stage.

‘Some patients from deprived areas are quite surprising in that they don’t want to be investigated – I have had a number who have declined investigations for a variety of reasons, to a much greater extent that people from more affluent areas.’

He added: ‘The Government is actively disinvesting in deprived areas, so that increasingly there is a struggle to provide decent quality primary care in deprived areas – and I suspect we’re seeing problems as a result not just for lung cancer but a whole range of conditions that require an early and accurate diagnosis.

‘I think it’s a wake-up call that the current systems of payment are really working against GPs in deprived areas when they actually need greater investment.’

Thorax 2014; available online 14 October

>>>> Clinical Newswire

Readers' comments (2)

  • Vinci Ho

    (1) I think the interpretation of this study by media (even you guys in Pulse) is a bit skewed
    (2) it is a very interesting study and highlight the severity of the problem in diagnosing lung cancer early enough.
    (3) We all expect the incidence of fatal lung cancer will be high in certain patient group(older ,socially deprived male and history of heavy smoking ,>30 a day). We were presuming that this group of patient is difficult to reach but as the discussion of the study suggested , these patients actually attended their GPs most certainly for various other co-morbidities before the diagnosis of lung cancer.
    (4) the most interesting part to me is the study found that even practices generally doing more CXRs for their patients were ironically worse on picking up these cases of lung cancer . We know the sensitivity of CXR to pick up features consistent with lung cancer is only around 70-80%. I certainly had a case where a patient was kept calling back by radiologist for more and more CXRs for 'atelectasis' in a period of 3 months before I decided to request a CT and advanced lung carcinoma was diagnosed . Perhaps the research point here is to link 'positive' findings on first CXR with the prognosis of eventual lung cancer.
    (5) Professor John Field in Liverpool has been researching in lung cancer (I had the pleasure to work with him in one of the projects involving a screening study in Chinese population for lung cancer ) and he suggested a screening with low dose CT in patients age 55-80 , at least those with high risks .

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  • Reliance on chest x-Rays and clinical suspicion but denying us other imaging eg ct scans is a big problem for us. Maybe they don't trust us to use more advanced diagnostics appropriately, resulting in more referrals to secondary care.

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