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GPs go forth

NICE opens consultation on guidelines recommending x-rays for diagnosing lung cancer

A consultation has launched into NICE guidelines that recommend x-rays for lung cancer, which has recently been criticised for being outdated. 

Research recently found that chest X-rays were failing to identify lung cancer in 20% of patients, yet the procedure continues to be recommended by NICE guidelines.

NICE launched a consultation today on its proposals to not update these guidelines after a review in August, and said it was giving stakeholders the opportunity to comment on this decision. 

It follows research published in the British Journal of General Practice which called on GPs to consider further investigation in high-risk patients who have had a negative chest X-ray.

The study said: ‘GPs should take limited reassurance from a non-diagnostic chest X-ray and consider additional imaging or referral of those at high risk, or re-imaging in the face of continuing symptoms.

'If chest X-ray were a novel technology, it is debatable whether the available evidence would be deemed sufficient to support its implementation as a diagnostic test for lung cancer.'

Author of the study, Stephen Bradley, said: X-ray has been with us for a long time but surprisingly, there has been very little research into how accurate it is for diagnosing lung cancer. It is important to know this because in the UK it is still the first-line test that GPs use when they are worried about their patient having lung cancer.

'This systematic review has compiled the best available evidence and we estimate that chest X-ray identifies around 80% of lung cancer cases. Our lung cancer outcomes still lag behind other high-income countries, with less patients diagnosed at early stages of the illness. There are likely to be many reasons for this, but this research suggests that one factor could be our reliance on chest X-ray, compared to other countries that make more use of tests like computed tomography (CT) scans.’

Chest X-ray, which is cheap, accessible and has a low radiation dose, remains the most common route to diagnosis in the UK. It is recommended by NICE guidelines as the initial evaluation tool for all patients - bar those over 40 with unexplained haemoptysis.

But researchers analysed the results of three high-quality studies in England, Ireland and Denmark and found that ‘chest X-ray fails to identify lung cancer - at least initially - in over 20% of people who are subsequently diagnosed with lung cancer’.

However although the study demonstrated a significant false-negative rate for chest X-ray, it also warned that the benefits of increased rates of CT investigation must be balanced against known harms including overdiagnosis and false-positives.

A NICE spokesperson said: 'We routinely review our guidance to ensure it reflects the most current and relevant research findings. We are currently assessing our ‘suspected cancer: recognition and referral’ guideline to determine if there are any areas that should be updated.

'Based on the review of evidence as recent as August 2019 it was decided that an update was not needed. However, stakeholders will have an opportunity to comment on this decision from today. Details on the consultation process will be available here.'

Lung cancer is the single largest cause of cancer mortality both worldwide and in the UK but unlike other cancers improvements in survival rates have only increased by 5% since 1971. By comparison, the improvement in breast cancer survival over the same period is 34%.

Outcomes for lung cancer in the UK remain poor compared to other advanced economies where computed tomography (CT) rather than X-ray is used more extensively. Early detection of lung cancer is associated with improved survival.

NICE recently updated its depression guidelines to warn of 'severe' and lengthy antidepressant withdrawal symptoms, having originally said symptoms were mild. The original guideline was criticised by doctors who said that the 'flawed' methodology and out-of-date evidence would 'seriously impede' patient care and choice.

Readers' comments (4)

  • Agree would love to have better direct access to CT especially for my higher risk patients (we do have abnormal CXR pathway direct to CT) but my radiology department is on its knees currently regarding capacity so suspect I would be a tad unpopular if even tried asking for this.

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  • Personally,I just do not like NICE,in fact I like very little Tony Blair did.

    The guidelines are so long you need a summary.

    They are for everyone,clearly there should be two sets,one for specialists and one for GP's, with clear boundaries.

    They tend to look back from the diagnosis,where the specialist starts and extrapolate to what the GP should have done.

    They make no allowance for actual resources available.

    A recent urgent CT request locally was indeed performed urgently,however the department did not consider it appropriate to report urgently,as that had not been specifically requested.

    NICE tend to ignore the big questions.

    Having performed whatever test,a week later the patient will still be a breathless smoker.How often should we x ray,every three ? six ? nine ? months,the clinical scenario is not going away.

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  • Once again resources and availability as well as speed are ignored.
    Nice one NICE. I wonder if the radiologist get charged with Gross Negligence Manslaughter for not doing a CT scan in good time or blame the GP again for "not highlighting it sufficiently". Toxic UK.

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  • it will pick up 80% of lung cancer which is great. if normal and you are not sure then request a cat scan. no one really knows how often to xray or cat scan people with lung cancer risk factors - eg with asbestos exposure, yearly cat scans were no better than 5 yearly ones in one study. There are some new tests coming including using sputum sample for dna markers but we are a few years from that yet. I repeat a CXR every 5 years in my high risk patients. any suspicious symptoms then cat scan. in copd patients, if they fail to respond to 2 courses of antibiotics and havn't had a CXR in the past 12 months i repeat the CXR, check the sputum and BNP levels to exclude drug resistance and heart failure which is very common. If new patient with lots sputum, normal CXR and spirometry I cat scan them as it may be bronchiectasis as this is often missed on a CXR. also check alpha one anti-trypsin as picked up quite a few patients in this scenario especially if there is a FH of copd in the female line who were non smokers or early age in smokers. if you are not sure about them then refer - the resp department have much better spirometry equipment or can access detailed pet scans which we can't. its not easy to pick up lung cancer as it often presents late and can be subtle. it would be unfair to blame a GP for missing a diagnosis with a normal CXR and few symptoms. we don't have enough scanners compared to Europe and the US which is why we are so far behind them.

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