The days are getting longer and there is a sense of optimism in the air along with Spring...to quote D:Ream (1993), 'Things can only get better' (apologies if that has planted an ear worm that you won't shift all day). As we come out of lockdown the promise that General Practice may be able to return to some sense of (new) normality is enticing. But what does that mean in practice for all those patients who have stayed away from us for the last 12 months and what are we going to discover?
I saw one such patient last week - a 74-year-old ex-smoker who had been feeling under the weather for months. He’d put all his symptoms down to deconditioning during lockdown and being a bit lonely. He hadn’t wanted to trouble us in the practice as we’ve been busy dealing with the day job and rolling out the vaccine programme. Eventually, his daughter persuaded him to call because the bothersome cough was now undeniably present and I chatted to him long enough to establish this was quite out of character and needed further evaluation. Given his cough symptom, I saw him in our car park shelter. Never has a 3x3m gazebo been so well used over the winter. Fortunately, the weather was kind, dry at least. The noise of leaves dancing in the breeze and birdsong posed a bizarre juxtaposition as I strained to listen to his chest. What I noted was the absence of breath sounds in the left apex. Not an easy task when competing with pinny rustle, road hum, or the chatter of local wildlife. Add to that the challenge of noting observational findings through a steamed-up visor – a whole new set of clinical skills have developed! I filed the CXR report today - apical opacification, probable tumour.
How many more patients like this are we going to uncover as we establish a more normal level of service? That so many have stayed away from us during the pandemic means we will be busy playing catch up for months or years to come.
The lung cancer referral pathway was particularly affected by the Covid pandemic and has been slow to recover. Cancer Research UK report that in England, urgent referrals for suspected lung cancer were down by 34% between March-January 2020/21 compared to the same period in the previous year, equating to 20,300 fewer people referred (1). A similar picture has been seen in Wales and Scotland.
Insight into the public’s help-seeking behaviour during the pandemic has been evaluated in a recent study led by researchers at Cardiff University in collaboration with Cancer Research UK. Within the sample size of 7,500 people, 40% reported a potential cancer symptom during the previous 6 months. In those with symptoms less than half had contacted their GP for advice, even for red flag symptoms such as haemoptysis. Reasons cited as barriers to seeking help included concerns about wasting the doctor’s time, over-stretching limited healthcare resources, and risk of Covid infection.
In response to findings such as this, NHSE in conjunction with PHE have launched a new National Campaign ‘Help Us Help You – Lung Cancer Symptoms’ (2) Running until the end of May, the campaign aims to increase public awareness of lung cancer symptoms. It reinforces the message that if a cough persists for more than 3 weeks and it is not Covid, patients should contact their GP. The Scottish Government has also launched a Detect Cancer Early Campaign, reminding people over 40y of the potential signs of lung cancer and reinforcing the point that cancer remains a priority during the pandemic. (3) The campaigns aim to reassure the public that the NHS is open for business so there is no reason to avoid making contact if new symptoms develop. We can do our bit by letting patients know that hospitals are Covid safe and therefore appointments should be kept, to minimise non-attendance rates as much as possible.
It’s worth noting that the pattern of presenting symptoms of lung cancer has changed over the last 20 years. An observational study published in the BJGP (2020:70;e193) (4) highlighted that whilst haemoptysis remains a cardinal ‘red flag’ symptom, the most common presenting symptoms for lung cancer are now cough and dyspnoea. Clearly, the overlap with Covid symptoms is significant and somewhat muddies the water for both patients and ourselves. The British Thoracic Oncology Group / Lung Cancer Clinical Expert Group (June 2020)(5) has helped this by publishing some clinical guidance to help differentiate between Covid and lung cancer. I would highly recommend downloading the infographic and sharing it amongst colleagues. Cancer Research UK has also produced a useful one-page summary highlighting the key messages for health professionals during the pandemic.
Our first line investigation for symptomatic patients in GP remains CXR. A systematic review published in the BJGP (2019:69;e827)(6) found that around 20% of people with lung cancer had a ‘false negative’ CXR in the year before diagnosis, calling into question the role of CXRs as an initial investigation.
A more recent prospective cohort study provided a bit more clarity to the role of CXR and the risk of lung cancer (BJGP 2021;71(705):e280-e286)(7). It highlights that whilst a 20% false-negative rate exists, the low prevalence of lung cancer in a symptomatic population means the NPV for CXR is still very high. The sensitivity of CXR for a diagnosis of lung cancer at one year was 75%. In combination with a NPV of 99%, the CXR is well suited to its role as a first-line investigation in a low prevalence setting.
Author Stephen Bradley comments, ‘I think the messages for GPs are really to keep an open mind regardless of CXR (it’s not an infallible test) and to take unexplained haemoptysis particularly seriously. Because of the difficulties in diagnosing lung cancer we should not ignore our intuition (sometimes known as 'gut feeling') that a patient may be seriously ill, or indeed if a patient or their family express such concern. It’s also worth remembering that referral guidelines can't cover every eventuality and doctors should feel empowered to use their own judgement when they are concerned about cancer.'
One question that has been asked in light of recent evidence on CXRs – is rapid CT scanning the answer? (BJGP 2019:69;90)(8). This analysis paper reviewed the evidence and concluded that direct access CT scanning for patients who have had a normal CXR but where the GP is concerned about the possibility of lung cancer can potentially expedite the diagnosis.
We await the publication of an observational study by Bradley et al. looking at the accuracy of CXR in over 2000 patients diagnosed with lung cancer and comparing outcomes for those who had a false negative CXR to those with a true positive CXR. The study found that although those with falsely normal CXRs had a longer interval to diagnosis, the outcomes in terms of stage and diagnosis and survival following diagnosis were similar. It is of course important to recognise that the limitations of an observational study might mean that adverse consequences of false-negative CXRs could not be captured.
As far as my practice goes, I will continue to rely on my clinical judgement and gut instinct. If my ‘spidey senses’ start to tingle it is a sign that I need to do more to investigate that particular patient. It is reassuring to know that CXRs are a valuable first-line investigation for symptomatic patients, but I no longer feel guilty for requesting a CT scan in those who I have ongoing concern about. If Covid has taught me anything, it is to expect the unexpected and be prepared to adapt behaviour in response to a constantly changing environment. Unusual and exciting times!
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