Persistent shoulder pain

A 56-year old man presented to his GP. He had been a smoker for 30 years, but had stopped six years ago. He had no significant past medical history. He presented with persistent right shoulder pain which limited his ability to play golf and to garden.

The GP examined the patient and made a working diagnosis of adhesive capsulitis. He recommended exercises, prescribed non-steroidal anti-inflammatory drugs and referred the patient for physiotherapy. When the symptoms failed to resolve, he also arranged for the patient to have an intra-articular corticosteroid injection.

Approximately four months after the initial presentation and with no resolution in symptoms, the patient returned to the GP. At this stage he also reported a non-resolving cough of five weeks’ duration. The GP arranged an urgent chest x-ray which showed a suspicious lesion. The GP referred the patient to his local respiratory physician under the two-week rule. A diagnosis of lung cancer was confirmed. This was found to be operable and the patient had surgery and made a good recovery. It was felt that the presenting pain was related to the site of the tumour.

He complained that the GP had not made the diagnosis earlier, and that he had therefore been in pain for longer than might have been the case, and also that the delay might have resulted in the tumour spreading, although there was no evidence that this had in fact occurred.

The MDU assisted the GP in responding to the complaint. The response included an apology and also described how the GP had reflected and learned from the case, which his practice had treated as a significant event. The complainant was satisfied with this response, and did not take the matter any further.

Avoiding delay in lung cancer diagnosis

Commentary on the MDU study findings

Dr. Simon Watkin, Consultant Respiratory Physician, Borders General Hospital

Dr Watkin is a full time consultant respiratory physician at the Borders General Hospital, Melrose. One of his main clinical interests is the diagnosis and assessment of patients with lung cancer. For some years he was lung cancer lead for the Norfolk and Waveney Cancer Network and before that a Cancer Research Campaign Lung Cancer Research Fellow in the Mersey Region.

How common is lung cancer?

Each year in the UK there are 43,000 new cases of lung cancer, 95% of which occur in current or ex-smokers. Although lung cancer in men reduced by a quarter between 1971 and 2006, rates in men still exceed those in women (77 versus 61 per 100,000). Lung cancer causes about one in five of cancer deaths in the UK and lung cancers outnumber breast and colon cancer combined.

A general practitioner might expect to see a new lung cancer patient once every 8-12 months. Unlike breast and colon cancer there is no agreed method for lung cancer screening and only about 5% of lung cancer patients will be cured.

Why is this study from the MDU archives important?

This case analysis highlights the importance of having a low threshold for considering that non-specific symptoms could indicate lung cancer.

In one third of the cases reviewed the patient had symptoms such as anorexia, weight loss or fatigue. Pain was also a common presenting feature and occurred in over 40%. While 25% of patients did not have any respiratory symptoms it remains the case that the most common presenting features of lung cancer are respiratory. Absence of haemoptysis is no guarantee that lung cancer is not present.

How common are delays in diagnosis?

Most studies relating to lung cancer symptoms show that patients delay reporting important symptoms to their GP for several months before the first consultation. This may be because of fear of the actual diagnosis, or because many already have chronic respiratory symptoms and are accustomed to temporary changes in the level of their symptoms.

The same studies also show that the diagnostic interval between first presentation and diagnosis is three to four months, often with several attendances in the intervening period. Lung cancer patients are often prescribed non-specific treatments or treatment for COPD exacerbations in this period.

A recent Danish study showed that longer diagnostic intervals were associated with higher mortality. The commonly held view – that lung cancer is silent until far advanced – is likely to be inaccurate because of the finding of symptoms for many months before diagnosis in this and similar studies. While improvements in public education about lung cancer may encourage early presentation, it is also important that doctors understand the key symptoms that should prompt a request for a chest x-ray and specialist referral.

Guidance

NICE guidelines¹, updated in 2015, recommend referral onto a suspected cancer pathway (for an appointment within two weeks) for lung cancer if there is a chest x-ray finding suggestive of lung cancer or if the patient is aged 40 or over with unexplained haemoptysis.

An urgent chest x-ray (to be performed within two weeks) should be requested to assess for lung cancer in people aged 40 and over if they have two or more of the following unexplained symptoms, or if they have ever smoked and have one or more of the following unexplained symptoms: cough, fatigue, shortness of breath, chest pain, weight loss or loss of appetite.

Consider an urgent chest x-ray (to be performed within two weeks) to assess for lung cancer in people aged 40 and over with any of the following: persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, thrombocytosis or chest signs consistent with lung cancer.

In some cases, such as smaller central tumours, the chest x-ray may be normal. If clinical suspicion remains high, patients should be considered for urgent referral for further investigation such as CT scanning.

Would screening be better than early symptom detection?

Screening for lung cancer should in theory increase the number of early tumours detected and therefore improve the chance of curative treatment but effective screening for lung cancer has proved elusive. There is no evidence that chest x-rays or sputum cytology are effective screening tools. Low dose non-contrast surveillance CT scanning has been associated with early case finding and modest increases in curative treatments. But these benefits are offset by a high number of false positive lesions requiring invasive investigations, and by health economic considerations. In the UK, CT screening is not performed.

This makes it all the more important for GPs to identify and refer patients who present with symptoms that suggest lung cancer. Early referral may lead to the identification of more treatable lung cancer, for example, where the cancer is still surgically resectable. Earlier referral also allows for confirmation of staging and histology, and the development of a treatment plan. Although an intuitive finding, the evidence confirms that lengthy diagnostic intervals have a negative psychological impact on patient experience. This MDU study illustrates the ways in which patients whose diagnosis was allegedly delayed had originally presented.

What happens when a patient is referred?

Most referral hospitals will have a system in place to notify the respiratory physicians dealing with lung cancer of any patient whose chest x-ray (or CT scan) shows a possible lung cancer. In many cases this will lead to an automatic outpatient appointment, backed up by relevant patient and GP correspondence. It is true that sometimes the chest x-ray is normal but this is not a sustainable argument for failing to refer in a timely way.

The maximum permissible time between GP referral for suspected lung cancer and specialist consultation is 14 days and this is achieved virtually 100% of the time throughout the UK. This presents a considerable improvement on the situation which existed prior to the national cancer initiatives from 1995 onwards.

High profile public campaigns, such as the Detect Cancer Early programme in Scotland, are also likely to result in greater numbers of patients presenting to their GP at an earlier stage.