It is always difficult and distressing to find out that you may have misdiagnosed a patient’s illness, or that there has been a delay in making the correct diagnosis. When the diagnosis in question is something as serious and potentially life-threatening as lung cancer, the distress may be all the greater. It is not unusual for the patient or their family to make a complaint, or to bring a claim for clinical negligence.

While some patients do present with the classic symptoms of haemoptysis or persistent cough, or chest signs, others may present less typically. In hindsight, it may be possible to connect the presenting symptoms to the final cancer diagnosis, but this may not be the case at the time of presentation. Patients may not recognise that their presentation was atypical, and may believe that their GP has, in some way, let them down.

The MDU has reviewed 205 cases from between 2008 and 2013 in which a GP received a complaint or a claim in relation to alleged delayed diagnosis of primary lung cancer. In this analysis we looked at:

  • the patients’ presenting symptoms
  • provisional or working diagnoses
  • how long before a correct diagnosis was made.

We also looked at whether chest x-rays were carried out, and what these showed.

“30 patients reported chest, rib or shoulder pain without any respiratory symptoms at the time of presentation”

Symptoms

Sign/symptoms

Number (percentage) of presentations

Cough 116 (56.6%)
Shortness of breath 66 (32.2%)
Haemoptysis 27 (13.2%)
Chest/rib pain 71 (35%)
Shoulder pain 37 (18%)
Weight loss 38 (19%)
Back pain 19 (9%)
Tiredness/lethargy/fatigue 15 (7%)
GI symptoms (dysphagia, epigastric pain, reflux, altered bowel habit) 14 (7%)
Swellings/lumps 11 (5%)
Voice changes 10 (5%)
Anorexia 5 (2%)


As one might expect, the commonest presenting features in patients who ultimately had a diagnosis of lung cancer were respiratory. These included cough, shortness of breath, and haemoptysis. Other presenting symptoms were more vague, such as lethargy, fatigue or anorexia. It is, however, notable that a significant minority (25.8%) reported no respiratory symptoms before they were diagnosed as having lung cancer.

Just over 30% (64) of the patients reported non-specific systemic symptoms such as anorexia, weight loss, fatigue or night sweats. Of these, 19 reported no respiratory symptoms.

Pain was a common presenting feature for patients who were ultimately diagnosed as having lung cancer, with 86 patients (42%) reporting pain at the time of presentation. Of these, 49 reported chest or rib pain, 15 reported shoulder pain and 22 reported both.

We were interested in particular to note that 30 patients reported chest, rib or shoulder pain without any respiratory symptoms at the time of presentation. Eight of this group also had systemic symptoms.

It is perhaps worth noting that it was not always apparent from the contemporaneous records that the symptoms which patients subsequently referred to in their complaint or a claim had been mentioned by the patient at the time of initial presentation.

Working diagnoses

Diagnosis

Number (percentage) of patients

Infection (including chest, flu etc) 44 (21%)
COPD 37 (18%)
Musculoskeletal 30 (15%)
GI symptoms/cause 10 (5%)
Asthma 7 (3%)


As one might expect, the initial working diagnoses for the patients who went on to be diagnosed with lung cancer were often primarily respiratory. Most were diagnosed with an infection, including chest infection, flu or flu-like illness, or with Chronic Obstructive Pulmonary Disease. However, a significant minority were diagnosed as having a non-respiratory illness, and of these the most common was a musculoskeletal problem. Others were diagnosed as suffering from a gastro-intestinal problem.

Of those who presented with a cough, 62% were diagnosed as having COPD and/or an infection. Over 50% of these patients (47 of 87) had systemic symptoms or pain as well as a cough.

Of those who presented with chest, rib or shoulder pain but without respiratory symptoms, the most common working diagnosis was of non-specific musculoskeletal pain. Other diagnoses included costochondritis, polymyalgia rheumatica, rotator cuff pain and depression.

In many of the cases, it was not clear from the records what the working diagnosis was.

Delay

The reported duration of symptoms between the first presentation and the ultimate diagnosis of lung cancer in this cohort of patients was between two weeks and five years. Excluding the two outliers who alleged that symptoms had been present for five years, the mean alleged delay was 7.9 months.

In those patients who presented with predominantly non-respiratory symptoms, the mean time between presentation and diagnosis was 6.4 months (range two weeks to two years). Patients with non-specific systemic symptoms reported that their symptoms had been present for an average of 6.7 months (range 1-18 months).

For the 16 patients who suffered rib or chest pain but no respiratory symptoms, the mean alleged delay was 7.6 months (range 1-24 months)

X-rays

While carrying out the review of presenting symptoms in patients who were alleging a delay in diagnosis of lung cancer, it became apparent that in a number of cases, a chest x-ray had been carried out. In total, 25 of the 205 patients had had a chest x-ray done some time before the diagnosis of lung cancer was reached. In 19 of these, the chest x-ray was reported as normal.

Conclusions

The review of cases notified to the MDU indicates that lung cancer may present in a variety of ways. Certainly, it can present in a classical manner, with respiratory symptoms such as haemoptysis, intractable cough or recurrent infection. However, it may also present with less typical symptoms, such as chest, rib or shoulder pain, or non-specific systemic symptoms. These may often present without any of the respiratory symptoms which might give the doctor an early clue as to the underlying reason for the presentation. The absence of respiratory symptoms, and even a normal chest x-ray, may not reliably exclude an underlying chest neoplasm.

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.

FOOTNOTES

  1. National Institute for Clinical Excellence (Accessed 8 July 2015)

This article was correct at publication on 12/08/2015. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

Dr Edward Farnan

Medico-legal adviser

MB BCh BAO LLM FRCGP DGM DCH DRCOG

Dr Farnan graduated from Queen's University, Belfast, in 1995 and completed his GP training in Northern Ireland, practising as a principal in general practice in Armagh for 11 years. He also sat on a research ethics committee, and had a particular interest in clinical governance.

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