Lung cancer

Many lung cancers being diagnosed in emergency departments

Many patients with lung cancer are being diagnosed in emergency settings, and fewer than half see a lung specialist in the lead up to diagnosis, a NSW study shows.

A review of “pathways to diagnosis” for  894 people with non-small cell lung cancer (NSCLC) in NSW between 2006 and 2012 found that 25% presented in emergency settings and 14% did not see a GP or lung specialist prior to being diagnosed.

The most common pathways (30% of patients with NSCLC) included GP attendance, GP-ordered imaging and lung specialist attendance, without an emergency admission.

However in the three months prior to diagnosis only 39% of patients saw a respiratory physician and fewer than half (46%) had a diagnostic procedure such as bronchoscopy or biopsy. Likewise, about half of patients had a chest X-ray or CT scan and almost a third of patients did not have either.

Patients who were diagnosed with NSCLC in an emergency setting were more likely to have distant spread (67% vs 40%), whereas patients who had a lung specialist attendance in the lead up to diagnosis had a lower proportion of lung cancers with distant spread (31% vs 59%) than those who did not. Patients who saw a lung specialist also had a higher proportion of cases with histopathologically confirmed diagnosis (77% vs 65%).

Researchers from the Cancer Institute NSW said the key role that primary care doctors played in lung cancer diagnosis was highlighted by the increasing rates of GP attendances before diagnosis, with 60% of patients seeing a GP multiple times in the three months prior to diagnosis and a similar proportion having GP-ordered thoracic imaging.

They noted that living in a rural or regional area made no difference to the pattern of attendances prior to diagnosis of NSCLC. Further research was needed to see whether attending respiratory physicians who are members multidisciplinary teams results in different outcomes, they added.

The high rates of emergency department presentation could be explained by some lung cancers having mild symptoms for a prolonged period until sudden onset of symptoms requiring emergency treatment. Some patients may avoid seeking help due to stigma about lung cancer, or lack of urgency about mild symptoms.

Patients with lung cancer symptoms may attend an emergency department as a way to avoid real or perceived barriers to accessing a lung specialist or lung tests, they suggested.

“Reasons for not seeing a lung specialist in the community before a diagnosis of NSCLC could include the sudden onset of severe symptoms requiring emergency presentation to hospital (e.g. haemoptysis), referral to a non-lung specialist (e.g. an oncologist or a general physician), referral to a specialist for the presenting symptoms of distant metastases (e.g. a neurologist) or an incidental finding of lung cancer while undergoing investigation for another condition,” they wrote in Primary Care Respiratory Medicine.

“Further research on barriers to recognition of lung cancer symptoms and access to lung specialists is needed from both a patient and physician perspective,” they concluded.

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