Intended for healthcare professionals

Practice Easily Missed?

Lung cancer

BMJ 2014; 349 doi: (Published 06 November 2014) Cite this as: BMJ 2014;349:g6560
  1. Richard D Neal, professor of primary care medicine1,
  2. William Hamilton, professor of primary care diagnostics2,
  3. Trevor K Rogers, consultant respiratory physician3
  1. 1North Wales Centre for Primary Care Research, Bangor University, Wrexham LL13 7YP, UK
  2. 2Department of Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
  3. 3Doncaster Royal Infirmary, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
  1. Correspondence to: R D Neal r.neal{at}

The bottom line

  • Suspect lung cancer in all at-risk patients (age, smoking, chronic obstructive pulmonary disease) with a new respiratory symptom, or atypical non-respiratory symptom, even if they appear otherwise well

  • Consider lung cancer in non-smokers with suspicious symptoms, especially haemoptysis and multiple symptoms

  • Chest radiography is cheap, easy, widely available, and relatively harm free, but can be falsely negative. Have a low threshold for repeating or referring for specialist opinion (or considering computed tomography if available) if there are diagnostic suspicions

  • Aim to diagnose patients as quickly as possible to optimise the chance of cure and active anti-cancer treatment

A 65 year old recent ex-smoker with a 20 pack year history and chronic obstructive pulmonary disease (COPD) consults his general practitioner because of worse chest symptoms over the past three weeks, with increasing breathlessness and production of green sputum, and a feeling of being “off colour.” Similar previous spells have been treated with antibiotics and steroids to good effect. On examination his temperature is normal, his heart rate is 88 beats/min, respiratory rate is 16 breaths/min, and oxygen saturation is 94% on air. He has tobacco stained fingers but no clubbing or evidence of weight loss. Scattered crackles and wheezes are found on auscultation of the lungs. After treatment with antibiotics and steroids he feels no better, and after two further consultations he is referred for chest radiography, which is reported as showing a lesion suspicious of lung cancer.

How common is it?

  • In 2011, there were 43 463 new cases of lung cancer in the United Kingdom, making it the second most common cancer and representing 13% of all new cancers1

  • The crude incidence rate is 77 cancer cases per 100 000 men in the UK, and 61 per 100 000 women

  • In most cases there is a history of smoking, and incidence increases with age

  • Patients …

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