Intended for healthcare professionals

Practice Clinical updates

Lung cancer

BMJ 2019; 365 doi: (Published 03 June 2019) Cite this as: BMJ 2019;365:l1725
  1. Richard D Neal, professor of primary care oncology1,
  2. Fei Sun, clinical research fellow, honorary specialty registrar in clinical oncology2,
  3. Jon D Emery, Herman professor of primary care cancer research3,
  4. Matthew E Callister, consultant respiratory physician2
  1. 1Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9NL, UK
  2. 2Leeds Teaching Hospitals Trust, St James’s Hospital, Leeds LS9 7TF, UK
  3. 3Centre for Cancer Research and Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victorian Comprehensive Cancer Centre, Victoria 3000, Australia
  1. Correspondence to: R D Neal R.D.Neal{at}

What you need to know

  • Most lung cancers present with non-specific symptoms; haemoptysis is a feature in only 20%

  • Consider a chest x ray for patients who have persistent symptoms or thrombocytosis, and repeat chest x ray or computed tomography (CT) if symptoms persist

  • Positron emission tomography-computed tomography (PET-CT) is used to identify distant metastases in those eligible for radical treatment after contrast-enhanced CT. If there is potential mediastinal node involvement, endobronchial ultrasound guided transbronchial needle aspiration is the optimal initial strategy for nodal sampling

  • Surgery remains the standard of care in early stage non-small cell lung cancer (NSCLC). Radical radiotherapy or stereotactic ablative radiotherapy (SABR) are alternatives. Options for locally advanced NSCLC include surgery with postoperative chemotherapy or chemoradiotherapy

  • Systemic therapy for metastatic NSCLC is now targeted primarily on tumour genetic mutations and biomarkers. Tyrosine-kinase inhibitor (TKIs) and immunotherapy are first line treatments for some patients with metastatic NSCLC. Combination chemotherapy is available for patients not eligible for TKIs or immunotherapy

Lung cancer is one of the commonest cancers worldwide.1 Outcomes are among the poorest of all tumour types, with five year survival of 10-20%.2 Survival is hugely influenced by stage at diagnosis, with five year survival varying from 92% to 0% for the earliest and latest stages respectively.3 In this update we discuss contemporary therapeutic options, and approaches to increasing symptom awareness and early diagnosis. Low-dose computed tomography (CT) screening is beyond the scope of this review.

Sources and selection criteria

In addition to searching Clinical Evidence and the Cochrane Collaboration, we based this article on databases of references. We also examined the citation lists of included articles.

Who gets it?

Worldwide, about three quarters of lung cancers are attributable to smoking; others are caused by occupational workplace exposure, radon exposure, and air pollution.4 It is more common in men, and incidence increases with age (fig 1). Recent …

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