Like many others, I am currently finding clinical work a challenge. It seems that making between 30 & 40 patient contacts each day is standard (for some it may be worse), and the majority of these are on the telephone with a few video consultations thrown into the mix. I see a couple of patients face to face each session. Seeing more poses many challenges in a practical sense; not least because whilst working in an old house is very characterful, it is totally impractical when it comes to having space to socially distance patients and have more than a few in the building at any one time. Am sure many of you are in a similar situation.
Two weeks ago I spoke to a patient, a 62y old who I shall call John. Whilst John has a 20-year pack history for smoking, he has been an ex-smoker for 15y and has never had any respiratory symptoms suggestive of smoking-related lung disease. He called because he had a cough. This cough had been present for the last 4 weeks. When it first started he felt under the weather with a temperature (>37.8) and some mild dyspnoea. He followed NHS 111 guidance and had a Covid test, which was negative. He was now frustrated that his symptoms had persisted for over a month and was keen to discuss treatment options. In terms of other symptoms, he was non-specific – yes he felt tired but thought that was due to interrupted sleep from the cough, yes he felt more SOB when he coughed, perhaps his appetite was slightly reduced but he couldn’t be sure…We discussed possible options and agreed on bloods and a CXR. Both were normal. What should I do with John now? I have spoken to several patients like John since, presentations like these are common at the moment as I am sure you will all agree.
In the ‘good old days’, we all strove to work to the trusty NICE NG12 guidelines when it came to improving our early diagnosis of cancer. For suspected lung cancer we aimed to urgently refer anyone aged 40y or above with an abnormal CXR or haemoptysis. For the rest of the over 40s it was recommended that we consider an urgent CXR if they had other clinical features, some of which were more concerning than others. It became the norm to consider a CXR if symptoms persisted, and thanks to several different public health campaigns such as CRUK’s Be Clear on Cancer lung cancer campaign we began to request CXRs if those pesky coughs or respiratory symptoms went on for more than 3 weeks. So far so good.
More recently however the waters have been muddied (as they often are) by new research. First to consider is our use of CXR as the first-line investigation for symptomatic patients. Almost all of us have direct access to CXRs which makes it a useful test to request. But is it enough? A recent systematic review published in the BJGP in December 2019 found that the sensitivity of CXR for symptomatic lung cancer is 77-80%. This false-negative rate means we are missing around 20% of early lung cancers. As we know from cancer survival statistics, these are the cancers we ideally want to be picking up as the chance of cure is significantly higher (and unfortunately 75% lung cancers are still diagnosed at a later/incurable stage).
Another factor to consider is the so-called ‘red flag’ symptoms that ought to prompt urgent action. It is now apparent that over the last 20 years we have seen a shift in the pattern of presenting symptoms for lung cancer and haemoptysis is no longer the prevailing symptom in the majority of cases. According to a recent observational study published in the BJGP in March 2020, cough and breathlessness are now more common presentations for lung cancer and haemoptysis occurs rarely. This is an important learning point for us – we need to place as much emphasis on considering persistent/unexplained cough and dyspnoea as possible red flags as we do on haemoptysis. It is likely that future symptom awareness campaigns for patients will reflect this shift in presentation.
OK, so that makes it a bit trickier to pick up new (and more importantly early diagnoses) of lung cancer. Now let’s throw in a curve ball – Covid 19. If you look at the reported referral rates for 2WW suspected lung cancer in England from NHS Digital, the number of patients referred urgently at the end of August was still only at 60% of the February 2020 weekly average, up from 36% at the peak of the pandemic.
The cause of this is likely to be multifactorial. In my blog, in May I considered the impact that changes in patient behaviour are likely to have as they try to avoid contact with the medical profession. There is also the effect that remote consulting has on our diagnostic ability, which my colleague Simon discussed in his blog back in July. Both of these factors are contributing to the reduction in referral rates for suspected lung cancer.
Perhaps the biggest challenge we face is the fact that Covid is a masterful mimic and there is significant symptom overlap with lung cancer. Fortunately in June 2020 some clinical guidance was published by the Lung Cancer Clinical Expert Group (CEG) and shared by the British Thoracic Oncology Group. The guidance helpfully sets out a framework for managing those patients who present with overlapping symptoms such as cough, breathlessness or fatigue and I think are very relevant and useful for us in Primary Care. In July the Scottish Government published clinical guidance using a similar framework – it is always reassuring when the recommendations are united. CRUK have also produced a useful summary on the recommendations for recognition and referral for suspected lung cancer during the Covid pandemic.
Moving forward the messages from recent publications are clear:
At present, the drive to increase referral rates needs to be balanced with the need to control the Covid pandemic. As ever we find ourselves the gatekeepers to secondary care at a time when our patients are perhaps at their most vulnerable. GP life is never dull!
Dr Kate Digby
NB Medical Education, Cancer Lead
GP in Gloucestershire
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