One in four chest X-rays in patients with lung tumours appear ‘normal’ and so cannot alone exclude the possibility of cancer, according to Dr Jaishree Bhosle, a consultant medical oncologist at the Royal Marsden Hospital in London.
She said some GPs did not want to unduly alarm or worry patients when investigating symptoms by suggesting they could have lung cancer, and so avoid spelling it out as a possibility on referral letters.
But it is vital GPs raise any concerns and specifically state a patient is at risk of cancer when referring patients to radiologists to prevent patients getting an all-clear from the X-ray and leaving their cancer undiagnosed, Dr Bhosle insisted.
Speaking at the MIMS Clinical Update conference in London on Thursday, Dr Bhosle said: ‘I think in some cases, GPs do suspect lung cancer, but because they have to give the request to the patient, they don’t want to write on it "lung cancer". So they write pneumonia instead. But the problem is if they haven't written lung cancer, they give the radiologist a get-out clause.’
She argued that radiologists could recommend further tests and CT scans to make extra checks if the X-ray came back normal yet cancer had been marked as a possibility. Without this highlighted, they may simply downgrade the case once pneumonia is ruled out.
Only GPs can 'see the whole picture'
She added that many radiologists look at scans in isolation and have often not seen a patient’s previous X-rays. In contrast, GPs can access much more information to view the 'whole picture’, and are uniquely placed to assess how a patient has changed over time between ‘normal’ X-rays.
Given this insight, she said, GPs should ‘just say no’ to a patient being downgraded based on normal-looking X-rays if they remain concerned about his or her health.
Many lung cancer symptoms are vague, making the decision to refer for X-ray difficult. They include a persistent cough, chest pain, shoulder pain and shortness of breath. Dr Bhosle said GPs should particularly be on the lookout for finger clubbing as a warning sign of lung cancer.
GPs should suspect lung cancer in anyone over 40 with such symptoms, and should be aware of and consider risk factors – including family history, COPD, asbestos exposure and smoking history – when considering a chest X-ray referral.
It is especially important that GPs fully understand a patient’s smoking history beyond just their current smoking status. Ex-smokers are still at greater risk than never-smokers, even if they quit years or decades before their symptoms develop. Patients who have smoked over longer periods, particularly if they started when they were under 20 years-old, are at the greatest risk.