What characteristics of primary care and patients are associated with early death in patients with lung cancer in the UK?

Background: The UK has poor lung cancer survival rates and high early mortality, compared to other countries. We aimed to identify factors associated with early death, and features of primary care that might contribute to late diagnosis. Methods: All cases of lung cancer diagnosed between 2000 and 2013 were extracted from The Health Improvement Network database. Patients who died within 90 days of diagnosis were compared with those who survived longer. Standardised chest X-ray (CXR) and lung cancer rates were calculated for each practice. Results: Of 20 142 people with lung cancer, those who died early consulted with primary care more frequently prediagnosis. Individual factors associated with early death were male sex (OR 1.17; 95% CI 1.10 to 1.24), current smoking (OR 1.43; 95% CI 1.28 to 1.61), increasing age (OR 1.80; 95% CI 1.62 to 1.99 for age ≥80 years compared to 65–69 years), social deprivation (OR 1.16; 95% CI 1.04 to 1.30 for Townsend quintile 5 vs 1) and rural versus urban residence (OR 1.22; 95% CI 1.06 to 1.41). CXR rates varied widely, and the odds of early death were highest in the practices which requested more CXRs. Lung cancer incidence at practice level did not affect early deaths. Conclusions: Patients who die early from lung cancer are interacting with primary care prediagnosis, suggesting potentially missed opportunities to identify them earlier. A general increase in CXR requests may not improve survival; rather, a more timely and appropriate targeting of this investigation using risk assessment tools needs further assessment

Symptom lead times in lung and colorectal cancers: What are the benefits of symptom-based approaches to early diagnosis?

This is the final version of the article. Available from Cancer Research UK via the DOI in this record.Background: Individuals with undiagnosed lung and colorectal cancers present with non-specific symptoms in primary care more often than matched controls. Increased access to diagnostic services for patients with symptoms generates more early-stage diagnoses, but the mechanisms for this are only partially understood. Methods: We re-analysed a UK-based case-control study to estimate the Symptom Lead Time (SLT) distribution for a range of potential symptom criteria for investigation. Symptom Lead Time is the time between symptoms caused by cancer and eventual diagnosis, and is analogous to Lead Time in a screening programme. We also estimated the proportion of symptoms in lung and colorectal cancer cases that are actually caused by the cancer. Results: Mean Symptom Lead Times were between 4.1 and 6.0 months, with medians between 2.0 and 3.2 months. Symptom Lead Time did not depend on stage at diagnosis, nor which criteria for investigation are adopted. Depending on the criteria, an estimated 27-48% of symptoms in individuals with as yet undiagnosed lung cancer, and 12-32% with undiagnosed colorectal cancer are not caused by the cancer. Conclusions: In most cancer cases detected by a symptom-based programme, the symptoms are caused by cancer. These cases have a short lead time and benefit relatively little. However, in a significant minority of cases cancer detection is serendipitous. This group experiences the benefits of a standard screening programme, a substantial mean lead time and a higher probability of early-stage diagnosis.This work was supported by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme, RP-PG-0608-10045

Symptom lead times in lung and colorectal cancers: what are the benefits of symptom-based approaches to early diagnosis?

BACKGROUND: Individuals with undiagnosed lung and colorectal cancers present with non-specific symptoms in primary care more often than matched controls. Increased access to diagnostic services for patients with symptoms generates more early-stage diagnoses, but the mechanisms for this are only partially understood. METHODS: We re-analysed a UK-based case–control study to estimate the Symptom Lead Time (SLT) distribution for a range of potential symptom criteria for investigation. Symptom Lead Time is the time between symptoms caused by cancer and eventual diagnosis, and is analogous to Lead Time in a screening programme. We also estimated the proportion of symptoms in lung and colorectal cancer cases that are actually caused by the cancer. RESULTS: Mean Symptom Lead Times were between 4.1 and 6.0 months, with medians between 2.0 and 3.2 months. Symptom Lead Time did not depend on stage at diagnosis, nor which criteria for investigation are adopted. Depending on the criteria, an estimated 27–48% of symptoms in individuals with as yet undiagnosed lung cancer, and 12–32% with undiagnosed colorectal cancer are not caused by the cancer. CONCLUSIONS: In most cancer cases detected by a symptom-based programme, the symptoms are caused by cancer. These cases have a short lead time and benefit relatively little. However, in a significant minority of cases cancer detection is serendipitous. This group experiences the benefits of a standard screening programme, a substantial mean lead time and a higher probability of early-stage diagnosis

Chronic Obstructive Pulmonary Disease and Risk of Lung Cancer: The Importance of Smoking and Timing of Diagnosis

Introduction:The majority of cases of both lung cancer and chronic obstructive pulmonary disease (COPD) are attributable to cigarette smoking, but whether COPD is an independent risk factor for lung cancer remains unclear.Methods:We used The Health Improvement Network, a U.K. general practice database, to identify incident cases of lung cancer and controls matched on age, sex, and practice. Using conditional logistic regression, we assessed the effects of timing of first diagnoses of COPD, pneumonia, and asthma on the odds of lung cancer, adjusting for smoking habit.Results:Of 11,888 incident cases of lung cancer, 23% had a prior diagnosis of COPD compared with only 6% of the 37,605 controls. The odds of lung cancer in patients who had COPD diagnosed within 6 months of their cancer diagnosis were 11-fold those of patients without COPD (odds ratio 11.47, 95% confidence interval 9.38–14.02). However, when restricted to earlier COPD diagnoses, with adjustment for smoking, the effect markedly diminished (for COPD diagnoses >10 years before lung cancer diagnosis, odds ratio: 2.18, 95% confidence interval: 1.87–2.54). The pattern was similar for pneumonia. The effect of COPD on lung cancer remained after excluding patients who had a codiagnosis of asthma.Conclusion:A diagnosis of COPD is strongly associated with a diagnosis of lung cancer, however, this association is largely explained by smoking habit, strongly dependent on the timing of COPD diagnosis, and not specific to COPD. It seems unlikely, therefore, that COPD is an independent risk factor for lung cancer

Recognising Lung Cancer in Primary Care

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