Defining the road map to a UK national lung cancer screening programme.

Lung cancer screening with low-dose CT was recommended by the UK National Screening Committee (UKNSC) in September, 2022, on the basis of data from trials showing a reduction in lung cancer mortality. These trials provide sufficient evidence to show clinical efficacy, but further work is needed to prove deliverability in preparation for a national roll-out of the first major targeted screening programme. The UK has been world leading in addressing logistical issues with lung cancer screening through clinical trials, implementation pilots, and the National Health Service (NHS) England Targeted Lung Health Check Programme. In this Policy Review, we describe the consensus reached by a multiprofessional group of experts in lung cancer screening on the key requirements and priorities for effective implementation of a programme. We summarise the output from a round-table meeting of clinicians, behavioural scientists, stakeholder organisations, and representatives from NHS England, the UKNSC, and the four UK nations. This Policy Review will be an important tool in the ongoing expansion and evolution of an already successful programme, and provides a summary of UK expert opinion for consideration by those organising and delivering lung cancer screenings in other countries.

Incidence trends for twelve cancers in younger adults-a rapid review.

Many cancer referral guidelines use patient's age as a key criterium to decide who should be referred urgently. A recent rise in the incidence of colorectal cancer in younger adults has been described in high-income countries worldwide. Information on other cancers is more limited. The aim of this rapid review was to determine whether other cancers are also increasing in younger age groups, as this may have important implications for prioritising patients for investigation and referral. We searched MEDLINE, Embase and Web of Science for studies describing age-related incidence trends for colorectal, bladder, lung, oesophagus, pancreas, stomach, breast, ovarian, uterine, kidney and laryngeal cancer and myeloma. 'Younger' patients were defined based on NICE guidelines for cancer referral. Ninety-eight studies met the inclusion criteria. Findings show that the incidence of colorectal, breast, kidney, pancreas, uterine cancer is increasing in younger age groups, whilst the incidence of lung, laryngeal and bladder cancer is decreasing. Data for oesophageal, stomach, ovarian cancer and myeloma were inconclusive. Overall, this review provides evidence that some cancers are increasingly being diagnosed in younger age groups, although the mechanisms remain unclear. Cancer investigation and referral guidelines may need updating in light of these trends.

Identification of patients with potential palliative care needs: A systematic review of screening tools in primary care.

BACKGROUND: Despite increasing evidence of the benefits of early access to palliative care, many patients do not receive palliative care in a timely manner. A systematic approach in primary care can facilitate earlier identification of patients with potential palliative care needs and prompt further assessment. AIM: To identify existing screening tools for identification of patients with advanced progressive diseases who are likely to have palliative care needs in primary healthcare and evaluate their accuracy. DESIGN: Systematic review (PROSPERO registration number CRD42019111568). DATA SOURCES: Cochrane, MEDLINE, Embase and CINAHL were searched from inception to March 2019. RESULTS: From 4,127 unique articles screened, 25 reported the use or development of 10 screening tools. Most tools use prediction of death and/or deterioration as a proxy for the identification of people with potential palliative care needs. The tools are based on a wide range of general and disease-specific indicators. The accuracy of five tools was assessed in eight studies; these tools differed significantly in their ability to identify patients with potential palliative care needs with sensitivity ranging from 3% to 94% and specificity ranging from 26% to 99%. CONCLUSION: The ability of current screening tools to identify patients with advanced progressive diseases who are likely to have palliative care needs in primary care is limited. Further research is needed to identify standardised screening processes that are based not only on predicting mortality and deterioration but also on anticipating the palliative care needs and predicting the rate and course of functional decline. This would prompt a comprehensive assessment to identify and meet their needs on time.

Understanding GPs' referral decisions for younger patients with symptoms of cancer: a qualitative interview study.

BACKGROUND: Cancer incidence increases with age, so some clinical guidelines include patient age as one of the criteria used to decide whether a patient should be referred through the urgent suspected cancer (USC) pathway. Little is known about how strictly GPs adhere to these age criteria and what factors might influence their referral decisions for younger patients. AIM: To understand GPs' clinical decision making for younger patients with concerning symptoms who do not meet the age criteria for USC referral. DESIGN AND SETTING: Qualitative study using in-depth, semi-structured interviews with GPs working in surgeries across England. METHOD: Participants (n = 23) were asked to recall consultations with younger patients with cancer symptoms, describe factors influencing their clinical decisions, and discuss their overall attitude to age thresholds in cancer referral guidelines. A thematic analysis guided by the Framework approach was used to identify recurring themes. RESULTS: GPs' decision making regarding younger patients was influenced by several factors, including personal experiences, patients' views and behaviour, level of clinical concern, and ability to bypass system constraints. GPs weighted potential benefits and harms of a referral outside guidelines both on the patient and the health system. If clinical concern was high, GPs used their knowledge of local systems to ensure patients were investigated promptly even when not meeting the age criteria. CONCLUSION: While most GPs interpret age criteria flexibly and follow their own judgement and experience when making clinical decisions regarding younger patients, system constraints may be a barrier to timely investigation.

Early-stage lung cancer associated with higher frequency of chest x-ray up to three years prior to diagnosis.

OBJECTIVES: Symptom awareness campaigns have contributed to improved early detection of lung cancer. Previous research suggests that this may have been achieved partly by diagnosing lung cancer in those who were not experiencing symptoms of their cancer. This study aimed to explore the relationship between frequency of chest x-ray in the three years prior to diagnosis and stage at diagnosis. SETTINGS: Lung cancer service in a UK teaching hospital. PARTICIPANTS: Patients diagnosed with lung cancer between 2010 and 2013 were identified. The number of chest x-rays for each patient in the three years prior to diagnosis was recorded. Statistical analysis of chest x-ray frequency comparing patients with early- and late-stage disease was performed. RESULTS: One-thousand seven-hundred fifty patients were included - 589 (33.7%) with stage I/II and 1,161 (66.3%) with stage III/IV disease. All patients had at least one chest x-ray in the six months prior to diagnosis. Those with early-stage disease had more chest x-rays in this period (1.32 vs 1.15 radiographs per patient, P = 0.009). In the period 36 months to six months prior to lung cancer diagnosis, this disparity was even greater (1.70 vs 0.92, radiographs per patient, P < 0.001). CONCLUSIONS: Increased rates of chest x-ray are likely to contribute to earlier detection. Given the known symptom lead time many patients diagnosed through chest x-ray may not have been experiencing symptoms caused by their cancer. The number of chest x-rays performed could reflect patient and/or clinician behaviours in response to symptoms.

Improving medical research in the United Kingdom.

Poor quality medical research causes serious harms by misleading healthcare professionals and policymakers, decreasing trust in science and medicine, and wasting public funds. Here we outline underlying problems including insufficient transparency, dysfunctional incentives, and reporting biases. We make the following recommendations to address these problems: Journals and funders should ensure authors fulfil their obligation to share detailed study protocols, analytical code, and (as far as possible) research data. Funders and journals should incentivise uptake of registered reports and establish funding pathways which integrate evaluation of funding proposals with initial peer review of registered reports. A mandatory national register of interests for all those who are involved in medical research in the UK should be established, with an expectation that individuals maintain the accuracy of their declarations and regularly update them. Funders and institutions should stop using metrics such as citations and journal's impact factor to assess research and researchers and instead evaluate based on quality, reproducibility, and societal value. Employers and non-academic training programmes for health professionals (clinicians hired for patient care, not to do research) should not select based on number of research publications. Promotions based on publication should be restricted to those hired to do research.

Associations between general practice characteristics and chest X-ray rate: an observational study.

BACKGROUND: Chest X-ray (CXR) is the first-line test for lung cancer in many settings. Previous research has suggested that higher utilisation of CXR is associated with improved outcomes. AIM: To explore the associations between characteristics of general practices and frequency of investigation with CXR. DESIGN AND SETTING: Retrospective observational study of English general practices. METHOD: A database was constructed of English general practices containing number of CXRs requested and data on practices for 2018, including patient and staff demographics, smoking prevalence, deprivation, and patient satisfaction indicators. Mixed-effects Poisson modelling was used to account for variation because of chance and to estimate the amount of remaining variation that could be attributed to practice and population characteristics. RESULTS: There was substantial variation in GP CXR rates (median 34 per 1000 patients, interquartile range 26-43). Only 18% of between-practice variance in CXR rate was accounted for by recorded characteristics. Higher practice scores for continuity and communication skills, and higher proportions of smokers, Asian and mixed ethnic groups, and patients aged >65 years were associated with increased CXR rates. Higher patient satisfaction scores for access and greater proportions of male patients and patients of Black ethnicity were associated with lower CXR rates. CONCLUSION: Substantial variation was found in CXR rates beyond that expected by chance, which could not be accounted for by practices' recorded characteristics. As other research has indicated that increasing CXR rates can lead to earlier detection, supporting practices that currently investigate infrequently could be an effective strategy to improve lung cancer outcomes.

Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review.

BACKGROUND: The cancer burden falls predominantly on older (≥65 years) adults. Prompt presentation to primary care with cancer symptoms could result in earlier diagnosis. However, patient symptom appraisal and help-seeking decisions involving cancer symptoms are complex and may be further complicated in older adults. AIM: To explore the effect of older age on patients' appraisal of possible cancer symptoms and their decision to seek help for these symptoms. DESIGN AND SETTING: Mixed-methods systematic review. METHOD: MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library, Web of Science Core Collection, ASSIA, the ISRCTN registry, and the National Institute for Health and Care Excellence were searched for studies on symptom appraisal and help-seeking decisions for cancer symptoms by adults aged ≥65 years. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis guidelines. RESULTS: Eighty studies were included with a total of 32 995 participants. Studies suggested a possible association between increasing age and prolonged symptom appraisal interval. Reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, in the current study a possible association was found between increasing age and prompt help-seeking. Themes affecting help-seeking in older adults included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, comorbidities, a desire to avoid doctors, a perceived need to not waste doctors' time, and patient self-management of symptoms. CONCLUSION: This review suggests that increasing age is associated with delayed cancer symptom appraisal. When symptoms are recognised as potentially serious, increasing age was associated with prompt help-seeking although other factors could prolong this. Policymakers, charities, and GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and seek help promptly.

Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review.

BACKGROUND: Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer. AIM: To examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis. DESIGN AND SETTING: A systematic literature review. METHOD: Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines. RESULTS: Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers. CONCLUSION: This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.

The ethics and politics of addressing health inequalities.

Social determinants of health are responsible for a large proportion of disease which disproportionately affects deprived population groups, resulting in striking disparities in life expectancy and quality of life. Even systems with universal access to healthcare (such as the UK's NHS) can only mitigate some consequences of health inequalities. Instead substantial societal measures are required both to reduce harmful exposures and to improve standards of housing, education, work, nutrition and exercise. The case for such measures is widely accepted among healthcare professionals but, in wider discourse, scepticism has remained about the role of government and society in improving life chances along with the belief that responsibility for health and wellbeing should rest with individuals themselves. The stark inequalities exposed by the coronavirus pandemic could be an opportunity to challenge this thinking. This paper argues that doctors should do more to persuade others of the need to address health inequalities and that to achieve this, it is important to understand the ethical and philosophical perspectives that are sceptical of such measures. An approach to gaining greater support for interventions to address health inequalities is presented along with reflections on effective political advocacy which is consistent with physicians' professional values.

Ensuring Informed Decision-Making for Cancer Screening.

The history of cancer screening has demonstrated that the case for cancer screening is not straightforward. In contemporary practice, sharing decision-making with patients has become expected of family physicians. At the same time, increasing emphasis has been placed on encouraging patients to participate in screening programs to improve cancer outcomes. The success of cancer screening is often judged by the number of those who participate. Improving cancer outcomes should be a priority for family medicine, but the importance of this goal should not undermine doctors' commitment to helping patients make informed decisions that are consistent with their values and priorities. If we are serious about empowering patients, we need to be more open about the limitations of cancer screening, to help patients make up their minds.

Estimating lung cancer risk from chest X-ray and symptoms: a prospective cohort study.

BACKGROUND: Chest X-ray (CXR) is the first-line investigation for lung cancer in many countries but previous research has suggested that the disease is not detected by CXR in approximately 20% of patients. The risk of lung cancer, with particular symptoms, following a negative CXR is not known. AIM: To establish the sensitivity and specificity of CXR requested by patients who are symptomatic; determine the positive predictive values (PPVs) of each presenting symptom of lung cancer following a negative CXR; and determine whether symptoms associated with lung cancer are different in those who had a positive CXR result compared with those who had a negative CXR result. DESIGN AND SETTING: A prospective cohort study was conducted in Leeds, UK, based on routinely collected data from a service that allowed patients with symptoms of lung cancer to request CXR. METHOD: Symptom data were combined with a diagnostic category (positive or negative) for each CXR, and the sensitivity and specificity of CXR for lung cancer were calculated. The PPV of lung cancer associated with each symptom or combination of symptoms was estimated for those patients with a negative CXR. RESULTS: In total, 114 (1.3%) of 8996 patients who requested a CXR were diagnosed with lung cancer within 1 year. Sensitivity was 75.4% and specificity was 90.2%. The PPV of all symptoms for a diagnosis of lung cancer within 1 year of CXR was <1% for all individual symptoms except for haemoptysis, which had a PPV of 2.9%. PPVs for a diagnosis of lung cancer within 2 years of CXR was <1.5% for all single symptoms except for haemoptysis, which had a PPV of 3.9%. CONCLUSION: CXR has limited sensitivity; however, in a population with a low prevalence of lung cancer, its high specificity and negative predictive value means that lung cancer is very unlikely to be present following a negative result. Findings also support guidance that unexplained haemoptysis warrants urgent referral, regardless of CXR result.

Chest X-ray sensitivity and lung cancer outcomes: a retrospective observational study.

BACKGROUND: Chest X-ray (CXR) is the first-line investigation for lung cancer in many healthcare systems. An understanding of the consequences of false-negative CXRs on time to diagnosis, stage, and survival is limited. AIM: To determine the sensitivity of CXR for lung cancer and to compare stage at diagnosis, time to diagnosis, and survival between those with CXR that detected, or did not detect, lung cancer. DESIGN AND SETTING: Retrospective observational study using routinely collected healthcare data. METHOD: All patients diagnosed with lung cancer in Leeds Teaching Hospitals NHS Trust during 2008-2015 who had a GP-requested CXR in the year before diagnosis were categorised based on the result of the earliest CXR performed in that period. The sensitivity of CXR was calculated and analyses were performed with respect to time to diagnosis, survival, and stage at diagnosis. RESULTS: CXR was negative for 17.7% of patients (n = 376/2129). Median time from initial CXR to diagnosis was 43 days for those with a positive CXR and 204 days for those with a negative CXR. Of those with a positive CXR, 29.8% (95% confidence interval [CI] = 27.9% to 31.8%) were diagnosed at stage I or II, compared with 33.5% (95% CI = 28.8% to 38.6%) with a negative CXR. CONCLUSION: GPs should consider lung cancer in patients with persistent symptoms even when CXR is negative. Despite longer duration to diagnosis for those with false-negative CXRs, there was no evidence of an adverse impact on stage at diagnosis or survival; however, this comparison is likely to be affected by confounding variables.

A prospective cohort evaluation of the sensitivity and specificity of the chest X-ray for the detection of lung cancer in symptomatic adults.

BACKGROUND: The accuracy of the chest x-ray (CXR) in the identification of lung cancer amongst symptomatic individuals is uncertain. PURPOSE: To determine the diagnostic accuracy of the CXR for the detection of non-small cell carcinomas (NSCLC) and all primary intrathoracic malignancies. METHODS: A prospective cohort study of consecutive CXR reports obtained within a primary care open access initiative. Eligibility criteria were symptoms specified by National Institute for Clinical Excellence as indicative of possible lung cancer and age over 50-yrs. A positive test was a CXR which led directly or indirectly to investigation with CT. The reference standards were malignancies observed within a one- or two-year post-test period. RESULTS: 8,948 CXR outcomes were evaluated. 496 positive studies led to a diagnosis of 101 patients with primary intrathoracic malignancy including 80 with NSCLC. Within two-years, a cumulative total of 168 patients with primary intrathoracic malignancies including 133 NSCLC were observed. The sensitivity and specificity for NSCLC were 76% (95 %CI 68-84) and 95% (95 %CI 95-96) within 1-year and 60% (95 %CI 52-69) and 95% (95 %CI 95-96) within 2-years. The 2-yr positive and negative likelihood ratios were 12.8 and 0.4. The results did not differ for NSCLC compared to all primary malignancies. Within this symptomatic population a negative test reduced the 2-year risk of lung cancer to 0.8%. CONCLUSIONS: A positive test strongly increases the probability of malignancy whereas a negative test does not conclusively exclude the disease. The findings allow the risk of malignancy following a negative test to be estimated.

Correction to: Recognising Lung Cancer in Primary Care.

The original article has published with incorrect license statement.

Reducing bias and improving transparency in medical research: a critical overview of the problems, progress and suggested next steps.

In recent years there has been increasing awareness of problems that have undermined trust in medical research. This review outlines some of the most important issues including research culture, reporting biases, and statistical and methodological issues. It examines measures that have been instituted to address these problems and explores the success and limitations of these measures. The paper concludes by proposing three achievable actions which could be implemented to deliver significantly improved transparency and mitigation of bias. These measures are as follows: (1) mandatory registration of interests by those involved in research; (2) that journals support the 'registered reports' publication format; and (3) that comprehensive study documentation for all publicly funded research be made available on a World Health Organization research repository. We suggest that achieving such measures requires a broad-based campaign which mobilises public opinion. We invite readers to feedback on the proposed actions and to join us in calling for their implementation.

Recognising Lung Cancer in Primary Care.

Significant advances in the management of both early and advanced stage lung cancer have not yet led to the scale of improved outcomes which have been achieved in other cancers over the last 40 years. Diagnosis of lung cancer at the earliest stage of disease is strongly associated with improved survival. Therefore, although recent advances in oncology may herald breakthroughs in effective treatment, achieving early diagnosis will remain crucial to obtaining optimal outcomes. This is challenging, as most lung cancer symptoms are non-specific or are common respiratory symptoms which usually represent benign disease. Identification of patients at risk of lung cancer who require further investigation is an important responsibility for general practitioners (GPs). Diagnosis has historically relied upon plain chest X-ray (CXR), organised in response to symptoms. The sensitivity of this modality, however, compares unfavourably with that of computed tomography (CT). In some jurisdictions screening high-risk individuals with low dose CT (LDCT) is now recommended. However uptake remains low and the eligibility for screening programmes is restricted. Therefore, even if screening is widely adopted, most patients will continue to be diagnosed after presenting with symptoms. Achieving early diagnosis requires GPs to maintain an appropriate level of suspicion and readiness to investigate in high-risk patients or those with non-resolving symptoms. This article discusses the early detection of lung cancer from a primary care perspective. We outline risk factors and epidemiology, the role of screening and offer guidance on the recognition of symptomatic presentation and the investigation and referral of suspected lung cancer.