Respiratory symptoms awareness campaign: Overview

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Public Health England is running a national awareness campaign focusing on the respiratory symptoms of a persistent cough and inappropriate breathlessness. The campaign will run from 14 July to 16 October 2016, encouraging those with relevant symptoms to present to their GP, with the aim of diagnosing more cases of lung cancer, lung and heart disease earlier.

Read the campaign overview briefing sheet

The decision to run a campaign on respiratory symptoms is based on positive evidence from the evaluation of the previous campaigns for lung cancer and breathlessness (as a symptom of chronic obstructive pulmonary disease, heart disease and a range of other conditions).

Read the campaign announcement for more information

This page contains information on previous lung cancer and breathlessness campaigns, which may be helpful for those who are planning local activity, preparing for an upcoming national campaign or interested in the impact of Be Clear on Cancer campaigns on patient outcomes.

About the respiratory symptoms awareness campaign

What is Be Clear on Cancer?

Be Clear on Cancer aims to achieve earlier diagnosis of cancer by raising awareness of the signs and symptoms. The campaigns encourage people with relevant symptoms to see their GP without delay.

When will activity be running?

The campaign will run from 14 July to 16 October 2016. Activity will include television, radio, press, online and out-of-home advertising, and face-to-face events in shopping centres.

The respiratory symptoms awareness campaign will be the main national Be Clear on Cancer broadcast campaign for 2016. The advertising for the campaign will therefore run for longer than usual (14 weeks), with the aim of raising the overall impact on diseases such as lung (including cancer and COPD) and heart disease. We recommend that you compare any uplift in service demand to previous campaigns, however please be mindful that in this instance, it may vary due to the length of the campaign. 

Who is the campaign targeting?

The campaign is aimed at men and women aged 50 and over, as well as their key influencers, such as friends and family. People over 50 are most at risk of having an undiagnosed respiratory disease and make up 97% of lung cancer diagnoses.[1]

What is the main message?

The key messages for the public are:

  • If you’ve had a cough for three weeks or more, it could be a sign of lung disease, including cancer. Finding it early makes it more treatable. So don’t ignore it, tell your doctor.
  • If you get out of breath doing things you used to be able to do, it could be a sign of lung or heart disease, or even cancer. Finding it early makes it more treatable. So don’t ignore it, tell your doctor.

References

  1. National Cancer Registration & Analysis Service (NCRAS) data based on 2010-2014 annual

The respiratory symptoms awareness campaign will be the first Be Clear on Cancer campaign to combine awareness raising activity for lung cancer with a range of other conditions, including lung and heart disease. The campaign aims to cover multiple disease areas with its messaging, with the potential to increase its overall impact by tackling a number of different conditions that share similar symptoms. Cough and breathlessness are linked to illnesses that are causing thousands of deaths in the UK each year – and many have complex diagnostic pathways, which lead to delays in diagnosis. Raising symptom awareness among the public and healthcare professionals is one of the ways to make people more aware of this problem. The conditions include (in addition to lung cancer), chronic obstructive pulmonary disease (COPD) and heart disease, including coronary heart disease (CHD). The campaign will particularly focus on the older population (>50), especially those who are from lower socio-economic backgrounds, who tend to have poorer outcomes.

Public Health England has run several lung cancer campaigns across England, including campaigns that have piloted locally, regionally and nationally. In addition to this, a regional breathlessness campaign ran in the east of England in 2015. There have been encouraging results from these activities, however more work is required in order to improve earlier diagnosis of lung diseases, such as lung cancer, COPD and heart disease.  

Older age in lung cancer is a risk factor for emergency presentation – which is linked to advanced stage disease, often leading to significantly poorer outcomes for patients. In addition to this, individuals from more deprived groups are also at an increased risk of presenting as an emergency.[1] Increased diagnosis by primary care can reduce emergency admissions and improve the prognosis for many lung and heart conditions. Be Clear on Cancer aims to encourage more people who are in the target age group of over 50, from lower socio-economic backgrounds, with appropriate symptoms to present earlier. The aim is for these patients to be referred on promptly for investigation.

An estimated 1,300 deaths from lung cancer could be avoided in England each year if survival matched the best in Europe.[2] The poor survival for lung cancer in Britain compared with Europe is thought to be predominantly due to larger numbers of patients being diagnosed with late stage disease, when the cancer is already locally advanced or has spread, therefore excluding them from potentially curative surgery. Early diagnosis is one of the key ways to improve survival, alongside improved access to diagnostics and optimal treatment.

References

  1. Mitchell et al, Risk factors for emergency presentation with lung and colorectal cancers: a systematic review 2015. BMJ Open 2015;5:e006965 doi:10.1136/bmjopen-2014-006965
  2. Source: British Journal of Cancer (2009) 101, S115–S124.  doi:10.1038/sj.bjc.6605401  http://www.nature.com/bjc/journal/v101/n2s/full/6605401a.html

For lung diseases such as lung cancer, each year:

 

  • Around 36,500 people in England are diagnosed (19,900 men, and 16,600 women)[1]
  • Approximately 28,400 die from lung cancer in England (15,700 men, and 12,600 women)[1]
  • In 2013, around 12,700 (35%) lung cancer cases were diagnosed via an emergency presentation,[2] which is often indicative of advanced stage disease when curative treatment is no longer possible
  • Most lung cancers are diagnosed at a late stage (74%), compared to 25% at an early stage[1]
  • One-year relative survival for those diagnosed via emergency presentation is low at 13%, compared to 43% for those diagnosed via the two week referral pathway[3]
  • The earlier lung cancer is diagnosed, the more treatable it is. 83% (81% of men and 85% of women) diagnosed at the earliest stage (Stage I) will live for a year after diagnosis. At a late stage (Stage IV), this drops to 17% (15% of men and 19% of women)[4]

View more lung cancer statistics on Cancer Research UK's cancer statistics pages. 

In addition to lung cancer, figures for chronic obstructive pulmonary disease (COPD) show:

  • An estimated one million people in England are diagnosed with COPD, however it is estimated that a further one million people are living with undiagnosed COPD[5]
  • 24,000 people die of COPD in England each year (approximately half men and half women)[6]

Heart disease statistics in England show:

  • Around 1.8 million are diagnosed with coronary heart disease in England (CHD),[7] an estimated 600,000 people living with coronary heart disease in England who haven’t been diagnosed[8]
  • Over 70,000 people died from heart disease in 2014 (figure includes coronary heart disease (CHD, 56,634 deaths in 2014) and ‘other heart diseases’)[9]
  • Coronary heart disease is the single biggest cause of death in England, accounting for around 12% of all deaths[10]

References

  1. Incidence and mortality data supplied by NCRAS 2016, based on the annual average for 2010-2014
  2. Incidence and mortality data supplied by NCRAS 2016, these data are based on a single year (2013)
  3. Routes to Diagnosis data http://www.ncin.org.uk/publications/routes_to_diagnosis
  4. Office for National Statistics (2016). Cancer survival by stage at diagnosis for England (experimental statistics). Access via: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/cancersurvivalbystageatdiagnosisforenglandexperimentalstatistics/adultsdiagnosed20122013and2014andfollowedupto2015
  5. Data calculated by PHE Knowledge and Intelligence Team East based on 2014-15 Quality and Outcomes Framework (QOF) data and  2011 Modelled disease estimates http://www.hscic.gov.uk/catalogue/PUB18887. 2014-15 Quality and Outcomes Framework (QOF) data indicate that 1,034,578 people have been diagnosed with COPD. Modelled disease estimates from 2011 indicate that diagnosed COPD is around 57% of actual prevalence. However these estimates have considerable margin of error and given this uncertainty the gap between the number of people on disease registers and predicted numbers could be as high as 1 million.
  6. http://www.opm.co.uk/wp-content/uploads/2016/04/Breathlessness-Report-6April.pdf
  7. Quality and Outcomes Framework (QOF) for April 2014 - March 2015, England. Health and Social Care Information Centre http://www.hscic.gov.uk/catalogue/PUB18887
  8. Provided by PHE National Cardiovascular Intelligence Unit based on 2011 and 2014 estimated prevalence of Coronary Heart Disease
  9. British Heart Foundation (2015), Cardiovascular Disease Statistics. Access via: https://www.bhf.org.uk/publications/statistics/cvd-stats-2015
  10. http://webarchive.nationalarchives.gov.uk/20160105160709  http:www.ons.gov.uk/ons/rel/vsob/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2014/sty-what-we-die-from.html

More than 90% of patients with lung cancer are symptomatic at diagnosis, with cough being the most common presenting symptom.[1] Breathlessness is a common symptom of COPD, heart disease and a range of other conditions.[2] The campaign will combine lung cancer and breathlessness, with the aim of encouraging more people with these symptoms to visit their GP earlier. For all of these diseases, finding them sooner will make treating them successfully more likely, which helps to prolong survival.

Patients who are most at risk of these conditions might not interpret their initial symptoms as serious, and may attribute them to ageing, lifestyle, smoking habits or other co-morbidities.[3] In the UK particularly, cancer awareness and beliefs differ to those of our European counterparts, which may contribute to later presentation and therefore a delayed diagnosis.[4] 

Complexity in diagnosis

GPs often face difficulties when evaluating new or evolving symptoms. One-third of lung cancer patients see their GP three or more times before a referral is made, compared to breast cancer where only 3% of patients experience this.[5] The harm in missing a diagnosis can add significant complications to a patient, including an increased risk of mortality. A study has also found that the length of the diagnostic interval affects mortality negatively, indicating that there is a need for earlier detection and prompter investigations.[6] In addition to this, patients with lower socio-economic status, elderly patients and patients with co-morbidities, tend to have longer diagnostic intervals.[7]

Missed opportunities to diagnose earlier

Opportunities to diagnose COPD earlier are also being missed, as GPs and secondary care clinicians are failing to refer patients with lower respiratory symptoms for further investigations, and patients are failing to recognise the significance of symptoms sooner.[8] One particular study found that 85% of patients consulted in primary care 5 years prior to a COPD diagnosis, which confirms that opportunities for the earlier diagnosis of COPD existed long before a diagnosis was made.[8] As decline in lung function seems to be more significant in the early stages of COPD, diagnosing it earlier is important in order to improve patient outcomes. Heart failure, a condition of heart disease is also poorly identified in primary care, with its symptoms often being mistaken for respiratory conditions, such as COPD.[9]

Many people who develop breathlessness as a symptom delay seeking medical help, as they dismiss their symptoms as ‘just a cough’ or don’t warrant the symptoms to any serious underlying illness. There are many complexities in the path to diagnosis, and delays may occur with presentations complicated by co-morbidities, false negative diagnostic tests and delayed referrals.[10] There is also a risk that patients will see multiple teams in a disjointed way, leading to uncoordinated care. It is increasingly important that both doctors and patients are aware of the significance of the symptoms, as well as the importance of being diagnosed early.

References

  1. Source: Beckles M A et al; Initial Evaluation of the Patient with Lung Cancer; Chest.  2003; 123(1_suppl):97S-104S. doi:10.1378/chest.123.1_suppl.97S
  2. http://www.nhs.uk/Conditions/shortness-of-breath/Pages/Introduction.aspx
  3. Brindle L, Pope C, Corner J, Leydon G, Banerjee A (2012) Eliciting symptoms interpreted as normal by patients with early-stage lung cancer: could GP elicitation of normalised symptoms reduce delay in diagnosis? Cross-sectional interview study. BMJ Open 2: e001977
  4. Forbes LJ, Simon AE, Warburton F, Boniface D, Brain KE, Dessaix A, …, Wardle J International Cancer Benchmarking Partnership Module 2 Working Group (2013) Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? Br J Cancer 108: 292–300
  5. Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP (2013) Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers. Br J Cancer 108: 686–690
  6. Torring et al, Evidence of increasing mortality with longer diagnostic intervals for five common cancers: a cohort study in primary care. Eur J Cancer. 2013 Jun;49(9):2187-98. doi: 10.1016/j.ejca.2013.01.025. Epub 2013 Feb 27.
  7. Guldbrandt L M et al. The role of general practice in routes to diagnosis of lung cancer in Denmark: a population-based study of general practice involvement, diagnostic activity and diagnostic intervals. BMC Health Services Research201515:21 DOI: 10.1186/s12913-014-0656-4
  8. Rupert C M Jones, MDa, Prof David Price, MDb, c, , , Dermot Ryan, MDd, e, Erika J Sims, PhDc, f, Julie von Ziegenweidtc, Laurence Mascarenhas, MScc, g, …, Prof Eric D Bateman (2014) Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort, The Lancet Respiratory Medicine, Volume 2, Issue 4, April 2014, Pages 267–276
  9. Cardiovascular Disease Outcomes Strategy: Improving outcomes for people with or at risk of cardiovascular disease. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/217118/9387-2900853-CVD-Outcomes_web1.pdf
  10. Mitchell ED, Rubin G, Macleod U (2013) Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports. Br J Gen Pract 63: e37–e46.

Lung cancer

Lung cancer is more common among the older population, with 97% of all lung cancer cases diagnosed in people over 50.[1]

Other risk factors for lung cancer include:[2]

  • Smoking is the main avoidable risk factor for lung cancer, accounting for nearly 9 out of 10 cases diagnosed
  • More than 1 in 10 cases are linked to occupational exposure (primarily in men) occurring decades ago before these carcinogens were banned (e.g. asbestos)
  • Around 1 in 20 cases can be linked to exposure to radiation for medical reasons e.g. radiotherapy. However, this risk should be taken in context of the obvious benefits of medical imaging and treatments which use radiation
  • Just under 1 in 10 cases are accounted for by deficiency of fruit and vegetables in one’s diet.

Chronic Obstructive Pulmonary Disease

The condition usually affects people over the age of 35. In addition to older age, other risk factors include:[3]

  • Smoking is a big lifestyle risk factor for COPD. It is thought to be responsible for around 90% of cases and 25% of smokers develop COPD
  • Passive smoking
  • Fumes and dust
  • Air pollution
  • Genetic tendency – there is a rare genetic tendency to develop COPD called alpha-1-1antitrypsin deficiency. However, this only effects about 1% of the population. People who have this deficiency usually develop COPD at a younger age, often under 35.

Heart disease

Heart disease usually affects people of older age, it includes a number of conditions including coronary heart disease, heart failure and heart attack. There are a number of factors that increase the risk of conditions such as heart disease, these include:

Medical risk factors include:[4]

  • Obesity
  • High Blood Pressure
  • Diabetes
  • High Cholesterol

Behavioural risk factors include:

  • Smoking
  • Poor diet (e.g. not getting ‘5 a day’ fruit and veg)
  • Physical inactivity
  • Alcohol consumption

References

  1. Incidence and mortality data supplied by NCRAS, based on the annual average for 2010-2014
  2. Parkin, D.M., Boyd, L. and Walker, L.C. (2011) the fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British Journal of Cancer. 105, S77-S81
  3. http://www.nhs.uk/Conditions/Chronic-obstructive-pulmonary-disease/Pages/Causes.aspx
  4. https://www.bhf.org.uk/heart-health/risk-factors

In England, lung cancer has one of the lowest relative survival of any cancer because around two-thirds of patients are diagnosed at a late stage when curative treatment is not possible. Reducing time to diagnosis leads to more timely treatments, and earlier interventions can extend survival and improve quality of life. Earlier diagnosis of conditions such as COPD, heart disease and lung cancer can make them more treatable and lead to improved outcomes. If doctors can identify the disease earlier, patients are more likely to have successful treatments, a better quality of life, and potentially extend their survival.

Cost savings of earlier diagnosis

Earlier diagnosis of conditions such as COPD, followed by appropriate intervention also has the potential to save the NHS an estimated £1 billion over 10 years.[1] Most people with COPD report breathlessness as being the major disabling symptom that interferes with everyday life. However, both GPs and patients are failing to recognise the significance of the symptoms, therefore delaying appropriate investigations and delaying diagnosis.[2] Patients who suffer from conditions such as COPD often experience exacerbations of symptoms, which in turn accelerate the decay of lung function, leading to quicker disease progression, reduced mobility and an overall poorer quality of life.[2] The earlier a diagnosis is made, the more chance of earlier intervention and therefore successful treatment. Some of the potential co-morbidities associated with the disease progression of COPD include a higher prevalence of conditions such as cardiovascular disease and an increased risk of lung cancer.[2] Some studies suggest that clinical improvements can be realised in patients who are detected at early disease or GOLD stage II (a standard for evaluating COPD symptom severity).[3]

Earlier diagnosis and specialist care has the potential to improve patients’ quality of life, it could also reduce the risk of disease progression and lead to considerable cost savings for the NHS. For example, there is a 50-fold difference in associated costs when comparing mild and very severe COPD, which strongly indicates the need for early diagnosis.[4] These numbers further demonstrate the need to raise awareness of the symptoms of these conditions, and that more work is needed to increase earlier diagnosis of lung and heart disease. 

References:

  1. Department of Health. Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England (2010) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_113279.pdf
  2. Rupert C M Jones, MDa, et al (2014) Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort, The Lancet Respiratory Medicine, Volume 2, Issue 4, April 2014, Pages 267–276
  3. Decramer M, Cooper C B, Treatment of COPD: the sooner the better? 2010, Thorax 2010;65:837-841 doi:10.1136/thx.2009.133355
  4. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216139/dh_128428.pdf

The campaign was initially set up as part of the Government’s strategy for improving cancer. This outlined the ambition to prevent 5,000 deaths per year, by 2014/2015, and aimed to bring survival in England up to the average for Europe. In line with the NHS Outcomes Framework, the CCG Outcomes Indicator Set 2015/16, continues to highlight cancer survival as a key area for improvement under indicator one: preventing people from dying prematurely.

The Be Clear on Cancer campaigns now form part of the 2015 recommendations of the Independent Cancer Taskforce, Achieving World-Class Cancer Outcomes: A strategy for England 2015-2020. If the strategy’s ambitions are achieved, it is estimated that an additional 30,000 patients per year will be surviving cancer for 10 years or more by 2020. Of these, almost 11,000 will be through earlier diagnosis. This ambition is reflected in the mandate to NHS England for 2016-17.

Be Clear on Cancer is a vital part of the work to drive the earlier diagnosis of cancer.

See the background to the campaign including evaluation results from previous campaigns.

For more information, or if you have any queries, please contact partnerships@phe.gov.uk.

Diagnostics

Lung cancer

The main symptoms for lung cancer include:

  • Cough
  • Fatigue
  • Shortness of breath
  • Chest pain
  • Weight loss
  • Appetite loss

The public facing leaflet for the campaign also lists the following symptoms as ones to look out for:

  • Frequent chest infections
  • Coughing up blood
  • Chest or shoulder pain

Lung cancer symptoms associated with delay in presentation include cough and shortness of breath. 25.4% of patients who experience chest symptoms delay going to their GP – leading to longer intervals in diagnosis and treatment.[1] It is important to raise awareness of these conditions amongst the public and healthcare professionals, as getting symptoms checked promptly and being diagnosed earlier can help improve outcomes for many patients diagnosed with lung cancer.

Visit NHS Choices for more information about lung cancer symptoms

Visit Cancer Research UK’s lung cancer symptoms page for more information

The NICE referral guideline for suspected cancer was updated in 2015. Take the opportunity to review the updated recommendations for lung cancer.

Cancer Research UK developed summaries of the referral guidelines in various formats:

  • Infographic style: Symptoms are grouped according to organ system, with a key directing you to NICE’s recommendations.
  • Text style: Symptoms are displayed alphabetically, with a key directing you to NICE’s recommendations.
  • Table style: Information is displayed in a table format with recommended pathways displayed along the top of the table.

You can also order physical copies of these poster resources, for free, from the CRUK publications website.

Chronic Obstructive Pulmonary Disease

Symptoms of chronic obstructive pulmonary disease (COPD) usually develop over a number of years. The most common symptoms include:

  • Increasing breathlessness whilst doing everyday activities
  • A persistent cough with phlegm that never seems to go away
  • Frequent chest infections, particularly in winter
  • Wheezing

Visit NHS Choices for more information about the symptoms of COPD

View NICE guideline for COPD

In England, COPD is often associated with other co-morbidities or long-term conditions. Around 40% of people who suffer with COPD also have heart disease, and a significant amount also have depression and/or anxiety.[2]

View NICE guideline for anxiety

Heart Disease

In some cases, people may not have any symptoms before they are diagnosed, but the most common symptoms of heart disease are:

  • Chest pain (angina) and a heart attack
  • Other symptoms include heart palpitations and unusual breathlessness

Visit NHS Choices for more information about the symptoms of coronary heart disease

View NICE guidelines for cardiovascular conditions

View NICE guideline for chronic heart failure

View NICE guideline for atrial fibrillation

References

  1. Forbes et al, Risk factors for delay in symptomatic presentation: a survey of cancer patients, British Journal of Cancer (2014) 111, 581–588. doi:10.1038/bjc.2014.304
  2. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216139/dh_128428.pdf
Lung cancer continues to be a leading cause of cancer death, with most patients diagnosed at an advanced stage, resulting in low 5-year survival. Currently, there is no national screening programme for lung cancer in the UK, this is due to not having a reliable test that can find lung cancer in people who don’t have symptoms.
 
Over recent years, a number of trials have been conducted to test whether screening could benefit groups of people at a high risk of developing lung cancer (e.g. people who have smoked for a long period of time).
 
One trial in the US has shown evidence that LDCT screening can result in a significant mortality benefit amongst those diagnosed with lung cancer. [1] Although LDCT screening has seen promising results, it is important to be mindful of the potential high number of false positive results that are associated with screening. Screening can also result in an increased level of risk and harm, due to high levels overdiagnosis. While some screening methods have the potential to detect aggressive tumours, they can also detect indolent tumours which may otherwise not have caused any clinical symptoms. [2]Other risks include major complications and mortality due to invasive testing. [3]
 
Further research is ongoing to see if lung cancer screening can save lives, and to test the relative harms and benefits of CT screening, especially amongst individuals who are considered to be at a lower risk of developing lung cancer. [4]
 
Overall,research that has looked into the use of chest X-ray and sputum cytology has not shown mortality benefit.[4]
 
References
  1. M Ruparel, S L Quaife, N Navani, J Wardle, S M Janes, D R Baldwin. Pulmonary nodules and CT screening: the past, present and future. Thorax doi:10.1136/thoraxjnl-2015-208107
  2. Patz EF Jr et al, Overdiagnosis in low-dose computed tomography screening for lung cancer. JAMA Intern Med. 2014 Feb 1;174(2):269-74. doi: 10.1001/jamainternmed.2013.12738.
  3. M U Ali et al. screening for lung cancer: A systematic review and meta-analysis. 2016. Elsevier doi:10.1016/j.ypmed.2016.04.015
  4. Manser R, Lethaby A, Ivring L.B, Stone C, Byrnes G, Abramson M.J, Campbell D, Screening for lung cancer, 2013, Cochrane Library

A chest X-ray is a key diagnostic test for the detection of lung cancer, and remains one of the main tools for diagnosis. One chest X-ray is the equivalent to 3 days of natural background radiation. Radiation levels for low-dose computed tomography (LDCT) are low, however those who are referring patients for tests must take into account repeat screening, such as follow-up scans – due to high levels of false positives and/or annual screening.[1]

Advances in scanning technologies mean that detection methods such as CT scanning have improved nodule detection and reduced radiation doses. However, radiation should always be considered when balancing risks and benefits.

References

  1. P. B Bach et al. Benefits and Harms of CT Screening for Lung Cancer, A Systematic Review 2012. JAMA. 2012 Jun 13;307(22):2418-29. doi: 10.1001/jama.2012.5521.

An urgent GP (two week wait) referral should be made irrespective of the chest X-ray result where there is a high clinical suspicion of lung cancer, e.g. persistent haemoptysis in smokers or ex-smokers over 40 years old. It is also reasonable to offer patients an urgent GP referral while awaiting the result.

If an X-ray result is normal you should still urgently refer any patient older than 40 with persistent symptoms or symptoms suggestive of malignancy. Patients who repeatedly visit with symptoms such as a cough that does not resolve, should have their recent history of presentations checked. Even if the patient presents their symptoms as pertaining to separate episodes of illness. 

View NICE guideline for suspected cancer pathway referral

COPD

The most commonly used grading scale for breathlessness severity is known as the Medical Research Council (MRC) dyspnoea scale. The MRC scale is widely used to describe patient cohorts and stratify them for interventions such as pulmonary rehabilitation for conditions such as COPD. The scale comprises of five statements that describe almost the entire range of respiratory disability from none (Grade 1) to almost complete incapacity (Grade 5).

MRC Dyspnoea Scale

Grade

Degree of breathlessness related to activity

1

Not troubled by breathless except on strenuous exercise

2

Short of breath when hurrying on a level or when walking up a slight hill

3

Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

4

Stops for breath after walking 100 yards, or after a few minutes on level ground

5

Too breathless to leave the house, or breathless when dressing/undressing

Another classification system also used for COPD is known as GOLD (Global Initiative on Obstructive Lung Disease).

This splits the severity of symptoms into five different categories and uses FEV1/FVC (Forced Expiratory Volume) as an indicator. The five categories include:

GOLD classification system

Stage

Severity of symptoms

0

At risk; chronic cough and sputum production. Spirometry is normal.

I

Mild COPD; mild airflow limitation (FEV1/FVC) less than 70% but FEV1 80% or more than predicted; usually, but not always, chronic cough and sputum production.

II

Moderate COPD; worsening airflow limitation (FEV1 50-79% predicted) and usually progression of symptoms, with shortness of breath, especially on exertion.

III

Severe COPD; further worsening of airflow limitation (FEV1 30-50% predicted), increased shortness of breath, and repeated exacerbations.

IV

very severe COPD; severe airflow limitation (FEV1 less than 30% predicted) or the presence of chronic respiratory failure.

Heart disease

Heart failure, which is a sub-condition of heart disease and shares the symptom of breathlessness, is graded using the New York Heart Association (NYHA) system. Classification of severity is based on symptoms:

Class I (no symptoms)

You have no symptoms and can perform daily activities without feeling tired or short of breath.

Class II (mild symptoms)

You are comfortable when resting, but moderate activity makes you tired or short of breath.

Class III (moderate symptoms)

You are comfortable when resting, but even limited physical activity makes you tired or short of breath.

Class IV (severe symptoms)

You are unable to do any physical activity without discomfort and experience some symptoms at rest.

For more information read the NICE guideline for heart failure

There is no single diagnostic test for COPD. Diagnosis is usually based on a combination of the patient’s history, examination and confirmation of airflow obstruction using spirometry testing. The onset of any signs of lung disease should prompt appropriate investigations, such as spirometry, however, both patients and doctors often fail to recognise the significance of symptoms.[1]

Other appropriate examinations include chest x-ray to exclude other diagnoses, and any abnormalities found should be followed up with a CT scan. In patients who are younger (aged <35), or in those who are not exposed to cigarette smoke or other factors known to be associated with COPD, consider a genetic test such as the alpha-1-antitrypsin deficiency test.

Through data analysis, one study suggests that:[1]

Although recurrent respiratory infections should always be assessed in their own right and treated accordingly, the possible presence of COPD should also be considered if:

  1. Patients who smoke (current or past), are aged 40 years or older, presenting with lower respiratory symptoms requiring a prescription should be recalled after 6 weeks for spirometry to detect COPD; and
  2. COPD symptoms should also be sought in patients who do or have smoked, are aged 40 years or older, and are attending clinics for COPD concordant comorbidities with screening (hand-held or similar) spirometry done as appropriate

For more information about spirometry testing, visit NHS Choices

References

  1. Rupert C M Jones, MDa, Prof David Price, MDb, c, , , Dermot Ryan, MDd, e, Erika J Sims, PhDc, f, Julie von Ziegenweidtc, Laurence Mascarenhas, MScc, g, …, Prof Eric D Bateman (2014) Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort, The Lancet Respiratory Medicine, Volume 2, Issue 4, April 2014, Pages 267–276

Evidence and evaluation

Public Health England has run several Be Clear on Cancer campaigns since 2011. There have been a number of lung cancer campaigns, including local and regional pilots followed by three national campaigns. Results from these activities indicate that Be Clear on Cancer is changing levels of public awareness and behaviour. There are indications that clinical outcomes are improving too.

Findings from the campaign that ran in England show:

  • Increases in unprompted awareness of cough as a symptom of lung cancer from 54% pre-campaign to 65% post campaign, with specific mention of persistent / prolonged cough increasing from 12% pre-campaign to 15% post-campaign[1]
  • An increase of 9.1% in the number of lung cancer cases diagnosed during the months surrounding the campaign[2]
  • An increase of 3.1 percentage points for the proportion of non-small cell lung cancers diagnosed at Stage I (14.1% to 17.3%). There was also a corresponding 3.5 percentage point decrease in the proportion of people diagnosed at Stage IV (52.5% to 49.0%)[2]
  • An increase of 2.3 percentage points (13.7% to 16.0%) for the proportion of patients receiving surgical resections as a first definitive treatment.[2]

For information about the potential impact on services, please visit the impact on health services page

References

  1. Be Clear on Cancer national lung  cancer awareness campaign evaluation – impact on patients attending GP  appointments. Produced by Mayden, February 2014 for NHS IQ
  2. National Lung Cancer Audit. Data provided by HSCIC

Results from the regional lung cancer campaign show:

  • Pilot areas saw a statistically significant (30%) increase in GP referrals for suspected lung cancer during October – December 2011 when compared to the same period in the previous year
  • There was a statistically significant increase in the percentage of small cell lung cancers diagnosed as “limited” in October – December 2011 in the pilot trusts (25.9%) compared with the same period in the previous year (36.6%)
  • The percentage of late stage non-small cell lung cancers decreased significantly in Oct–Dec 2011 from the same period in the previous year in the pilot trusts, whilst no significant change was seen in control areas
  • The percentage of carcinoid tumours detected increased significantly in the pilot trusts from 0.4% to 1.3% between October – December 2010 and October – December 2011.
  • Pilot trusts also saw a statistically significant increase in surgical resections which was not replicated in the non-pilot trusts.

See the full results

The results in the months surrounding the first national lung cancer campaign show:

  • Urgent referrals for suspected lung cancer saw a statistically significant increase of 32% in May – July 2012 when compared to the same period in the previous year
  • Analysis from 486 GP practices showed a statistically significant 63% increase in attendances for cough in the over 50s during the campaign period when compared with the same period in the previous year, equating to an additional 3 visits per practice, per week
  • Statistically significant increase (9%) in lung cancer cases diagnosed (equating to 700 additional cases) in patients first seen for lung cancer during the campaign months when compared to the same period in previous year. No significant increase was seen over the control months
  • Statistically significant increase, from 23.4% to 26.9%, in the proportion of non-small cell lung cancers diagnosed at early stage (approximately 400 more cancers) across the campaign months when compared to the same time in the previous year. This is matched by a corresponding statistically significant decrease in the proportion diagnosed as late stage
  • Statistically significant increase in the proportion of patients receiving surgical resection as a first definitive treatment (from 13.7% to 16.0%, equating to around 300 more patients) during the campaign months when compared to the same period in 2011. No significant change in surgical resections was seen across the control months.

For more information on the impact of this campaign on raising public awareness of lung cancer symptoms, please read the publication from the British Journal of Cancer.

Findings from the second national lung cancer campaign show:

  • There were increases in the number of GP referrals for suspected lung cancer, with a 30% increase in July-September 2013 compared to the same months in 2011 , and compared to a 26% increase in urgent GP referrals for other suspected cancers
  • Tracking research following the second national lung cancer campaign shows that spontaneous knowledge of the key campaign awareness message of a persistent cough increased significantly, to a higher level than after the first national campaign (22% after the second national campaign, up from 15% after the first national campaign).

See the full findings

Initial findings show that:

  • The monthly numbers of urgent GP referrals for suspected lung cancer were above the general trend for April and May 2014, particularly for April following the third national lung cancer campaign.

Evaluation of the second and third national lung cancer campaigns is still ongoing. Information for these campaigns (including analysis of urgent GP (two week wait) referrals and related diagnoses) will be published in the coming months, so please keep checking back for more information.

See the full findings

The breathlessness campaign was piloted first at a local level and then at a regional level, with the aim of scoping whether it was possible to achieve earlier diagnosis of a range of conditions, particularly lung and heart disease but also other conditions such as anxiety.

Evaluation of the regional breathlessness campaign showed that:

  • There were significant increases in spontaneous knowledge of what breathlessness could be a sign of:
    • lung disease, up from 50% pre-campaign to 60% post campaign
    • heart disease, up from 42% pre-campaign to 52% post campaign
  • Of those people who recalled seeing advertising, when asked to describe the main message, 59% in the pilot region spontaneously mentioned “to encourage people to see their GP if they are getting out of breath” (up from 43% pre-campaign). Similarly, there was an increase in people mentioning that getting out of breath could be a sign of something more serious, up to 44% from 34%.

As the breathlessness campaign has only run at a regional level to date, we do not have national level data. However, qualitative research carried out with GPs in the regional pilot area following the campaign reported that while they while they were unsure if they had seen an increase in presentations for breathlessness, when retrospectively looking at the campaign materials they could recall patients using the same language.

For more information about the breathlessness campaign, please read the NHS evaluation

Be Clear on Cancer statement

Be Clear on Cancer  is a cancer awareness campaign led by Public Health England, working in partnership with the Department of Health and NHS England. This page contains links to documents that we hope you find useful. Please note however that the views or opinions expressed within those links are not necessarily those of Cancer Research UK.

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