Referral guidelines can support decision making when assessing patients with suspected lung cancer. Alongside appropriate investigations, they help primary care professionals identify, investigate and refer patients in a timely way to support earlier diagnosis.
The guidance for suspected lung cancer referral can be found below:
NICE NG12 guidelines for lung cancer in England and Wales
Scottish Referral Guidelines for lung cancer
Symptoms of lung cancer include cough, shortness of breath and chest/shoulder pain, see guidelines for full symptom list.
There are other non-respiratory symptom, such as finger clubbing, that are associated with lung cancer and warrant investigation. Find out more about finger clubbing here.
Be aware of non-specific symptoms, such as fatigue, weight loss and appetite loss. Use guidelines and clinical judgement to consider referral.
Evidence has found a significant proportion of patients presenting with dyspnoea (86%) or haemoptysis (50%) did not receive prompt chest imaging despite being eligible in clinical guidance.
Chest x-ray should be offered as a first line investigation for people with lung cancer symptoms.
Unexplained haemoptysis warrants urgent referral, without need for chest x-ray results.
Consider further investigation for those with recurrent or persistent chest infections.
Chest x-rays are relatively cheap, safe and accessible and should be used as first line investigation for suspected lung cancer. However, chest x-rays can miss up to 20% of cancers, highlighting the importance of safety netting people with a negative chest x-ray.
Direct access to chest x-ray aims to improve primary care’s access to these investigations, and research has demonstrated that improved access and use of chest x-ray can have a positive impact on patient outcomes. There is significant variation across the UK in availability of direct access pathways. Check local pathways for what is available in your area.
Some areas in England have implemented self-referral to chest x-ray services. This involves a patient providing clinical information to arrange a chest x-ray if clinically indicated, without the need to see a health professional. These services aim to reduce barriers to accessing chest x-rays. There is some evidence to suggest that these pathways effectively target those at greatest risk of being diagnosed with lung cancer, but more evaluation is needed to understand the impact of these pathways.
CT scans are more sensitive than chest x-rays in detecting lung cancer. If available, direct access CT scans (or referral for CT if direct access not available) should be considered where patients have a normal chest x-ray, but clinical symptoms and risk factors continue to cause concern.
Thrombocytosis is a risk marker for certain types of cancer, including lung cancer, in adults. Therefore, a full blood count may be a useful investigation in people presenting with potential lung cancer symptoms.
Non-specific symptom pathways are available across most areas of the UK and can be a useful referral route for patients who do not fit clearly into a single referral pathway. Evaluation of national pathways has shown that lung cancer is often one of the most common cancer diagnoses via these pathways. Check what your local pathway looks like, including referral criteria.
Denise is 72 years old and has never smoked.
Denise presents to her GP with chest pain and a dry, persistent cough.
Denise tells her GP that she’s had these symptoms for at least a month.
Denise’s symptoms and age mean that she warrants an urgent chest x-ray, as recommended across each nation’s referral guidelines.
It is important to consider suspected lung cancer in those who have never smoked, if they are presenting with symptoms that could be attributed to cancer.
Consider tracking Denise’s chest x-ray referral using e-safety netting tools, to check attendance and follow up.
It is important to provide clear safety netting information to Denise on when to represent.
Advise her that if her symptoms persist, or worsen, she should arrange another appointment. Make sure you provide a timeframe for her to re-present if her symptoms do persist.
It is also worth exploring any other additional symptoms she may be experiencing, or alternative explanations for her symptoms.
Exercising clinical judgement, and referring to your national cancer referral guidelines are critical here.
An USC/red flag referral can still be considered if a chest x-ray is normal but there’s a high clinical suspicion of lung cancer.
You may be able to seek advice from respiratory services to support your decision-making if the most appropriate next steps are not clear. Check the most appropriate way to do this in your area.
Next steps may depend on the clinical presentation.
There are some specific recommendations in guidelines for those who have a negative CXR but concerning symptoms. For example, SRG recommend urgent suspicion of cancer referral should be considered for people who present with weight loss and thrombocytosis, even after a negative chest x-ray.
Consider the results of other tests. For example, NICE NG12 guideline highlights thrombocytosis as a sign GPs should be aware of for several cancers including lung cancer.
Next steps could include:
ordering another chest x-ray
referring to direct access CT (if available)
referral along urgent suspected cancer/suspicion of cancer/red flag referral pathway for lung cancer
referral into RCDS/NSS pathway/vague symptom pathway if appropriate
having a discussion with the respiratory medicine team
This case highlights the importance of safety netting and being alert to the risk of lung cancer in people with respiratory and non-specific symptoms, even when they have never smoked and initial investigations are normal.
DNUK lung cancer course (under education section)
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