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LUNG cancer is the fifth most common cancer in Australia, but is the leading cause of cancer deaths. Why?
The majority of lung cancers have already spread by the time they are diagnosed, and many people assume there is little that can be done.
The latest figures show that in NSW, only around 22% of lung cancers are diagnosed while they are still localised, when the chances of survival at 1 year are 62% following curative intent surgery. For those diagnosed when the cancer has spread to distant organs, 1-year survival drops to as low as 19%.
So, what can be done to improve survival rates for people with lung cancer?
GPs arguably have one of the most important roles to play in early detection and referral for treatment. We all know the greatest risk factor for a lung cancer diagnosis is being a current or former smoker.
While many doctors do keep a record of smoking status, using a standard measurement for a person’s smoking status, such as “pack-years” (where the number of cigarettes a person has smoked is multiplied by the years they have smoked) will be most effective. This would give an indication of cancer risk, and should be used to inform both general consultations and the threshold for investigation of symptoms and referral for diagnosis.
Making time during every consultation with current and former smokers to discuss cancer-related symptoms they need to be aware of, as well as offering quit support to all current smokers such as brief interventions or referral to the Quitline, is a critical role for primary care.
Discussions about lung cancer symptoms are particularly important. While most people would associate coughing up blood with lung cancer, this is often a symptom of late-stage disease. To offer the best chances of survival, we need to look at symptoms like a cough that lasts longer than 3 weeks or changes over time.
In addition, GPs need to be willing to lower the threshold for investigating symptoms based on the risk assessment. If a non-smoker in their thirties did not respond to the first round of antibiotics for a bad cough, you would likely prescribe another dose.
However, if the patient was a smoker or former smoker with a high pack-year score, GPs should refer them for a chest x-ray rather than try a second round of treatment. We know that every day counts with lung cancer, so the earliest possible referral for testing is vital.
Importantly, at-risk patients presenting with symptoms will often have been experiencing these symptoms for some time before seeing their doctor.
There is significant stigma surrounding lung cancer and other smoking-related illnesses, with people often feeling as though they have brought it on themselves, which can lead patients to minimise the importance of symptoms. Open and supportive conversations relating to current or former smoking as part of all consultations can address this.
There is also a sense of nihilism among patients — and even some doctors — believing there is little hope for survival after a lung cancer diagnosis. This can lead to delays in presentation, referral and diagnosis when, in fact, 36% of patients diagnosed with localised disease will still be alive 5 years after diagnosis (despite the overall 5-year survival rate for lung cancer being 17.6%).
GPs are in a unique position to encourage and support patients to monitor their own health, be aware of symptoms that might need investigation, and to be proactive about visiting their doctor straightaway about changes in their health.
Having systems in place to measure and act on risk, and referring high-risk patients for testing as early as possible, means GPs can have a significant impact on the numbers of people diagnosed with lung cancer early, which will ultimately improve survival rates for our nation’s biggest cancer killer.
Professor Sanchia Aranda is the deputy CEO and Director of the Cancer Services and Information division of the Cancer Institute NSW — a state government agency dedicated to the control and cure of cancer through prevention, detection, innovation and information. www.cancerinstitute.org.au
In contrast to the opinion expressed by Jim Dickinson, brief interventions undertaken by medical practitioners using the intention to change model have been showed in multiple studies to improve quitting rates amongst smokers. Indeed the Cochrane pooled analysis showed an increase of up to 2/3 amongst smokers exposed to brief interventions (RR 1.66, 95%CI 1.42-1.94). This equates to a number NNT of as few as 35.
We should discuss smoking with our patients at EVERY interaction. The chance to help people to change only comes about through this discussion. Smokers will still attend and the relationship will remain intact, because we will do it in supportive and non-confrontational way.
Once again specialists are telling GPs their job, without understanding epidemiology, selection bias, length bias and the distribution of disease. Sorry, but cough is very common. Even prolonged cough is very common. Most gets better, regardless of treatment: much of the rest is allergic disease. It is not appropriate for GPS to do chest Xray on every such patient, especially since many smokers are not very adherent to COPD treatment, and by the time a mass is visiable on plain XRay, indeed nihilism is understandable, and many specialsts express it.
In primary care, new lung cancer is extremely rare. Sure 36% of those with localised disease survive 5 years, but these people are mostly the ones with slowly developing disease, not the rapidly developing ones that are disseminated when found. Medical care makes a difference: but show me evidence that it is more than marginal. Many lung cancers are untreateble because the concurent damaged lungs and arteries mean that surgical options are limited.
Most 30+ pack year smokers are aware that their antisocial habit will kill them. Certainly we should discuss smoking with patients where that is relevant: maybe even a few times a year, but not every consultation: that would destroy the relationship and the chance to help people change. Many smokers do not attend, becasue they know what they will hear.
Professor Aranda should reveiw the science about what actually happens in primary care, and what is reasonably possible and appropriate before resorting to the same old tired exhortations that we have heard all my practicing lifetime. They have not changed anything before nor will change nothing now. Time for a rethink!
As someone who works in the area of lung disease, I never cease to be amazed at how long it takes some GP’s to perform a CXR on their patients. Prolonged respiratory symptoms (cough or other), require a CXR as a part of the diagnostic process, even more so if the patient is in a higher risk group..