Dr Barbara O’Beirne, GP, writes that the burden of lung cancer can be lessened if general practitioners take the steps to ensure that the disease is diagnosed as early as possible.
Lung cancer is one of the most common cancers in Ireland and of all cancers, it is the biggest killer in men.1 Approximately 1,646 people develop the disease each year,1 and in 2006, some 1,593 Irish people died from lung cancer.2 Furthermore, it is predicted that lung cancer will overtake breast cancer as the leading cause of cancer mortality in Irish women in the near future.3
The majority of lung cancers, which is one of the most preventable causes of death3, are caused by smoking and by passive smoking. In fact, it is estimated that more than 90 per cent of all lung cancers are caused by smoking, while exposure to certain other carcinogens, such as radon, also increases the risk of the disease.
h4. Peak between 65-70 years
The epidemiology of lung cancer is also changing, and increasing numbers of non-smokers and women are being diagnosed with the disease than ever before. It is also worth noting that less than one per cent of new lung cancer cases occur before the age of 40 years.4 The rates of the disease increase amongst the 40-year+ age cohort and they peak between the ages of 65-70 years.
There are two main types of lung cancer. These are non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC accounts for more than 55 per cent of all lung cancers.5 Unfortunately, the majority of NSCLC cases are diagnosed at an advanced stage when the cancer is inoperable or metastatic. Typically, lung cancer patients have an average life expectancy of a short eight to 10 months.
November is Lung Cancer Awareness Month and it sees a much-needed spotlight turned on the disease. Lung Cancer Awareness Month also provides a platform to increase knowledge of the signs and symptoms of lung cancer amongst both healthcare professionals and the general public.
h4. GPs and early detection
In 2007, Roche Products (Ireland) Limited commissioned a TNS mrbi survey that revealed that 90 per cent of the Irish public agreed that recovery from lung cancer is dependent on early diagnosis.6 However, studies have shown that most patients recall having symptoms for more than one year before they speak to their doctor about the problem.
Given their key position in the local community, general practitioners continue to play a pivotal role in the early detection and prevention of lung cancer. More than 80 per cent of patients with common cancers first present to their GP with symptoms.
In addition, more than 90 per cent of patients are symptomatic at the time of presentation.
The signs and symptoms of lung cancer can be extremely difficult to identify. The most common symptoms of the disease may actually take years to develop.
These include: a persistent cough that lasts for more than two to three weeks; constant chest or shoulder pain; haemoptysis; dyspnoea; shortness of breath; hoarseness; features suggestive of metastasis from a lung cancer (for example in brain, bone, liver or skin); persistent chest infections; unexplained fatigue and unexplained weight loss.
The symptoms may also vary from person to person. In the event that a patient presents with suspicious symptoms such as a new onset unexplained cough; a chronic and persistent cough or alteration in character of a chronic cough; haemoptysis; or hoarseness, a general practitioner should immediately assess the patient to exclude lung cancer as a possible cause of these symptoms. Ultimately, patients showing any of the signs of the disease should be sent for a chest x-ray.
Unfortunately, subsequent patient referral to specialists can be quite slow and this is especially true for public patients. According to the American Thoracic Society (ATS), any suspicious or abnormal findings on the x-ray should be dealt with urgently and the patient should be referred to the appropriate specialist.
Best practice suggests that it is the GP’s responsibility to organise for patients to be seen by lung cancer specialists, preferably within one week of receiving the results.
h4. Referral routines
A general practitioner needs to be fully familiar with the typical symptoms of the disease but he or she should preferably have experience of cancer diagnosis and the referral routines that are commonly used.
In 2007, the Irish College of General Practitioners and the Irish Cancer Society published a study which was entitled ‘Early Detection of Cancer, A Needs Assessment of General Practitioners’. This study highlighted the most common barriers experienced by GPs in relation to the early detection of cancer.
These include: a delay in patient presentation, a lack of clear recommendations, inequity of access, long waiting lists and inadequate access for investigations, referral of patients who cannot pay privately, a lack of direct access to hospital-based diagnostics, communication difficulty with referral to hospital services for investigation/assessment and a lack of GMS funding for cancer screening.
h4. Guidelines are necessary
Clearly defined general practitioner guidelines are necessary – firstly, these are needed to ensure that patients present to their GP in a timely manner and secondly, when patients do present, to enable GPs to identify lung cancer symptoms.
In May 2007, the Health Service Executive released a publication titled ‘Cancer Referral Guidelines for GPs’. These guidelines provide a synopsis of the specifics of lung cancer, including the symptoms, the likely causes and methods of prevention. A diagram of the referral process for lung cancer patients is also available for reference.
It is clear that general practitioners can play a critical role in the fight against the lung cancer through earlier diagnosis, and so therefore, the necessary steps need to be undertaken to ensure that their role is clearly defined and that patients present to their general practitioners in a timely manner.
About Gary Culliton
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