Early detection of lung cancer is key to improving outcomes. This can be achieved through improved public awareness and quick referral to specialist care when lung cancer is suspected.

Symptoms of lung cancer can be vague and may be mistaken for other illnesses, such as chest infections. Delayed detection of lung cancer means that the disease has had more time to progress and is often at an advanced stage at the time of diagnosis.

National Cancer Registration and Analysis Service (NCRAS) data show that almost half of all lung cancers are stage 4 at diagnosis, whereas the majority of breast and prostate cancers are stage 1 or 2 at diagnosis. Late diagnosis, where curative treatment is not possible, is a contributing factor to poor survival rates for people with lung cancer.

The late diagnosis of lung cancer can be a result of several factors, including a lack of awareness and recognition of symptoms, how quickly people visit a doctor and the speed at which cancer is suspected and then diagnosed. NICE’s guidelines and quality standards on suspected cancer and lung cancer have been developed to address these issues. They state that people should be made aware of lung cancer through coordinated public awareness campaigns and outline the criteria for referring people for relevant investigations or onto a suspected cancer pathway.

Implementation of these recommendations will raise public awareness of the signs and symptoms of lung cancer, which could encourage and empower people to seek advice from a healthcare professional. In addition, increasing primary care awareness and clear referral criteria can reduce the time from when lung cancer is first suspected by a clinician to the relevant investigations being undertaken, reducing the likelihood of late stage diagnosis.

The NHS Long Term Plan has committed to extending a programme of lung health checks, which have produced strong results in Liverpool and Manchester by boosting the proportion of cancers detected at stage 1 and 2. NICE welcomes evidence arising from this programme.

Our guidelines on suspected cancer and lung cancer:

Public awareness campaigns

To increase the number of lung cancers that are diagnosed at an earlier stage, NICE recommends that the public should be better informed on the signs and symptoms that are characteristic of lung cancer.

Public awareness campaigns have been shown to increase early stage cancer diagnoses

Results from the Be Clear on Cancer campaign show how successful public awareness campaigns can be. The campaign, led by Public Health England working in partnership with the Department of Health and Social Care, NHS England and Cancer Research UK, was set up in 2010 to promote awareness and early diagnosis of lung cancer. An estimated 700 additional cancers were diagnosed in the months surrounding campaign activity, compared to the same period in the previous year, and around 400 more people had their cancer diagnosed at an earlier stage.

Referral to a specialist

As well as increased public awareness of lung cancer, fast referral to a specialist for relevant investigations is also key to increasing diagnoses made at an earlier stage of disease. To ensure that people with any cancer are seen at the earliest opportunity, NICE developed a guideline on suspected cancer: recognition and referral. The guideline includes a section on the signs and symptoms of lung cancer which healthcare professionals should look out for to trigger an urgent referral to a specialist.

Data from NHS England’s Cancer Waiting Times annual report show that the proportion of people with suspected lung cancer seen by a specialist within 2 weeks, following an urgent GP referral, has remained at around 96% for the last 3 years. This exceeds the operational standard of 93% set by NHS England.

As lung cancer staging is a key part of guiding treatment and prognosis, it is very important to have valid, complete staging data. NICE has developed an indicator on the proportion of lung cancer cases for which a stage at diagnosis is recorded. This fed into the development of a CCG outcome indicator, designed to encourage staging of lung cancer at the time of decision to treat. The percentage of people diagnosed with lung cancer who have a valid stage recorded at the time of decision to treat has increased over recent years, from 86% in 2013 to 94% in 2017.

An associated outcome reported by the National Cancer Patient Experience Survey (CPES) is how many times people saw their GP about the health problem caused by cancer, before they were referred to a specialist.

Over the last 4 surveys around a third of people with lung cancer could recall being referred to a specialist after just 1 GP appointment. This is lower than in the ‘all cancer’ population, where 43% of people recalled seeing their GP once before referral. In 2018 the proportion of people with lung cancer who recalled seeing their GP 5 or more times before referral was almost 8% compared with 6% for the ‘all cancer’ population.. 

To support GPs in recognising cancer symptoms, NICE has endorsed an online cancer education platform called GatewayC. Using recommendations from our guideline on suspected cancer: recognition and referral, the interactive platform aims to improve cancer outcomes by facilitating earlier and faster diagnosis through supporting clinical decision making in primary care.

A NICE shared learning example reports how one GP implemented the NICE guideline on suspected cancer: recognition and referral in their area. They set up an implementation group that identified implementation barriers such as the cost of increased referrals and worked with the CCG to ensure sustained funding. By engaging with other GP practices, cancer pathways were re-designed, referral forms were standardised, and plans to enhance patient engagement were set.

Recognition of lung cancer in never-smokers

In the UK it is estimated that nearly 6,000 people who have never smoked die of lung cancer every year, making it the eighth most common cause of cancer-related death. While causes can be partly attributed to environmental pathogens such as air pollution, identifying the cause of the cancer in individuals can be difficult.

Never-smokers generally refers to people who have smoked less than the equivalent of 100 cigarettes in their lifetime.

The latest Roy Castle awareness campaign Like Me, challenges the misconception that only certain people get lung cancer. The campaign highlights that lung cancer can affect anyone, which can lead to late diagnosis and increased mortality rates.

I had a bad back and it wasn’t getting any better so I went to see the GP, where he told me he was checking for cancer. This surprised me as I have never smoked. After 3 months of tests and scans, I was told that I had a tumour in my lung. I then had a lung biopsy and an MRI scan.

While I was very satisfied with the people and the care I received, I wish they had implemented a faster diagnosis process. Greater Manchester have now instituted a faster 1-month diagnosis pathway and are in the process of rolling it out.

Male, diagnosed at stage 4