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We report a cohort study of survival of patients with lung cancer presenting to a single multidisciplinary team between 1997 and 2011, according to symptoms at presentation. The overall median survival of the 3800 lung cases was 183 days (95% CI 171 to 195). There was a statistically significant difference in survival between the 12 symptom groups identified both without and with adjustment for the prognostic variables of age, gender and histology (P

BACKGROUND: Achieving earlier stage diagnosis is one option for improving lung cancer outcomes in the United Kingdom. Patients with lung cancer typically present with symptoms to general practitioners several times before referral or investigation. METHODS: We undertook a mixed methods feasibility individually randomised controlled trial (the ELCID trial) to assess the feasibility and inform the design of a definitive, fully powered, UK-wide, Phase III trial of lowering the threshold for urgent investigation of suspected lung cancer. Patients over 60, with a smoking history, presenting with new chest symptoms to primary care, were eligible to be randomised to intervention (urgent chest X-ray) or usual care. RESULTS: The trial design and materials were acceptable to GPs and patients. We randomised 255 patients from 22 practices, although the proportion of eligible patients who participated was lower than expected. Survey responses (89%), and the fidelity of the intervention (82% patients X-rayed within 3 weeks) were good. There was slightly higher anxiety and depression in the control arm in participants aged >75. Three patients (1.2%) were diagnosed with lung cancer. CONCLUSIONS: We have demonstrated the feasibility of individually randomising patients at higher risk of lung cancer, to a trial offering urgent investigation or usual care.British Journal of Cancer advance online publication 10 January 2017; doi:10.1038/bjc.2016.414 www.bjcancer.com.

Background: Survival rates in lung cancer in England are significantly lower than in many similar countries. A range of Be Clear on\ud Cancer (BCOC) campaigns have been conducted targeting lung cancer and found to improve the proportion of diagnoses at the\ud early stage of disease. This paper considers the cost-effectiveness of such campaigns, evaluating the effect of both the regional\ud and national BCOC campaigns on the stage distribution of non-small-cell lung cancer (NSCLC) at diagnosis.\ud Methods: A natural history model of NSCLC was developed using incidence data, data elicited from clinical experts and model\ud calibration techniques. This structure is used to consider the lifetime cost and quality-adjusted survival implications of the early\ud awareness campaigns. Incremental cost-effectiveness ratios (ICERs) in terms of additional costs per quality-adjusted life-years\ud (QALYs) gained are presented. Two scenario analyses were conducted to investigate the role of changes in the ‘worried-well’\ud population and the route of diagnosis that might occur as a result of the campaigns.\ud Results: The base-case theoretical model found the regional and national early awareness campaigns to be associated with QALY\ud gains of 289 and 178 QALYs and ICERs of d13 660 and d18 173 per QALY gained, respectively. The scenarios found that increases\ud in the ‘worried-well’ population may impact the cost-effectiveness conclusions.\ud Conclusions: Subject to the available evidence, the analysis suggests that early awareness campaigns in lung cancer have the\ud potential to be cost-effective. However, significant additional research is required to address many of the limitations of this study.\ud In addition, the estimated natural history model presents previously unavailable estimates of the prevalence and rate of disease\ud progression in the undiagnosed population.

Background Poor UK lung cancer survival rates may, in part, be due to late diagnosis. Objectives To evaluate the effectiveness of a mixedmethod community-based social marketing intervention on lung cancer diagnoses. Methods A public awareness campaign in conjunction with brief intervention training in general practices was piloted in six localities with a high lung cancer incidence. End points were self-reported awareness of lung cancer symptoms; intention to seek healthcare; chest x-ray referral rates in primary care; secular trends in the incidence of lung cancer and stage at diagnosis, compared before and after the intervention. Results 21% (128/600) (95% CI 18% to 25%) of the targeted population recalled something about the campaign. Compared with a responder in the control area, the odds of a responder in the intervention area saying that they would visit their general practitioner and request a chest x-ray for a cough was 1.97 times (95% CI 1.18 to 3.31, p¼0.01). Primary care chest x-ray referral rates increased by 20% in the targeted practices in the year following the intervention compared with a 2% fall in the control practices. The difference was highly significant, with an incidence rate ratio of 1.22 (95% CI 1.12 to 1.33, p¼0.001). There was a 27% increase in lung cancer diagnoses in the intervention area compared with a fall in the control area. The incidence rate ratio was 1.42 (95% CI 0.83 to 2.44 p¼0.199). Conclusion This is encouraging early evidence that an awareness and early recognition initiative may facilitate lung cancer diagnosis.

Finding an abnormality on a plain chest radiograph is usually the first definite evidence of a lung cancer, so this investigation is currently pivotal in the diagnosis of the disease. Although the National Institute for Clinical Excellence (NICE) has produced guidance on when a chest radiograph should be done for putative lung cancer presentations, cancer will usually be only one of a number of possible diagnoses, so this is somewhat artificial. Neither is there any evidence that obtaining a chest radiograph for these features leads to an improved outcome. Another major concern is the poor public awareness of the symptoms for which a chest radiograph is recommended. This article discusses the role of the chest radiograph in the early diagnosis of lung cancer with particular emphasis on the limited value of a single negative result and on the potential implications of interventions to increase the number of chest radiographs done in primary care.

Background In order to improve lung cancer survival in the UK, a greater proportion of resectable cancers must be diagnosed. It is likely that resectability rates would be increased by more timely diagnosis. Aside from screening, the only way of achieving this is to reduce the time to diagnosis in symptomatic cancers. Currently, lung cancers are mainly diagnosed by general practitioners (GPs) using the National Institute for Health and Clinical Excellence (NICE) guidelines for urgent referral for chest X-ray, which recommend urgent imaging or referral for patients who have one of a number of chest symptoms for more than 3 weeks. We are proposing to expand this recommendation to include one of a number of chest symptoms of any duration in higher-risk patients. Methods/Design We intend to conduct a trial of imaging in these higher-risk patients and compare it with NICE guidelines to see if imaging improves stage at diagnosis and resection rates. This trial would have to be large (and consequently resource-intensive) because most of these patients will not have lung cancer, making optimal design crucial. We are therefore conducting a pilot trial that will ascertain the feasibility of running a full trial and provide key information that will be required in order to design the full trial. Discussion This trial will assess the feasibility and inform the design of a large, UK-wide, clinical trial of a change to the NICE guidelines for urgent referral for chest X-ray for suspected lung cancer. It utilizes a combination of workshop, health economic, quality of life, qualitative, and quantitative methods in order to fully assess feasibility. Trial registration Clinicaltrials.gov NCT01344005

We appreciate the paper by O'Dowd et al 1 as an interesting contribution to the literature concerning the primary care diagnosis of lung cancer. By concentrating on those patients dying soon after diagnosis, this paper is addressing the issue of access to care of patients with lung cancer who are already gravely ill. The disappointingly low chest X-ray (CXR) referral rates (we calculate obtained in only 40.2% and 50.4% of the patients attending with medium/high frequency and dying before and after 90 days, respectively) may represent irregular recording of CXR requests in The Health Improvement Network (THIN). Electronic research databases store their data in …

Lung cancer is a major global health burden with high incidence rates but poor long-term survival. Currently, the majority of cases are diagnosed at an advanced stage when surgical resection is not feasible. Screening for lung cancer has been a major focus of research for the last 40 years. Despite this, there is still a lack of evidence to promote its use outside clinical trials. More recently, interest has focused on promoting earlier recognition of symptomatic disease among both the general public and primary care physicians in order to encourage more timely investigation and referral to secondary care. The hope is that this approach may increase the proportion of disease identified in the early stages, allowing more surgical resections and improved five-year survival rates. This article provides an overview of the current evidence base in terms of early diagnosis of lung cancer and provides some examples of innovations to promote this.

Background\ud The ELCID Trial is a feasibility randomised controlled\ud trial examining the effect on lung cancer diagnosis of\ud giving an urgent chest x-ray to smokers, and recent exsmokers,\ud aged over 60 with new chest symptoms.\ud Aims\ud The qualitative component explores the feasibility of\ud individually randomising patients to an urgent CXR or\ud not and investigates any barriers to patient participation.\ud Methods\ud To date we have conducted semi-structured interviews\ud with six primary care staff (practice managers, research\ud nurses), ten patients randomised to ‘extra-NICE’ guidelines\ud for referral for urgent chest x-ray, and six patients\ud randomised to ‘usual care’ (NICE guidelines)). We hope\ud to also interview patients who decline randomisation.\ud Interviews were analysed using a Framework approach.\ud Results\ud Initial analysis indicated that practices have struggled to\ud recruit patients, partly due to the eligibility criteria that\ud requires ex-smokers to have stopped smoking within the\ud last five years. Practices with a research nurse have\ud recruited the most patients. Patients indicated that they\ud are happy to take part in the trial and their anxiety\ud levels were not raised. Most patients hoped to be\ud randomised to urgent chest x-ray, although those who\ud were not did not go back to their GP to request one.\ud Conclusions\ud Eligibility criteria needed revision to include ex-smokers\ud of any duration. These preliminary findings suggest that\ud the trial appears to be feasible and patients are happy to\ud accept randomisation. The findings will inform the\ud design of the main trial in the future.