Time from presentation to pre-diagnostic chest X-ray in patients with symptomatic lung cancer: a cohort study using electronic patient records from English primary care

Kirsten D Arendse; Fiona M Walter; Mark Pilling; Yin Zhou; Willie Hamilton; Garth Funston

doi:10.3399/bjgp20X714077

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Figure 1.
Evaluated time intervals from presentation to diagnosis.
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Figure 2.
Application of study inclusion criteria. CPRD = Clinical Practice Research Datalink. HES DID = Hospital Episode Statistics Diagnostic Imaging Dataset. NCRAS = National Cancer Registration and Analysis Service. NICE = National Institute for Health and Care Excellence.

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How this fits in

England’s national cancer referral guidelines recommend that patients attending general practice with unexplained symptoms possibly caused by lung cancer, such as persistent cough, shortness of breath, and weight loss, have a chest X-ray promptly (within 14 days) to aid timely diagnosis. Only 35% of patients with lung cancer in this study had a chest X-ray within the recommended 14 days; and time between attending general practice with symptoms and having an X-ray was longer among people who smoke, females, and older patients. This research highlights a potential source of delayed lung cancer diagnosis and could inform initiatives aiming to achieve earlier diagnosis and improve outcomes.

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Box 1.

National Institute for Health and Care Excellence guidelines for referral of suspected cancer (2005)⁸

Section 1.3: Lung cancer
Specific recommendations
1.3.2. An urgent referral for a chest X-ray should be made when a patient presents with:

haemoptysis, or
any of the following unexplained persistent, that is, lasting >3 weeks, symptoms and signs: chest and/or shoulder pain, dyspnoea, weight loss, chest signs, hoarseness, finger clubbing, cervical and/ or supraclavicular lymphadenopathy, cough with or without any of the above, features suggestive of metastasis from a lung cancer, for example, in brain, bone, liver, or skin.

1.3.3. An urgent referral should be made for either of the following:

persistent haemoptysis in smokers or ex-smokers who are aged ≥40 years; or
a chest X-ray suggestive of lung cancer (including pleural effusion and slowly resolving consolidation).

1.3.4. Immediate referral should be considered for the following:

signs of superior vena caval obstruction (swelling of the face and/or neck with fixed elevation of jugular venous pressure); or
stridor.

Referral timelines
The referral timelines used in this guideline are as follows:

Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
Urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks).

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Table 1.

Proportion of NICE-guideline concordant pre-diagnostic chest X-rays (≤ 14 days after presentation) among symptomatic patients with lung cancer by sociodemographic factors

	Patients in cohort, n (%)		Total, N

	Chest X-ray ≤ 14 days (guideline concordant)	Chest X-ray >14 days (guideline non-concordant)
All	727 (35)	1375 (65)	2102

Sex
Male	426 (37)	722 (63)	1148
Female	301 (32)	653 (68)	954

Age categories, years
<40	1 (33)	2 (67)	3
40–49	25 (48)	27 (52)	52
50–59	85 (35)	156 (65)	241
60–69	214 (37)	362 (63)	576
70–79	240 (32)	517 (68)	757
80–89	142 (34)	279 (66)	421
≥90	20 (38)	32 (62)	52

Deprivation quintile
1 (least deprived)	133 (36)	234 (64)	367
2	147 (40)	223 (60)	370
3	141 (33)	280 (67)	421
4	152 (35)	286 (65)	438
5 (most deprived)	154 (30)	352 (70)	506

Smoking status
Non-smoker	71 (48)	78 (52)	149
Ex-smoker	396 (34)	772 (66)	1168
Smoker	260 (33)	525 (67)	785

Number of features on first presentation
1	692 (35)	1285 (65)	1977
>1	35 (28)	90 (72)	125

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Table 2.

Association between demographics and presentation–test intervals using negative binomial regression^a

	Patients in cohort		Presentation–test interval, days

	n (%)	Median (IQR)	IRR (adjusted)^b	95% CI (P-value)
Total	2102 (100)	49 (5–172)	–	–

Constant	–	–	35.77	23.09 to 55.40 (<0.001)

Sex
Male	1148 (55)	41 (4–162)	Ref	–
Female	954 (45)	63 (7–182)	1.12	1.02 to 1.24 (0.016)

Age
For every additional	–	–	1.07	1.01 to 1.12 (0.013)
10 years from age 27

Deprivation quintile
1 (least deprived)	367 (17)	43 (4–162)	Ref	–
2	370 (18)	37 (3–147)	0.86	0.73 to 1.02 (0.081)
3	421 (20)	46 (6–173)	1.01	0.86 to 1.18 (0.927)
4	438 (21)	49 (6–184)	1.03	0.88 to 1.21 (0.704)
5 (most deprived)	506 (24)	73 (9–184)	1.08	0.93 to 1.25 (0.326)

Smoking status
Non-smoker	149 (7)	18 (1–85)	Ref	Ref
Ex-smoker	1168 (56)	52 (6–173)	1.58	1.26 to 1.99 (<0.001)
Smoker	785 (37)	55 (6–181)	1.63	1.29 to 2.05 (<0.001)

Number of features on first presentation
1	1977 (94)	48 (5–170)	Ref	Ref
>1	125 (6)	91 (10–190)	1.20	1.00 to 1.43 (0.052)

ln (alpha)	–	–	0.82	0.77 to 0.88

↵a Likelihood ratio (LR) test of alpha = 0, χ² = 240 000, P < 0.001.
↵b Variables included in the adjusted analysis include sex, age in years, level of deprivation, smoking status, and number of features at first presentation. IQR = interquartile range. IRR = incidence rate ratio. ln (alpha) = natural log of alpha. Alpha is the over-dispersion parameter (values >0 indicate the distribution’s variance is greater than its mean).

Supplementary Data

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