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Background: Evidence on whether general practice rates of investigation in symptomatic patients using chest x-ray (CXR) affects outcomes is equivocal., Aim: Determine if there is an association between rates of general practice (GP) requested CXR and lung cancer outcomes., Design and Setting: Retrospective observational study (England) Methods: Cancer registry data for patients diagnosed with lung cancer 2014-2018 was linked to data on GP CXRs 2013-2017. Stage at diagnosis (I/II vs III/IV) and one and five year survival (conditional on survival to one year) following diagnosis was reported by quintile of CXR rate of patients' GP with adjustment for population differences (age, smoking, prevalence of COPD and heart failure, ethnicity and deprivation) and by unadjusted category (low, medium, high)., Results: 192,631 patient records and CXR rates for 7,409 practices were obtained. Practices with highest quintile CXR rate had fewer cancers diagnosed at stage III/IV compared to lowest quintile (OR=0.87, 95% CI 0.83-0.92, p<0.001). The association was weaker for high unadjusted CXR category (OR=0.94, 95% CI 0.91-0.97). For the highest adjusted quintile HRs for death within one year and five years were 0.92 (0.90-0.95), p<0.001) and 0.95 (95% CI 0.91-0.99, p=0.023) respectively. For the high unadjusted CXR category the HR for one year survival was 0.98 (95% CI 0.96-0.99, p=0.004) with no association demonstrated for five year survival., Conclusions: Patients registered at GPs with higher CXR use have a favourable stage distribution and slightly better survival. This supports use of CXR in promoting earlier diagnosis of symptomatic lung cancer in general practice., (Copyright © 2024, The Authors.)

Objectives: To determine the incidence of lung cancer amongst primary care referrals for investigation with a chest radiograph (CXR)., Methods: Retrospective evaluation of datasets from the national Clinical Practice Research Datalink (CPRD) and from a single large regional centre. Data were extracted for cohorts of consecutive adults aged over 40 years for whom a CXR had been performed between 2016 and 2018. Using cancer registry data, the incidence of lung cancer within a 2 years of the CXR referral and the variations with age, gender, and smoking status were evaluated., Results: A total of 291 294 CXR events were evaluated from the combined datasets. The incidence of lung cancer amongst primary care CXR referrals was 1.4% in CPRD with a consistent correlation with increasing age and smoking status. The incidence of lung cancer within two-years of the CXR varied between 0.03% (95%CI, 0.0-0.1) amongst never smokers aged 40-45 years to 4.8% (95%CI, 4.2-5.5) amongst current-smokers aged 70-75 years. The findings were similar for the single large centre data, although cancer incidence was higher., Conclusions: A simple estimation and stratification of the risk of lung cancer amongst primary care referrals for investigation with a CXR is possible using age and smoking status., Advances in Knowledge: This is the first estimate of the incidence of lung cancer amongst primary care CXR referrals and a demonstration of how the demographic information contained within a request could be used to optimize investigations and interpret test results., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology.)

Competing Interests: Declaration of competing interest None.

Background: Cancer incidence increases with age, so some clinical guidelines include patient age as one of the criteria used to decide whether a patient should be referred through the urgent suspected cancer (USC) pathway. Little is known about how strictly GPs adhere to these age criteria and what factors might influence their referral decisions for younger patients., Aim: To understand GPs' clinical decision making for younger patients with concerning symptoms who do not meet the age criteria for USC referral., Design and Setting: Qualitative study using in-depth, semi-structured interviews with GPs working in surgeries across England., Method: Participants ( n = 23) were asked to recall consultations with younger patients with cancer symptoms, describe factors influencing their clinical decisions, and discuss their overall attitude to age thresholds in cancer referral guidelines. A thematic analysis guided by the Framework approach was used to identify recurring themes., Results: GPs' decision making regarding younger patients was influenced by several factors, including personal experiences, patients' views and behaviour, level of clinical concern, and ability to bypass system constraints. GPs weighted potential benefits and harms of a referral outside guidelines both on the patient and the health system. If clinical concern was high, GPs used their knowledge of local systems to ensure patients were investigated promptly even when not meeting the age criteria., Conclusion: While most GPs interpret age criteria flexibly and follow their own judgement and experience when making clinical decisions regarding younger patients, system constraints may be a barrier to timely investigation., (© The Authors.)

Objectives: To estimate the time required to undertake consultations according to BMJ's 10-minute consultation articles.To quantify the tasks recommended in 10-minute consultation articles.To determine if, and to what extent, the time required and the number of tasks recommended have increased over the past 22 years., Design: Analysis of estimations made by four general practitioners (GPs) of the time required to undertake tasks recommended in BMJ 's 10-minute consultation articles., Setting: Primary care in the UK., Participants: Four doctors with a combined total of 79 years of experience in the UK National Health Service following qualification as GPs., Main Outcome Measures: Median minimum estimated consultation length (the estimated time required to complete tasks recommended for all patients) and median maximum estimated consultation length (the estimated time required to complete tasks recommended for all patients and the additional tasks recommended in specific circumstances). Minimum, maximum and median consultation lengths reported for each year and for each 5-year period., Results: Data were extracted for 44 articles. The median minimum and median maximum estimated consultation durations were 15.7 minutes (IQR 12.6-20.9) and 28.4 minutes (IQR 22.4-33.8), respectively. A median of 17 tasks were included in each article. There was no change in durations required over the 22 years examined., Conclusions: The approximate times estimated by GPs to deliver care according to 10-minute consultations exceed the time available in routine appointments. '10 minute consultations' is a misleading title that sets inappropriate expectations for what GPs can realistically deliver in their routine consultations. While maintaining aspirations for high-quality care is appropriate, practice recommendations need to take greater account of the limited time doctors have to deliver routine care., Competing Interests: Competing interests: SHB, CS, NT, HD, HP, JG and JW are general practitioners (GP), while AH is a GP trainee., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Lung cancer screening with low-dose CT was recommended by the UK National Screening Committee (UKNSC) in September, 2022, on the basis of data from trials showing a reduction in lung cancer mortality. These trials provide sufficient evidence to show clinical efficacy, but further work is needed to prove deliverability in preparation for a national roll-out of the first major targeted screening programme. The UK has been world leading in addressing logistical issues with lung cancer screening through clinical trials, implementation pilots, and the National Health Service (NHS) England Targeted Lung Health Check Programme. In this Policy Review, we describe the consensus reached by a multiprofessional group of experts in lung cancer screening on the key requirements and priorities for effective implementation of a programme. We summarise the output from a round-table meeting of clinicians, behavioural scientists, stakeholder organisations, and representatives from NHS England, the UKNSC, and the four UK nations. This Policy Review will be an important tool in the ongoing expansion and evolution of an already successful programme, and provides a summary of UK expert opinion for consideration by those organising and delivering lung cancer screenings in other countries., Competing Interests: Declaration of interests RWL is funded by the Royal Marsden National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Royal Marsden Cancer Charity. RWL's institution receives compensation from NHS England for time spent in a secondment role for the lung health check programme and as a National Specialty Lead for the NIHR. He has received research funding from Cancer Research UK, Innovate UK (co-funded by GE Healthcare, Roche, and Optellum), Small Business Research Initiative for Healthcare (co-applicant with QURE.AI), RM Partners Cancer Alliance, and NIHR (co-applicant in grants with Optellum). He has received honoraria from Cancer Research UK. SHB reports being clinical lead for cancer for the Leeds office of the West Yorkshire Integrated Care Board and received funding from Cancer Research UK for doctoral research. KB receives funding from the Welsh Government via the Health and Care Research Wales-funded Wales Cancer Research Centre (grant number 517190) and Primary and Emergency Care Research Centre (grant number 517195). MEJC reports being principal investigator for Leeds Lung Health Check and the Yorkshire Enhanced Stop Smoking study (funding from Yorkshire Cancer Research). YC reports being the lead for PERFECTS: the first national External Quality Assurance scheme for lung cancer imaging assessment funded by NHS England and NHS Improvement. AD declares a role as Medical Director for Thoracic Radiology at Brainomix. JKF has received fees for participation in speaker's bureau from AstraZeneca and participation on advisory boards from Epigenomics, NUCLEIX, AstraZeneca, and iDNA; and grant support from Janssen Research & Development. SMJ declares paid advisory board membership for 2017–20 with AstraZeneca, Bard1 Bioscience, Achilles Therapeutics, and Jansen; has received assistance for travel to meetings from AstraZeneca; is grant income lead investigator for GRAIL, GSK, and Owlstone; and is a shareholder in Optellum and BARD1 Lifescience. AM declares her role on the National Screening Committee. RLM declares honorarium from AstraZeneca and has been commissioned by Action on Smoking and Health to produce a report on smoking cessation in targeted lung health checks. AN declares grants from UK Department of Health and Social Care's NIHR Biomedical Research Centre's funding scheme and GRAIL (Summit study); consulting fees from Aidence, Faculty Science, and MSD; support for attending meetings from Takeda; advisory board participation with Aidence and Faculty Science; leadership roles for the British Society of Thoracic Imaging, British Lung Foundation, and NHS England Targeted Lung Health Checks Programme. ELO’D reports research funding from Roy Castle Lung Cancer Foundation. SLQ receives funding from Cancer Research UK (grant number C50664/A24460), Barts Charity (MRC&U0036), and University College London Hospital NHS Trust. RR reports advisory boards and consultancy for Inivata, AstraZeneca, and Olympus Medical and research funding support from Owlstone Medical, Victor Dahdaleh Charitable Foundation, Cancer Research UK, and Asthma and Lung UK. RB declares honoraria from Siemens for speaker fees. DRB declares his role as Clinical Advisor to the UK National Screening Committee, UK Department of Health and Social Care, and honoraria from AstraZeneca, MSD, Roche, and Bristol Myers Squibb. PC reports consultancy for Novartis, Everest Detection, AstraZeneca, and North West eHealth; and stock options for Everest Detection. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: Symptom awareness campaigns have contributed to improved early detection of lung cancer. Previous research suggests that this may have been achieved partly by diagnosing lung cancer in those who were not experiencing symptoms of their cancer. This study aimed to explore the relationship between frequency of chest x-ray in the three years prior to diagnosis and stage at diagnosis., Settings: Lung cancer service in a UK teaching hospital., Participants: Patients diagnosed with lung cancer between 2010 and 2013 were identified. The number of chest x-rays for each patient in the three years prior to diagnosis was recorded. Statistical analysis of chest x-ray frequency comparing patients with early- and late-stage disease was performed., Results: One-thousand seven-hundred fifty patients were included - 589 (33.7%) with stage I/II and 1,161 (66.3%) with stage III/IV disease. All patients had at least one chest x-ray in the six months prior to diagnosis. Those with early-stage disease had more chest x-rays in this period (1.32 vs 1.15 radiographs per patient, P = 0.009). In the period 36 months to six months prior to lung cancer diagnosis, this disparity was even greater (1.70 vs 0.92, radiographs per patient, P < 0.001)., Conclusions: Increased rates of chest x-ray are likely to contribute to earlier detection. Given the known symptom lead time many patients diagnosed through chest x-ray may not have been experiencing symptoms caused by their cancer. The number of chest x-rays performed could reflect patient and/or clinician behaviours in response to symptoms.

Competing Interests: Competing interests: SB is a clinical research fellow funded through the multi-institutional CanTest Collaborative, which is funded by Cancer Research UK (C8640/A23385) and he is also the clinical lead for cancer for Leeds (West Yorkshire Integrated Care Board). A full disclosure statement is available: https://medicinehealth.leeds.ac.uk/medicine/staff/1211/dr-stephen-bradley. The other authors have no competing interests to declare.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: SHB has submitted a grant application for a project which plans to evaluate the performance of AI systems in diagnosing lung cancer. He is clinical lead for cancer for NHS Leeds clinical commissioning group. He receives PhD funding from CanTest collaborative (Cancer Research UK C8640/A23385) and was a member of the executive committee of the Fabian Society, a political think tank affiliated with the Labour Party (unpaid). The publication costs of a collection of essays on health inequalities which he co-edited for the Fabian Society were funded by the Association of the British Pharmaceutical Industry and Lloyds Pharmacies. He has received funding from the Mason Medical Foundation for a study on lung cancer diagnosis.

Background: The cancer burden falls predominantly on older (≥65 years) adults. Prompt presentation to primary care with cancer symptoms could result in earlier diagnosis. However, patient symptom appraisal and help-seeking decisions involving cancer symptoms are complex and may be further complicated in older adults., Aim: To explore the effect of older age on patients' appraisal of possible cancer symptoms and their decision to seek help for these symptoms., Design and Setting: Mixed-methods systematic review., Method: MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library, Web of Science Core Collection, ASSIA, the ISRCTN registry, and the National Institute for Health and Care Excellence were searched for studies on symptom appraisal and help-seeking decisions for cancer symptoms by adults aged ≥65 years. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis guidelines., Results: Eighty studies were included with a total of 32 995 participants. Studies suggested a possible association between increasing age and prolonged symptom appraisal interval. Reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, in the current study a possible association was found between increasing age and prompt help-seeking. Themes affecting help-seeking in older adults included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, comorbidities, a desire to avoid doctors, a perceived need to not waste doctors' time, and patient self-management of symptoms., Conclusion: This review suggests that increasing age is associated with delayed cancer symptom appraisal. When symptoms are recognised as potentially serious, increasing age was associated with prompt help-seeking although other factors could prolong this. Policymakers, charities, and GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and seek help promptly., (© The Authors.)

Many cancer referral guidelines use patient's age as a key criterium to decide who should be referred urgently. A recent rise in the incidence of colorectal cancer in younger adults has been described in high-income countries worldwide. Information on other cancers is more limited. The aim of this rapid review was to determine whether other cancers are also increasing in younger age groups, as this may have important implications for prioritising patients for investigation and referral. We searched MEDLINE, Embase and Web of Science for studies describing age-related incidence trends for colorectal, bladder, lung, oesophagus, pancreas, stomach, breast, ovarian, uterine, kidney and laryngeal cancer and myeloma. 'Younger' patients were defined based on NICE guidelines for cancer referral. Ninety-eight studies met the inclusion criteria. Findings show that the incidence of colorectal, breast, kidney, pancreas, uterine cancer is increasing in younger age groups, whilst the incidence of lung, laryngeal and bladder cancer is decreasing. Data for oesophageal, stomach, ovarian cancer and myeloma were inconclusive. Overall, this review provides evidence that some cancers are increasingly being diagnosed in younger age groups, although the mechanisms remain unclear. Cancer investigation and referral guidelines may need updating in light of these trends., (© 2022. The Author(s).)

Background: Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer., Aim: To examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis., Design and Setting: A systematic literature review., Method: Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines., Results: Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers., Conclusion: This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important., (© The Authors.)

Background: Chest X-ray (CXR) is the first-line test for lung cancer in many settings. Previous research has suggested that higher utilisation of CXR is associated with improved outcomes., Aim: To explore the associations between characteristics of general practices and frequency of investigation with CXR., Design and Setting: Retrospective observational study of English general practices., Method: A database was constructed of English general practices containing number of CXRs requested and data on practices for 2018, including patient and staff demographics, smoking prevalence, deprivation, and patient satisfaction indicators. Mixed-effects Poisson modelling was used to account for variation because of chance and to estimate the amount of remaining variation that could be attributed to practice and population characteristics., Results: There was substantial variation in GP CXR rates (median 34 per 1000 patients, interquartile range 26-43). Only 18% of between-practice variance in CXR rate was accounted for by recorded characteristics. Higher practice scores for continuity and communication skills, and higher proportions of smokers, Asian and mixed ethnic groups, and patients aged >65 years were associated with increased CXR rates. Higher patient satisfaction scores for access and greater proportions of male patients and patients of Black ethnicity were associated with lower CXR rates., Conclusion: Substantial variation was found in CXR rates beyond that expected by chance, which could not be accounted for by practices' recorded characteristics. As other research has indicated that increasing CXR rates can lead to earlier detection, supporting practices that currently investigate infrequently could be an effective strategy to improve lung cancer outcomes., (© The Authors.)

Background: The accuracy of the chest x-ray (CXR) in the identification of lung cancer amongst symptomatic individuals is uncertain., Purpose: To determine the diagnostic accuracy of the CXR for the detection of non-small cell carcinomas (NSCLC) and all primary intrathoracic malignancies., Methods: A prospective cohort study of consecutive CXR reports obtained within a primary care open access initiative. Eligibility criteria were symptoms specified by National Institute for Clinical Excellence as indicative of possible lung cancer and age over 50-yrs. A positive test was a CXR which led directly or indirectly to investigation with CT. The reference standards were malignancies observed within a one- or two-year post-test period., Results: 8,948 CXR outcomes were evaluated. 496 positive studies led to a diagnosis of 101 patients with primary intrathoracic malignancy including 80 with NSCLC. Within two-years, a cumulative total of 168 patients with primary intrathoracic malignancies including 133 NSCLC were observed. The sensitivity and specificity for NSCLC were 76% (95 %CI 68-84) and 95% (95 %CI 95-96) within 1-year and 60% (95 %CI 52-69) and 95% (95 %CI 95-96) within 2-years. The 2-yr positive and negative likelihood ratios were 12.8 and 0.4. The results did not differ for NSCLC compared to all primary malignancies. Within this symptomatic population a negative test reduced the 2-year risk of lung cancer to 0.8%., Conclusions: A positive test strongly increases the probability of malignancy whereas a negative test does not conclusively exclude the disease. The findings allow the risk of malignancy following a negative test to be estimated., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Chest X-ray (CXR) is the first-line investigation for lung cancer in many healthcare systems. An understanding of the consequences of false-negative CXRs on time to diagnosis, stage, and survival is limited., Aim: To determine the sensitivity of CXR for lung cancer and to compare stage at diagnosis, time to diagnosis, and survival between those with CXR that detected, or did not detect, lung cancer., Design and Setting: Retrospective observational study using routinely collected healthcare data., Method: All patients diagnosed with lung cancer in Leeds Teaching Hospitals NHS Trust during 2008-2015 who had a GP-requested CXR in the year before diagnosis were categorised based on the result of the earliest CXR performed in that period. The sensitivity of CXR was calculated and analyses were performed with respect to time to diagnosis, survival, and stage at diagnosis., Results: CXR was negative for 17.7% of patients ( n = 376/2129). Median time from initial CXR to diagnosis was 43 days for those with a positive CXR and 204 days for those with a negative CXR. Of those with a positive CXR, 29.8% (95% confidence interval [CI] = 27.9% to 31.8%) were diagnosed at stage I or II, compared with 33.5% (95% CI = 28.8% to 38.6%) with a negative CXR., Conclusion: GPs should consider lung cancer in patients with persistent symptoms even when CXR is negative. Despite longer duration to diagnosis for those with false-negative CXRs, there was no evidence of an adverse impact on stage at diagnosis or survival; however, this comparison is likely to be affected by confounding variables., (© The Authors.)

Background: Chest X-ray (CXR) is the first-line investigation for lung cancer in many countries but previous research has suggested that the disease is not detected by CXR in approximately 20% of patients. The risk of lung cancer, with particular symptoms, following a negative CXR is not known., Aim: To establish the sensitivity and specificity of CXR requested by patients who are symptomatic; determine the positive predictive values (PPVs) of each presenting symptom of lung cancer following a negative CXR; and determine whether symptoms associated with lung cancer are different in those who had a positive CXR result compared with those who had a negative CXR result., Design and Setting: A prospective cohort study was conducted in Leeds, UK, based on routinely collected data from a service that allowed patients with symptoms of lung cancer to request CXR., Method: Symptom data were combined with a diagnostic category (positive or negative) for each CXR, and the sensitivity and specificity of CXR for lung cancer were calculated. The PPV of lung cancer associated with each symptom or combination of symptoms was estimated for those patients with a negative CXR., Results: In total, 114 (1.3%) of 8996 patients who requested a CXR were diagnosed with lung cancer within 1 year. Sensitivity was 75.4% and specificity was 90.2%. The PPV of all symptoms for a diagnosis of lung cancer within 1 year of CXR was <1% for all individual symptoms except for haemoptysis, which had a PPV of 2.9%. PPVs for a diagnosis of lung cancer within 2 years of CXR was <1.5% for all single symptoms except for haemoptysis, which had a PPV of 3.9%., Conclusion: CXR has limited sensitivity; however, in a population with a low prevalence of lung cancer, its high specificity and negative predictive value means that lung cancer is very unlikely to be present following a negative result. Findings also support guidance that unexplained haemoptysis warrants urgent referral, regardless of CXR result., (© The Authors.)

The history of cancer screening has demonstrated that the case for cancer screening is not straightforward. In contemporary practice, sharing decision-making with patients has become expected of family physicians. At the same time, increasing emphasis has been placed on encouraging patients to participate in screening programs to improve cancer outcomes. The success of cancer screening is often judged by the number of those who participate. Improving cancer outcomes should be a priority for family medicine, but the importance of this goal should not undermine doctors' commitment to helping patients make informed decisions that are consistent with their values and priorities. If we are serious about empowering patients, we need to be more open about the limitations of cancer screening, to help patients make up their minds., Competing Interests: Conflict of interest: The authors have no conflicts of interest to declare., (© Copyright 2021 by the American Board of Family Medicine.)

Competing Interests: Competing interests: GCR receives funding from the NHS National Institute of Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation and the Rotary Foundation to study for a Doctor of Philosophy (DPhil) at the University of Oxford. GCR is a member of the EBMLive Steering Committee. SHB, ABD, CBH, BCK, TR, CW and LZJW were Doug Altman Scholars, presented at EBMLive 2019 and had their expenses reimbursed to travel to and attend the conference. CW is funded through the National Institute of Health grant number F30 CA243651-01. BCK has received funding from the NIHR Doctoral Research Fellowship program. PJG has received grant funding from the Canadian Paediatric Society, and the Canadian Institute of Health Research (CIHR) in the past 5 years. He is on the CMAJ Editorial Advisory Board and on the Institute Advisory Board for the CIHR Institute of Human Development, Child and Youth Health (IHDCYH) where he has expenses reimbursed to attend meetings. He is on the editorial board of BMJ Evidence Based Medicine. He is a member of the EBMLive Steering Committee, and he has expenses reimbursed to attend the conference.