Scottish Referral Guidelines for Suspected Cancer: Lung Cancer

More than 90% of people with lung cancer are symptomatic at the time of diagnosis. Many symptoms of lung cancer (particularly cough and fatigue), however, are common presentations in primary care, often associated with chronic diseases such as gastric reflux or chronic obstructive pulmonary disease. It is therefore important that changes in symptoms are identified and acted upon.

Chest X-ray findings are abnormal in over 96% of symptomatic people with lung cancer. In most cases where lung cancer is suspected, it is appropriate to arrange an urgent chest X-ray before urgent referral to a chest physician. However, a normal chest X-ray does not exclude a diagnosis of lung cancer. If the chest X-ray is normal but there is a high suspicion of lung cancer, people should be offered urgent suspicion of cancer referral to a respiratory physician.

In people with a history of asbestos exposure, mesothelioma, as well as lung cancer, should be considered. Approximately 80 to 90% of people with mesothelioma will have a history of occupational or close contact exposure. More common presentations include chest pain, dyspnoea and unexplained systemic symptoms.

Urgent suspicion of cancer chest X-ray (CXR)

Any unexplained haemoptysis
Unexplained and persistent (more than three weeks)

change in cough or new cough
dyspnoea
chest/shoulder pain
loss of appetite
weight loss
chest signs
hoarseness (if no other symptoms present to suggest lung cancer refer via Head & Neck pathway)
fatigue in a smoker aged over 40 years

New or not previously documented finger clubbing
Persistent or recurrent chest infection
Cervical and/or persistent supraclavicular lymphadenopathy*
Thrombocytosis where symptoms and signs do not suggest other specific cancer**
Any person who has consolidation on chest X-ray should have further imaging no more than six weeks later to confirm resolution

* if CXR normal, refer via Head and Neck pathway

** if CXR normal, consider alternative diagnosis including other cancer

Urgent suspicion of cancer referral

Any unexplained symptoms or signs detailed on previous page persisting for longer than six weeks, despite a normal chest X-ray (other than isolated thrombocytosis or cervical and/or persistent supraclavicular lymphadenopathy)
Chest X-ray suggestive/suspicious of lung cancer (including pleural effusion, pleural mass and slowly resolving consolidation)
Persistent haemoptysis in smokers/ex-smokers over 40 years of age

Good practice points

There should be a locally agreed pathway for radiology to notify the respiratory team of an abnormal chest X-ray suggestive of cancer
It is good practice for the referrer to consider taking bloods, including full blood count and an assessment of renal function if not done in preceding three months, in order to expedite further imaging
In people with features, suggestive of cancer including suspected metastatic disease, but no other signs to suggest the primary source, consider CT chest, abdomen and pelvis in accordance with local guidelines about the investigation of an unknown primary cancer