Lung and pleural cancers

Scottish referral guidelines for suspected cancer
Centre for Sustainable Delivery

Urgent suspicion of cancer (USC) referral

Refer a person with any of the following to the Respiratory Service as a USC referral:

  • Chest x-ray (or CT scan) that is concerning for lung or pleural cancer (including unilateral pleural effusion, pleural mass and slowly resolving consolidation)
  • Unexplained haemoptysis (arrange a USC chest x-ray but no need to wait for the result)

If the chest X-ray is not suspicious for lung or pleural cancer a USC referral should still be considered particularly if there are concerning symptom combinations57.

In smokers:

  • Breathlessness with weight loss or appetite loss
  • Chest pain with weight loss, appetite loss or thrombocytosis
  • Weight loss and appetite loss together*

In all people:

  • Weight loss and thrombocytosis together*

*referral to a Rapid Cancer Diagnostic Service (RCDS) or GP direct access to CT is an appropriate alternative for this combination.

 

Assessment for suspected lung or pleural cancers

USC chest x-ray should be requested if a person has:

  • Unexplained haemoptysis
  • Unexplained symptoms lasting three weeks or longer (one or more symptoms in an ever-smoker or a person exposed to asbestos, two or more symptoms for all other people):
    • new cough or a change in a cough
    • breathlessness
    • chest or shoulder pain
    • weight loss
    • loss of appetite
    • fatigue
    • hoarseness – constant with voice never normal
  • Examination findings:
    • focal chest signs (e.g. rhonchi, reduced breath sounds or dullness to percussion)
    • new or not previously documented finger clubbing
    • supraclavicular lymphadenopathy
  • A chest infection or exacerbation of airways disease that does not resolve after two courses of antibiotics
  • Thrombocytosis where clinical features do not suggest another cause

Good practice points

Haemoptysis:

Haemoptysis is bleeding arising from below the glottis. In addition to lung cancer, there are a range of benign causes including infection, bronchiectasis, pulmonary embolism and vasculitis.

 

Referral guidance:

Please arrange bloods including a full blood count (FBC) and renal function if not done in the preceding three months to expedite any further imaging required.

If the chest x-ray shows consolidation, repeat imaging should be arranged six weeks later to confirm resolution. A USC referral to respiratory should be made if it remains abnormal.

 

Overlap with other pathways:

Head and neck cancer and lung cancer symptoms overlap (e.g. hoarseness and neck lumps). If the chest x-ray is normal, consider referring according to the Head and neck and thyroid cancer guideline.

 

Thrombocytosis:

Thrombocytosis is associated with a range of cancers including lung17. If the chest x-ray is not concerning for cancer and there are no other features suggestive of lung cancer (see above), then consider a USC referral to an alternative cancer pathway if appropriate. Please see the section on cancer and thrombocytosis. Please see the section on cancer and thrombocytosis in Referral process/Further considerations for assessment and referral.

 

Background

Lung cancer is the most common cause of cancer death in the UK53. On average, in 2021-2022, 46% of lung cancer cases in Scotland were diagnosed at stage 45. Data from England demonstrates that emergency presentation is a common route to diagnosis, making up 32.5% of routes in 201919. Inequalities exist in those most likely to present as an emergency, including women, older age groups, those from areas of higher deprivation, and those with non-respiratory symptoms54,55.

The most significant risk factor for lung cancer is smoking, although family and occupational history are relevant. In people with a history of asbestos exposure, mesothelioma, as well as lung cancer, should be considered. Across the UK, 95% of mesothelioma cases in men and 85% of cases in women are caused by asbestos exposure56.