1. Lung cancer appears to be more difficult to detect via remote/phone/video/e-consultations than through face to face interactions. Always proactively ask about risk factors and other lung cancer symptoms in patients presenting with respiratory illness, and beware the patient presenting more than once with non resolving symptoms.
2. Follow NG12 recommendations for requesting a CXR- any unexplained suggestive symptom or sign in a smoker or ex-smoker >40 should lead to a chest X-ray. 2 or more suggestive symptoms in never smokers should lead to a chest Xray
3. 25% of CXRs are normal in lung cancer - if you remain concerned about a possible lung cancer, refer on 2WW lung cancer pathway. Threshold of concern is elevated by presence of risk factors, multiple symptoms, persistent symptoms, severe symptoms or unexplained symptoms.
4. Thrombocytosis is a risk factor for lung cancer
5. Follow NG12 recommendations for referring on 2WW lung pathway
6. Code everyone’s smoking status and include if they could be a passive smoker by living with a smoker- at least ten percent of patients with lung cancer have never smoked.
7. Ensure if you have e-consult and smoking status is recorded on the submission that admin can code smoking status as this is not automatically pulled through.
8. Don’t assume coughs lasting more than 3 weeks are due to COVID, request a CXR if they haven’t had one recently.
9. Lung cancer is a disease of deprivation and associated with high smoking prevalence. Identify if a patient is high risk for lung cancer, don’t assume breathlessness is COPD alone and check if they have had a CXR
10. Weight loss or constitutional symptoms such as fevers or sweats are worrying features in association with the features above and warrant urgent referral.
11. Patients referred with suspected lung cancer will require an urgent CT scan of the chest and upper abdomen with i.v. contrast. To avoid the risk of contrast nephropathy, please include an eGFR within the past 3 months or confirm a blood test has been sent.
12. Patients with transient haemoptysis in the setting of a chest infection, who have a normal CXR, have a low probability of having lung cancer (c. 1%)

An urgent referral for a chest x-ray should be made when a patient presents with:

• haemoptysis, or unexplained or persistent (that is, lasting more than 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, secondary's in the brain, bone, liver or skin)
• underlying chronic respiratory problems with unexplained changes in existing symptoms

An urgent referral for a chest X-ray or to a team specialising in the management of lung cancer should be made as for other patients but may be considered sooner, for example if symptoms or signs have lasted for less than 3 weeks.

Referral Criteria

Lung cancer or mesothelioma

• has chest X ray findings that suggest lung cancer or mesothelioma
  • Chest X-ray should be no more than 3 weeks old

• is aged 40 and over with unexplained haemoptysis
  • Please arrange a chest X-ray to take place in next 48 hours

• for minor or resolved haemoptysis without other symptoms suggestive of lung cancer, consider just a chest X-ray

• has a normal chest X-ray but with a high index of suspicion

The following recent blood results, less than 8 weeks old, would be extremely helpful:

• FBC
• eGFR
• clotting
• U&E
• LFT
• bone profile

Referral Instructions

The GP should use e-Referral Service to book an appointment or send the referral.

Please ensure you include:

• The patient's NHS number
• Tell the patient that this is an urgent referral and they will be seen within 14 days

e-Referral selection:

• Specialty: 2WW
• Clinic type: 2WW Lung
• Service: Two Week Wait Lung RAS -RDE-RH8

For any patients that you are unable to process through NHS e-Referral please contact the drss.helpdesk@nhs.net

Referral Forms

Suspected Lung cancer referral form - No merge fields

Suspected Lung cancer referral form - EMIS

Suspected Lung cancer referral form - SystmOne 

Evidence

NICE referral guidelines for suspected cancer

GP Information

Suspected Cancer Guidelines A-Z

NICE referral guidelines for suspected cancer

bmj - New NICE guidance on referral for cancer

bmj - Assessing and referring adult cancers infographic

New Leaflet available for patients who are referred to exclude a diagnosis of cancer

Patient Information

Macmillan

New Leaflet available for patients who are referred to exclude a diagnosis of cancer

Pathway Group

This guideline has been signed off by NHS Devon.

Publication date: November 2016