Healthcare safety watchdog, HSIB, recently investigated the factors that contribute to England’s high number of cases of delayed diagnosis of lung cancer. Its findings are published in a national learning report, Missed detection of lung cancer on chest X-rays of patients being seen in primary care. The national investigation was triggered by one patient’s experience but acknowledges that delayed diagnosis of lung cancer is a nationally recognised patient safety risk. The report focusses specifically on GPs’ patients whose lung cancer diagnosis was delayed after their cancer was missed on chest X-ray, and recommends research, new guidance and investment to reduce delays in diagnosing lung cancer. Earlier diagnosis is essential to improve patient outcomes in NHS care.
The patient’s experience – HSIB’s ‘reference event’
HSIB’s national investigation was triggered by the experience of a patient whose lung cancer diagnosis was delayed by eight months, limiting her treatment options when the diagnosis was finally made. She was low risk for cancer as a 49-year-old non-smoker when she began to have persistent respiratory symptoms and consulted her GP. Over the course of a year, she had a total of 15 telephone or in-person consultations with GPs or nurse practitioners at her GP surgery and three chest X-rays in hospital, which were all reported as normal. Her widespread lung cancer was finally diagnosed when she was referred to A&E for an urgent CT scan after her condition deteriorated. The respiratory consultant who advised her of her diagnosis noted that her chest X-rays had suggested cancer, and referred her case to HSIB for investigation.
HSIB identifies factors causing delays in lung cancer diagnosis
According to HSIB’s report, there are around 46,700 new diagnoses of lung cancer each year in the UK. Lung cancer is most commonly diagnosed in people over 70 years of age.
Smoking is the biggest risk factor for lung cancer, with eight out of ten cases caused by smoking, but HSIB says lung cancer is not solely a ‘smokers’ disease’. Lung cancer in people who have never smoked is the eighth most common cancer-related cause of death in the UK. In fact, more deaths occur each year from non-smoker lung cancer than from cervical cancer, lymphoma, leukaemia, ovarian and stomach cancer. Lung cancer in non-smokers is under-recognised but not uncommon.
Diagnosis can be difficult as lung cancer does not always cause symptoms in its early stages. Its signs and symptoms can also be caused by other conditions. Common symptoms of lung cancer include:
• a persistent cough
• being short of breath
• coughing up phlegm (sputum) with blood in it
• chest or shoulder aches or pain
• feeling tired all the time (fatigue)
• losing weight.
Lung cancer is the third most common cancer that is diagnosed in England, but causes the most deaths. England’s five-year survival rates for people diagnosed with lung cancer are among the worst in Europe. HSIB says that this is because two-thirds of patients with lung cancer are diagnosed when their cancer is too advanced for treatment to cure them.
HSIB says that delayed diagnosis of lung cancer is a nationally recognised patient safety risk. Early diagnosis is essential to improve survival rates but in 2016, only a quarter of all lung cancer patients were diagnosed at an early stage. The NHS has a target to diagnose cancer at an early stage in three quarters of patients by 2028.
Chest X-ray is the UK’s recommended first diagnostic test for lung cancer. Around 56% of people who have lung cancer are diagnosed after being referred for a chest X-ray. However, 20% of lung cancers are missed on X-rays, resulting in delayed diagnosis and a worse outcome for the patient.
Common causes of missed diagnosis of lung cancer on chest X-rays include:
- observer errors, including :
- scanning errors, where the person checking the X-ray misses the cancer (30% of missed lung cancers);
- recognition errors, where the person checking the X-ray fails to recognise the cancer (25% missed lung cancers);
- decision-making errors, where the person checking the X-ray detects an anomaly but incorrectly interprets it as normal (45% of missed cancers).
- lesion characteristics, such as the size of the cancer or if it is hidden by other structures;
- technical considerations in the performing of the X-rays.
Countries with better outcomes for patients with lung cancer use CT scans to diagnose the condition. It is easier to detect lung cancer with a CT scan and only 5% of missed cancers are from CT scans compared with around 90% from X-rays. The NHS does not have the resources to use CT scanning as a first-line diagnostic test. In fact, HSIB says that in 2017 England was ranked lowest out of 23 developed countries for CT provision. The UK has a CT scanning capacity of 8 scanners per million people, compared with the European average of 21.4. The UK is also estimated to have only 7 radiologists per 100,000 population, one of the lowest rates in Europe.
HSIB’s findings and recommendations
HSIB made a number of findings and recommendations, including:
- Media messaging which highlights the link between lung cancer and smoking, and the non-specific symptoms of lung cancer, have made it challenging for GPs to diagnose lung cancer. Fewer people are smoking, but lung cancer in people who have never smoked is increasing.
- Chest X-rays are still recommended in the UK as the first diagnostic test for lung cancer, but they are difficult to interpret and about one in five cancers are missed. Chest X-rays which are incorrectly reported as normal are falsely reassuring to GPs.
- NICE guidance should make clearer to GPs what should be offered to patients who have ongoing, unexplained symptoms after a negative chest X-ray. ‘Safety netting’ is important in case a diagnosis has been missed.
- GP reluctance to refer patients for scarce CT resources contributes to delays in lung cancer diagnosis for their patients.
- CT scanning is a more accurate test for diagnosing lung cancer and is used more widely in other countries which have better cancer survival rates. The NHS needs major investment in CT scanning equipment and the staff who carry out and report on the scans.
- Research is needed to establish whether low-dose CT, which exposes a patient to less radiation than conventional CT and is known to help in screening those at high risk of lung cancer, should replace chest X-ray as the first-line diagnostic test for lung cancer in GP patients with non-specific symptoms.
- The expertise of the person checking the chest X-rays also affects whether cancers are missed. HSIB suggests that healthcare staff who review and interpret X-rays use educational platforms to develop their skills and assess their own performance.
Boyes Turner’s medical negligence specialists have helped many cancer sufferers and their families through the disability, loss and distress that follows a delayed diagnosis of potentially avoidable or treatable cancer. We welcome the HSIB’s report and its recommendations in the hope that the recommended changes are made leading to a reduction in the current unacceptable level of avoidable harm suffered by NHS cancer patients.
If you have suffered severe injury or the loss of a loved one as a result of negligent delays in diagnosis or treatment, you can talk to one of our solicitors, free and confidentially, to find out more about making a claim by contacting us here.