Primary Care Update archive

Should GPs be referring more patients for chest X-rays?

This article is an opinion piece written by one GP. It does not necessarily reflect the views of Macmillan.

We are frequently reminded that chest X-rays miss lung cancers. We are advised that with a high clinical suspicion of lung cancer, a normal chest X-ray provides false reassurance and further investigation is essential.

A retrospective cohort study of patients with lung cancer in 2006 [1] showed almost 10% of cancers were missed on chest X-rays completed in the three months prior to diagnosis. This figure increased to 23% in X-rays performed within the last year. More recent evidence supports this data [2].

Should we be doing more chest X-rays, or should our priority be the roll out of low-dose CT scans for lung cancer screening?

A recent article in Thorax [3] supports the idea that increased chest X-ray, following symptom awareness campaigns, leads to a lung cancer stage-shift. The article describes an early diagnosis campaign that commenced in 2011 in Leeds. It comprised public and primary-care facing components. Rates of community referral for chest X-ray and lung cancer stage at presentation were collected between 2008 and 2015.

The article presents headline figures for the three years pre-campaign (2008-2010) and the latest three years during the campaign (2013-2015). There was an 80.8% increase in community-ordered chest X-Rays, with a significant stage shift towards earlier stage lung cancer. An 8.8% increase in the proportion of patients diagnosed with stage one or two lung cancer (26.5% pre-campaign, compared to 35.3% during campaign) was observed, with a 9.3% reduction in the absolute number of patients diagnosed with stage three or four disease (1254 pre-campaign, compared to 1137 during campaign). The authors comment that a causal link between the campaign and stage-shift cannot be proven but appears plausible.

The campaign identified an increase in referral for chest X-rays after each educational intervention, suggesting education of public and health care professionals is a critical component of any early diagnosis strategy. Interestingly, while the public were given open access to chest X-rays in this campaign, most of the observed increase followed GP referrals rather than self-referrals.

Evidence suggests low dose CT screening will only diagnose 20% of patients who have lung cancer. The majority will be diagnosed after presenting with symptoms. Therefore, it is vitally important that we have other strategies in place to improve early diagnosis.

Fatalistic health beliefs around lung cancer can be common in both patients and health care professionals. It is therefore important to educate public and health professionals about the significant improvements to lung cancer survival that can be achieved by early diagnosis and prompt treatment [4].

Reducing the threshold for chest X-ray referral makes sense, with the proviso that a normal chest X-ray does not exclude lung cancer when clinical suspicion is high. Use of low-dose CT screening alone will not achieve our ambition to improve lung cancer survival. A multifaceted approach is needed, including education of health care professionals, public awareness campaigns, rapid diagnostic pathways and prompt treatment.

The critical role of preventive strategies, health promotion and smoking cessation must not be overlooked in our bid to improve early diagnosis and treatment of lung cancer.

National Cancer Diagnosis Audit: your questions answered

4 February was World Cancer Day. Macmillan Cancer Support, Cancer Research UK, RCGP, Public Health England and NHS England are promoting the National Cancer Diagnosis Audit (NCDA), which provides an opportunity to learn more about patient journeys in the cancer diagnosis pathway.

Find out more at or visit to take part in the audit. Please note, this link is only accessible from an NHS networked PC.

What is the National Cancer Diagnosis Audit (NCDA)?

The NCDA looks at the patient pathway from initial presentation up to the point of cancer diagnosis and includes primary and secondary care data. The audit looks at various aspects of pathways involved in the diagnosis of cancer, including length between initial presentation and diagnosis and what referral pathways were used.

The first national audit of cancer diagnosis in primary care was completed in 2010 and involved data from over 18,000 patients in England. A second audit was carried out in 2016-2017, which gathered data from over 19,000 patients in England and Scotland. The next audit is due to begin this year and GP practices in England can register from February 2019, with Scotland and Wales opening for registration later this year.

Why take part?

The main aim of the audit is to help GPs evidence good practice and to identify where improvements could be made. The findings will help to drive improvements in cancer diagnosis pathways to transform cancer care for your patients.

The confidential, tailored practice reports provided to each participating practice by Public Health England (PHE) are valuable tools to help practices understand how they compare nationally, as well as to a group of similar services. The reports highlight diagnostic challenges and can serve as an educational tool. They are completely confidential to each practice and are not shared more widely by PHE.

In the last audit round, many GPs found this activity helpful for revalidation and appraisal purposes, and some practices submitted their tailored NCDA reports during their CQC inspections. GP participation in the NCDA also benefits GP clusters and Federations, CCGs, Cancer Alliances and STPs in a variety of ways, from providing vital local and regional cancer intelligence, to enabling the sharing of good practice, and allocating resources effectively to support quality improvement in primary care.

What are the findings so far?

In the previous audit, data were collected from 17,000 patients with a new diagnosis of cancer in England. It showed the median diagnostic interval (time from first presentation to diagnosis) was 40 days.

However, the median primary care interval (time from first presentation to referral) was only five days, indicating that most patients were referred promptly by their GP. RCGP Chair, Dr Helen Stokes Lampard, said the audit shows GPs are doing a good job to refer patients they suspect have cancer, as reported in the article on Pulse.

However, for one in five patients (22%), GPs felt there had been an avoidable delay somewhere in the patient pathway, highlighting potential areas for quality improvement along the care continuum. The full paper of the key findings is available online.

By taking part in the audit, you will not only understand more about how cancers are diagnosed at your practice, but you will also further our understanding of pathways to cancer diagnosis nationally and support important research to inform care in the future.

How do I register to take part in the audit?

In England, GPs will be able to register for the audit online from February. Visit to find out more.

To take part, visit from an NHS connected computer. Registration only takes a few minutes.

What is expected of me if I sign up to participating in the audit?

After registering, you will receive an account and login details for the NCDA portal. Data collection will start from April 2019 and you will receive a monthly email to alert you to new eligible patients for whom you can submit data.

Collecting data on a single patient takes 15-20 minutes and a practice with 10,000 patients will have about five eligible cancer diagnoses each month, requiring a time commitment of around two hours. Trainees, registrars and students can do the data collection on behalf of a practice, but a suitably qualified supervising GP will need to oversee their work.

GPs do not need to seek patient consent as this is an audit coordinated by Public Health England as part of Cancer Registration services. However, you will be supplied with a poster to display in waiting rooms to allow patients to find out more and to opt out if they wish.

After the first six months of data collection are complete, PHE will analyse the data and you will receive a tailored interim practice report, followed by a full annual report after 12 months of data collection. The reports are provided to help you and your practice team reflect on how cancers are diagnosed and can be used to evidence good practice or to identify areas for targeted quality improvement.

Is there any support available to GPs who want to participate in the audit?

Your local Macmillan GP, Nurse Facilitators, and CRUK facilitators can work with your team to guide your participation in the audit. This could be in the form of regional or local workshops in addition to tailored support to individual practices.

GPs who took part in past audits commented it was useful for personal development as well as quality improvement. We heard from several GPs who took part in the previous audit:

‘I found the whole process incredibly easy and very informative. The information gathered highlighted good practice and areas that require improvement to help change future practice and improve patient care. Furthermore, the work can go towards my Continued Professional Development as part of my annual appraisal.’ GP from Doncaster.

‘Completing the audit really helped shine a light on the whole patient journey and where things could be improved for the better.’ GP from Aberdeen.

‘The report was surprising in some ways, and undoubtedly practice-changing.’ GP from Caterham.

We encourage you to sign up and participate in the audit to help improve cancer outcomes.

Written by Jana Witt and Dr Bhushan Rao.

Cancer care in primary care: resources to support you

Are you interested in exploring specialist areas of general practice? The Royal College of General Practitioners (RCGP) has recently added Cancer Care to its series of Education Libraries. The series also includes libraries on the topics of Women’s Health and Dermatology.

Developed in partnership with Macmillan Cancer Support, the Cancer Care Library provides GPs and primary care professionals with the latest guidelines, eLearning, journal articles, podcasts and more. These libraries are designed to support you as primary care professionals to easily access relevant resources for yourselves, your peers and your patients.

Working in collaboration with Macmillan, the RCGP has collated a huge variety of professional resources spanning prevention and early diagnosis through to living with and beyond cancer. There is also a wealth of patient information covering the different cancer types, practical information about accessing travel insurance and guidance on how to support a loved one who has been diagnosed with cancer.

The Cancer Care Library will be available from early March 2019 and is free to access on the RCGP Learning website.

Patient perspective: Multidisciplinary Diagnostic Centres (MDCs)

I was recently diagnosed with lymphoma. Hearing the word ‘cancer’ was a surreal moment, especially as I viewed myself to be fit and healthy. I had been to my GP six times with headaches and dizziness without making any progress and without receiving much information. It was not until I passed out at home, and was taken to my local hospital, that I got a referral to the Multidisciplinary Diagnostic Centre (MDC).

My experience of the MDC pathway was really positive. I was worried at first when I was told it was all going to be happening on the same day in the hospital, but I knew that I was in the best place possible. I was told by a GP that one of the symptoms I had could indicate cancer. She wasn’t quite sure but advised that I go to a clinic where all my tests could be done quickly.

I was apprehensive at first, but it was a really quick process and my consultation and tests were all done in one day. I also had my CT scan on the same day as my initial consultation and was told that I may have lymphoma. The staff at the hospital were all very supportive and I had my wife with me throughout the day too, which helped make everything more bearable.

The consultant I saw at the MDC was excellent, as was my Navigator, Kath. She helped me on the day and gave me confidence as she took me to the scanner and told me more about the hospital. It was helpful having a dedicated person to answer my questions. The nurse on the day also explained things that had initially confused me.

Fortunately, I was able to phone the nurse up when I was sent for further tests and she answered all my questions and explained them thoroughly. She was there when I first heard my diagnosis and also when I saw the Haematology consultant. And here I am today quite happy.

The ACE Programme

The ACE Programme is piloting a new diagnostic pathway for patients with ‘non-specific but concerning symptoms’. The Multidisciplinary Diagnostic Centre (MDC) concept enables patients to undergo several diagnostic tests in one location. MDCs involve a number of specialists working together to speed up diagnosis for the patient.

Find out more about the MDC pathway on our website.

GP case study: work and cancer

How can a cancer diagnosis affect a person’s ability to work?

The effect of cancer and its treatment on a person’s ability to work can vary widely. Factors can include the type and stage of cancer, the treatment and its side effects, and how the person copes when faced with a traumatic situation. While some people can continue to work during their treatment, others may need to take time off, require support to help them return to work, or need to leave the workplace completely.

How many people does this affect?

An estimated 1 in 3 people with cancer in the UK are of working age. In 2015, it was estimated that this equated to approximately 890,000 people. While not all of these will be in employment, research by Macmillan has found that 87% of those who were working when diagnosed say it is important to continue working after their diagnosis.

As a GP, what am I expected to know to support people to remain in or return to work?

As a GP, you do not need specialist knowledge of workplaces or occupational health. However, by helping your patients to understand the potential impact of their cancer and its treatment, you can help them consider what work they might be able to do. This will help them to have early and informed conversations with their employer about their work support needs.

Are there services that I can refer my patients to if they need help around work and cancer?

Macmillan has a dedicated team of work support advisers who can help your patients understand their rights at work. They provide information and guidance on talking to employers and negotiating adjustments and can answer questions on sick pay or taking time off. The team can also refer people with more complex needs to one-off legal advice. The team is available Monday-Friday, 8am-6pm on 0808 808 00 00. We also provide information about work and cancer on our website.

What support is available for me and my colleagues?

Macmillan has developed resources to guide healthcare professionals through work-related conversations with patients. Our Work support route guides contain specific information for professionals in England, Northern Ireland, Scotland and Wales. They can help you feel prepared to talk about work and signpost patients to further sources of support.

How do I build this into practice?

As a GP, one way you can ensure that you’re supporting patients in work-related conversations is through the Cancer Care Review discussion. Macmillan has worked with each of the main GP IT providers over the past year to develop integrated, standardised cancer care review templates within EMIS Health, INPS vision and TPP SystmOne. These templates take a holistic approach to the discussion, covering conversations about employment, financial support and the clinical needs of the person living with cancer.

Using these templates to guide you through conversations with people, following a cancer diagnosis, is one way to easily incorporate conversations about work into practice. The templates are also a helpful way to ensure that appropriate information is coded back on to the patient file, as well as supporting signposting to further support, with embedded Macmillan information available to print.

Written by Rebecca Coaker, Macmillan Services Influencing Manager – Work and Cancer

Topical highlights

Millimetres matter: implementing the National Optimal Lung Cancer Pathway (UKLCC)

The latest figures for five-year survival for patients diagnosed in England show that only 14% of males and 17.5% of females survived for five years post-diagnosis of lung cancer [1]. Significant changes in the diagnosis and treatment of lung cancer are essential to achieve the UKLCC ambition of improving five-year survival rate for lung cancer to 25% by 2025 [2].

Patients diagnosed with lung cancer at the earliest stage are almost five times more likely to survive a year from diagnosis than those diagnosed in the latest stages [3]. Both time and millimetres matter. Even at stages one and two, the growth of a tumour while waiting for treatment can be hugely significant, with small increases in tumour size and or lymph node involvement impacting on survival [4]. Studies have shown a direct link between shorter pathways and improved survival [5].

The National Optimal Lung Cancer Pathway aims to improve lung cancer survival and tackle local variation, to improve patient experience and enable effective use of resources.

Risk algorithm using serial biomarkers

Ovarian cancer screening strategy, using serial biomarker change interpreted through a risk algorithm (instead of previously used single biomarker thresholds), can increase cancer detection rates [1].

In the UK Collaborative trial of ovarian cancer screening [2], women aged 50 years or over underwent incidence screening using Multimodal Strategy (MMS), in which the annual serum cancer antigen 125 (CA-125) was interpreted using the risk of ovarian cancer algorithm (ROCA).

Women were triaged by the ROCA:

  • Normal risk: returned to annual screening
  • intermediate risk: repeat CA-125
  • elevated risk: repeat CA-125 and transvaginal ultrasound.

Women with persistently increased risk were evaluated clinically. Screening by using the ROCA doubled the number of screen detected invasive epithelial ovarian or tubal cancers over single threshold rules.

This supports the use of velocity-based algorithms in cancer screening strategies which use blood biomarkers.

New life-extending treatment for advanced lung cancer

Over three thousand patients with untreated, metastatic, non-squamous non-small-cell lung cancer have been given a chance of treatment, as immunotherapy drug pembrolizumab, in combination with pemetrexed and platinum chemotherapy, has been approved by NICE (National Institute of Health and Care Excellence) [1].

Clinical trial evidence from the ongoing KEYNOTE-189 trial [2] showed a large difference in overall survival at 12 months (69.2% in the trial group, compared to 49.4% in the usual treatment group). This equates to almost four months extra without progression of disease, but evidence for further benefit will need to be seen before this will be funded as routine NHS treatment.

Currently, as the treatment has shown potential to be cost effective and extend life, it has been approved for use with finance from the Cancer Drugs Fund (CDF), thereby allowing patients to benefit while further research evidence is collected. The full guidance was published on 10 January 2019 and is available at on the NICE website.

Ovarian cancer mortality

Ovarian Cancer has a poor prognosis, with just 40 % of patients surviving five years [1]. Five-year survival for ovarian cancer shows a rapid decrease by stage, ranging from 90% at Stage I to 4% at Stage IV [2].

In a randomised controlled trial [1] over 200,000 women aged 50-74 were allocated to annual multimodal screening (MMS), annual transvaginal ultrasound screening and to no screening.

This trial is the first randomised controlled trial of ovarian cancer screening to produce findings that show that in postmenopausal women from the general population, annual screening with use of MMS is safe and could reduce deaths due to ovarian cancer. However, to establish the magnitude of the reduction in deaths, a longer duration of follow up was deemed necessary.

Meanwhile efforts to refine ovarian cancer screening strategies should continue.


Should GPs be referring more patients for chest X-rays?

  1. Negative chest X-rays in primary care patients with lung cancer. Sally Stapley, Deborah Sharp and William Hamilton. Br J Gen Pract 2006; 56 (529): 570-573.
  2. Sensitivity of chest X-ray for lung cancer: systematic review. Stephen Bradley et al. Br J Gen Pract 2018; 68 (suppl 1).
  3. Lung cancer stage-shift following a symptom awareness campaign. Martyn PT Kennedy et al. Thorax vol.73 issue12.
  4. UKLCC ‘Millimetres Matter: Implementing the National Optimal Lung Cancer Pathway. November 2018.


Topical highlights

Millimetres matter: Implementing the National Optimal Lung Cancer Pathway (UKLCC)

  1. National Cancer Registration and Analysis Service, PHE
  2. UKLCC ’25 by 25’, a ten-year strategy to improve lung cancer survival rates’, October 2016
  3. Roy Castle Lung Cancer Foundation. Detecting lung cancer early 2016
  4. Jacobsen et al. ‘Timeliness of access to lung cancer diagnosis and treatment: A scoping literature review’. Lung cancer, 2017

Risk algorithm using serial biomarkers

  1. U Menon, A Ryan, J Kalsi et al; Risk Algorithm Using Serial Biomarker Measurements Doubles the Number of Screen-Detected Cancers Compared With a Single-Threshold Rule in the United Kingdom Collaborative Trial of Ovarian Cancer Screening.J Clin Oncol. 2015 Jun 20; 33(18): 2062–2071
  2. Long term impact of screening on ovarian cancer mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

New life-extending treatment for advanced lung cancer

  1. New life-extending lung cancer treatment approved by NICE
  2. Study of pemetrexed+platinum chemotherapy with or without pembrolizumab (MK-3475) in participants with first line metastatic nonsquamous non-small cell lung cancer (MK-3475-189/KEYNOTE-189)

Ovarian cancer mortality

  1. I J Jacobs, U Menon, A Ryam et al; Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. Lancet 2016 Mar 5;387(10022):945-956.
  2. Ovarian cancer statistics (Cancer Research UK)