The journey to diagnosing Non-Small Cell Lung Cancer (NSCLC) is often complex, involving various healthcare services and specialists. Understanding the typical pathways patients take to receive a definitive diagnosis is crucial for improving early detection and optimizing healthcare delivery. This article delves into a Descriptive Diagnosis of these pathways, highlighting the roles of general practitioners (GPs), specialists, and hospital emergency departments in the diagnostic process of NSCLC.
One notable trend is the increasing utilization of community-based health services in the two months preceding an NSCLC diagnosis. General Practitioners are pivotal in this phase, with a significant 93% of patients consulting a GP within three months before diagnosis. Alarmingly, 60% of these individuals visited their GP at least four times, and a similar proportion underwent thoracic imaging ordered by their GP. This underscores the critical role GPs play as the first point of contact and in initiating the diagnostic workup for lung cancer.
Two prevalent diagnostic pathways for NSCLC involve GPs and lung specialists within the community, without requiring emergency hospital admission. These pathways account for approximately one-third of all diagnoses, suggesting that patients with less acute or more typical lung cancer symptoms are effectively being referred to appropriate specialists outside of emergency settings. However, it’s noteworthy that less than half (45%) of patients consulted a lung specialist (either a respiratory physician or cardiothoracic surgeon) before their diagnosis. This figure aligns with previous research, indicating a consistent pattern in specialist consultation rates at initial presentation. Several factors may explain why some patients do not see a lung specialist prior to an NSCLC diagnosis. These include the sudden onset of severe symptoms necessitating emergency hospital presentation, referral to specialists outside of lung cancer expertise (such as oncologists or general physicians), referrals related to symptoms of distant metastases (like neurologists), or the incidental discovery of lung cancer during investigations for unrelated conditions. Studies indicate that a significant proportion of lung cancer cases, around 23%, are diagnosed incidentally, which naturally bypasses planned GP-ordered imaging or specialist consultations.
Interestingly, geographical remoteness does not appear to be a significant barrier to accessing specialist care in the diagnostic phase. The study found no substantial differences in GP and specialist visits or chest imaging rates between individuals residing in outer regional and remote areas compared to major cities. This suggests that physical distance alone may not impede access to lung specialists. However, the study acknowledges a limitation in data regarding the lung cancer Multidisciplinary Team (MDT) membership of specialists, which could vary by location. Further investigation is warranted to determine if referral to specialists actively participating in lung cancer MDTs contributes to improved treatment outcomes, particularly in major urban centers.
Emergency hospital admissions constitute a significant pathway to lung cancer diagnosis, accounting for a quarter of all cases. Alarmingly, over half of these emergency presentations occurred without prior GP-ordered imaging or consultation with a lung specialist. A higher incidence of distant metastasis was observed in patients diagnosed via emergency hospitalization compared to those without emergency admissions. This indicates that symptoms indicative of late-stage disease are, in some instances, leading directly to emergency presentations. Emergency treatments may be required due to the abrupt onset of severe lung cancer symptoms or after a period where patients may have delayed seeking medical attention for milder symptoms. Public health campaigns aim to enhance symptom awareness and encourage timely medical consultation. However, factors such as perceived lack of symptom urgency and stigma associated with lung pathologies, especially among smokers, can contribute to delayed help-seeking behavior. Another contributing factor to emergency department presentations might be physician referrals or patient self-referrals to emergency departments as a perceived means to circumvent waiting times, financial constraints, or distance barriers in accessing community-based specialists or diagnostic procedures.
Comparing pathway outcomes with other research is challenging due to variations in data sources, methodologies, and healthcare systems. The 25% emergency diagnosis rate in this study is lower than reported figures from some Australian and UK studies, yet considerably higher than rates observed in Danish research. Discrepancies may arise from how emergency department data is coded, often reflecting presenting symptoms rather than definitive diagnoses. To mitigate this, this study defined an emergency diagnosis pathway based on emergency hospital admissions with a confirmed lung cancer diagnosis, avoiding cases where emergency department visits did not result in a definitive diagnosis. Furthermore, variations in the definition of “lung specialist” across studies also complicate comparisons. This research included respiratory physicians and cardiothoracic surgeons, while some studies broaden the definition to include medical and radiation oncologists.
A limitation of this study is the absence of data on presenting symptoms during GP and specialist visits, as well as imaging results. This data gap prevents the calculation of time intervals between initial symptom presentation and diagnosis or treatment. It also limits the assessment of pathway appropriateness against clinical guidelines and the identification of incidentally diagnosed cases. Although healthcare service utilization appeared similar across urban and rural areas leading up to diagnosis, potential disparities in the time elapsed between symptom onset and access to specialist and diagnostic services could not be measured. Additionally, diagnostic procedures were not identifiable for approximately one-third of patients with a histopathological diagnosis, aligning with known underreporting in hospital admission data.
The study population, participants in the 45 and Up Study, exhibits lower smoking prevalence and is generally more socio-economically advantaged and healthier compared to the broader NSW population with lung cancer. While hospital and emergency department utilization in the year prior to diagnosis was comparable, primary and outpatient care usage could not be fully assessed. It’s important to consider that participants in cohort studies may differ from non-responders in health literacy and health-seeking behaviors, potentially influencing diagnostic pathways compared to the general population.
In contrast to studies often limited to medical record reviews, surveys, or small geographical areas, this study’s strength lies in utilizing linked health records for a large, population-level sample across New South Wales. This approach provides a comprehensive view of healthcare utilization across primary care, outpatient imaging, specialist care, and hospital admissions in the lead-up to lung cancer diagnosis, filling a previous knowledge gap in lung cancer care pathways.
The Australian Optimal Care Pathway (endorsed in 2015) outlines recommended steps for initial investigations, referral, diagnosis, and treatment of suspected lung cancer, aiming for consistent best practice care irrespective of location or treatment setting. This study focused on GP-ordered imaging and specialist referrals, key components of the Optimal Care Pathway. While the optimal pathway is contingent on individual patient presentations, it often includes GP-referred imaging, specialist referral to MDT members, and emergency department referral for severe cases. This study’s data, collected before the Optimal Care Pathway’s publication, provides valuable baseline information on health service utilization. Localized implementations of optimal care pathways, utilizing GP decision support tools and referral pathways to MDT specialists and rapid access clinics, hold promise for ensuring timely and appropriate investigations for symptomatic individuals.
In conclusion, this descriptive diagnosis of NSCLC pathways reveals that a significant proportion of patients do not consult a lung specialist during their diagnostic journey. Emergency presentations remain a substantial route to diagnosis, often without prior GP or specialist involvement. The study reaffirms the crucial role of GPs in lung cancer diagnosis. Efforts to equip GPs with the necessary information to initiate appropriate investigations and facilitate timely referrals to lung cancer MDT specialists are essential for promoting best practice care. Further research is needed to explore barriers hindering symptom recognition and access to specialist care from both patient and physician perspectives, ultimately striving for earlier and more effective lung cancer diagnosis.
