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1. 10-minute consultation: Suspected lung cancer

   • Daniel K C Lee, MB, BCh, MRCP, MD
   • Robert C Buttery, Robert C Rintoul

   Department of Thoracic Oncology, Papworth Hospital, Papworth Everard, Cambridge, CB3 8RE, England

   A 60-year-old ex-smoker presents to your surgery with mild breathlessness and cough. These symptoms have persisted for about 4 weeks despite treatment with a penicillin antibiotic prescribed by one of your colleagues.

   What you need to do

   • Organise an urgent chest x-ray (CXR) in view of the smoking history and persisting cough (see box). CXR is widely and rapidly available, inexpensive and results in minimal radiation exposure.
   • Send sputum sample to microbiology for culture and antibiotic sensitivity testing.
   • Consider a further course of antibiotic such as a macrolide antibiotic to treat penicillin-resistant organisms and atypical organisms.

   Clinical features requiring an urgent CXR Haemoptysis Any of the following unexplained symptoms or signs persisting more than three weeks Breathlessness Chest signs Cough that is unexplained or persisting Features suggestive of metastases from lung cancer (bone, brain, liver or skin) Finger clubbing Hoarseness of voice Pain in the chest or shoulder Persistent cervical or supraclavicular lymphadenopathy Weight loss

   The CXR shows a solitary mass-like shadow in the lung and is reported by a radiologist as being suspicious of lung cancer.

   What issues you should cover

   • Revisit the history paying particular attention to certain pertinent aspects that may point towards either lung cancer or other differential diagnoses (see box).
   • Discuss the benefits of stopping smoking. There is good evidence that smoking cessation improves outcome for patients with lung cancer. It reduces the perioperative risk and improves outcome following chemotherapy as well as long-term survival and quality of life in both small cell and non-small cell lung cancer.

   Patients with a solitary lung shadow Relevant history Respiratory Chest or shoulder pain Cough Haemoptysis Hoarseness of voice Shortness of breath Sputum production Wheezing Constitutional Lethargy Night sweats Poor appetite Weight loss Asbestos exposure Previous malignancy Smoking history Travel history Differential diagnoses Abscess Adenoma Aspergilloma Carcinoma Hamartoma Metastasis from another organ Pulmonary infarction Round atelectasis Round pneumonia Round pulmonary oedema Tuberculosis

   What you should do

   • Examine the patient carefully, observing for finger clubbing and signs indicating locally extensive or metastatic disease, such as peripheral lymphadenopathy, organomegaly, superior vena cava (SVC) obstruction and stridor. Urgent referral for specialist care should be made whilst awaiting the results of CXR in patients who present with stridor or SVC obstruction.
   • Assess the general fitness of the patient taking into account the build of the patient and whether the patient appears well nourished or cachetic while making a note of the height and weight.
   • Discuss the results of the CXR with the patient and convey your concerns to the patient regarding your suspicion of lung cancer if appropriate. Further tests will be required to clarify the diagnosis and extent of the problem. These will usually include a computed tomography (CT) of the thorax, and (depending on fitness) either bronchoscopy or percutaneous biopsy.
   • Refer the patient to a chest physician without delay in keeping with the Department of Health guidelines on the '2-week wait' scheme for referral of patients with suspected lung cancer to secondary care.
   • Address and treat any associated conditions such as concomitant chest infection or airway bronchoconstriction for patient optimisation prior to further investigation and management.

   Useful reading Management of patients with lung cancer: a national clinical guideline. Scottish Intercollegiate Guidelines Network 2005. http://www.sign.ac.uk/pdf/sign80.pdf Lung cancer: the diagnosis and treatment of lung cancer. National Institute for Clinical Excellence 2005. http://www.nice.org.uk/pdf/CG024niceguideline.pdf Lung cancer information centre. CancerBACUP 2005. http://www.cancerbacup.org.uk/cancertype/lung Lung cancer online. Lung Cancer Online Foundation 2005. http://www.lungcanceronline.org

   Conflict of Interest:

   None declared

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   Published August 30, 2006