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Blogs by the online BMJ respiratory medicine champion
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Lung Cancer, is it all doom and gloom? Forum X-Post
At the ERS in Amsetrdam last year I heard a nice presentation from a Resp SpR in Kent (Maidstone, I think) who had looked at the cause for delayed referral to secondary care in patients with lung cancer. They looked at the NICE guidance on who should be referred, and when, with what symptoms: in a large number of cases it was felt that GPs didn't refer early enough, given the symptoms documented. But that doesn't tell half of the story. If every GP referred every smoker or ex smoker with breathlessness and persistent cough to secondary care, we would be swamped by referrals very quickly. I don't think we'd pick up any more cases, so our sensitivity would stay the same, we would pick them up earlier, more of which later, but our hit rate would plummet, as we see far too many 'false positives'. Picking up disease early in lung cancer is always going to be difficult without a formal screening program. The lungs have no pain receptors, so patients can't feel their tumour. They can't see their tumour. Tumours generally don't bleed until they're large, or proximal, and generally un-curable. Patients more frequently present with symptoms caused by metastases, local invasion, or general systemic complications, by which point, it's inoperable/uncurable. We need screening programs to make an impact into lung cancer mortality. The 5 year survival of lung cancer has not changed in the past 20 years - compare this with some childhood leukaemias where the 5 year survival has gone from single fingers to over 90% in the same timescale. Nicola Sturgeon announced last week that Scotland is to begin a large prospective study looking at a molecular marker for lung cancer screening. I'm the local respiratory lead for this study, here in Dundee - the other centre will be Glasgow. We are planning an October start for this study, and I'll be updating my blog, and the respiratory forum with our progress as we go along. The study will bring its own difficulties, and complications, but once we have more formal go ahead to discuss it, I'll write more here. Interesting times, no doubt.
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However, before we get carried away with the advances in treating stage 4 lung cancer, the graph shows an increasing trend upwards in smoking prevalence in China, India etc whereas it is falling in countries like Australia.
Public health initiatives to stop smoking being an attractive option is the elephant in the room. Doctors like to get fixated at treating patients in their tumour's last doubling time when the prevalence of smoking is doubling as they speak. Prevention is less sexy than EBUS, targeted cell receptors, PCR and melting DNA to find out which brand of adenocarcinoma is consuming you like a spider's pupa in a caterpillar.
That sobering statistic also applies to pulmonary fibrosis, silicosis, asbestos diseases and probably sarcoidosis and COPD. We are trail blazers in improving the lot of man.
Asthma is another story and we now have lots of fat people on CPAP which will make them live longer with their diabetes.
In France there is a shortage of the blighters (thoracic physicians) as no one wants to pursue a discipline which is now in the penumbra of oncology, infectious diseases, radiology, immunology and rheumatology not to mention cardiology. We can blow into bags and spirometers but not much else.
Our radiation oncologists don't do radiotherapy on weekends, public holidays or servicing-the-machine-days (every second Fridays) as tumours don't grown on those days. Over Easter they just put up their feet (the tumours that is) and eat chocolate. That is the wonder of oncology.