Summary

Lung cancer is the leading cause of cancer deaths worldwide.1 Many people are diagnosed in the late stages of the disease, when treatment is less likely to be effective.2 In response, several countries have introduced rapid referral pathways between primary care and specialist clinics to reduce diagnostic delays.3 These pathways have been linked to a reduction in waiting times for diagnosis and treatment,2 4-7 and the proportion of people diagnosed with metastatic lung cancer.8

Challenge

Over two million people were diagnosed with lung cancer in 2020.9 It is the leading cause of cancer deaths worldwide, with a five-year survival rate of less than 20%.1

Many people are diagnosed at an advanced stage, when treatment options are limited.2 The one-year survival rate drops from 68–80% for stage I lung cancer to 15% for stage IV.10 Symptoms such as persistent cough, shortness of breath and repeated lung infections may be difficult to recognise as being linked to lung cancer. As such, people may contact their primary care physician in the later stages of the disease and referrals for specialist-led diagnosis may be delayed.10

Solution

Several countries have introduced rapid referral pathways to reduce diagnostic delays for people with suspected lung cancer.3 The structure of these pathways differs slightly between countries, but they typically involve primary care professionals making priority referrals to specialist clinics.

Rapid referral clinics are typically staffed by lung and/or cancer specialists, who conduct chest X-rays, computed tomography (CT) scans and additional tests to diagnose or exclude lung cancer.3 Most pathways have specific referral criteria and waiting time targets, and some programmes have implemented electronic record systems to track the diagnostic process.

For example, in Australia, a specialist-led lung assessment clinic aims to conduct clinical review and diagnostic testing within 14 days of referral.6 The Rapid Access to Pulmonary Investigation (RAPID) programme in the UK offers next-day CT scans and same-day results for people with suspected lung cancer.7 11

What has been achieved

Rapid referral pathways have been implemented in Australia, Canada, Denmark, Ireland, New Zealand, Norway, Sweden and the UK.3 12 Examples of how these pathways have improved the diagnostic process for lung cancer are outlined in Table 1.

Table 1. The impact of rapid referral pathways on lung cancer diagnosis

Country Initiative  Outcome 
Australia Rapid access clinic at the Latrobe Regional Hospital (2018 data) Proportion of people starting treatment within 7 weeks of first CT scan: 77% in the rapid access clinic v. 33% in standard care6
Canada Time to Treat Pathway in Toronto (2004–2006 data) Median waiting time between the suspicion and diagnosis of lung cancer decreased from 128 to 20 days2
Denmark National Cancer Patient Pathways (2006–2010 data) Median waiting time between first referral and treatment initiation decreased from 56 to 42 days5
Ireland Rapid Access Lung Cancer Clinic (2012-2018 data) Median time to diagnosis for lung cancer between referral and first appointment was reduced from 34.5 days to 21 days13
New Zealand Respiratory fast-track clinics in Northland District Health Board (2015–2016 data) Median waiting time decreased between the first clinic appointment and diagnosis (15 to 0 days) and first appointment and treatment initiation (37 to 24 days)4
Norway National Cancer Patient Pathways (2007–2016 data) Proportion of people diagnosed with metastatic lung cancer decreased from 52% to 45%, and waiting time between diagnosis and treatment decreased by up to 2 weeks8
UK RAPID programme in Manchester (2016–2019 data) Increase in the proportion of people with suspected lung cancer having their first CT scan within 3 days (0% to 56%), 7 days (27% to 91%) and 2 weeks (74% to 99%)7

Next steps

The success of existing initiatives can inspire the development and implementation of similar pathways in other countries and regions.3 Rapid referral pathways, paired with targeted screening of high-risk populations and protocols for inadvertently discovered lung nodules, will help reduce diagnostic delays and improve outcomes for people with lung cancer.12

Further information

References:

  1. Zappa C, Mousa SA. 2016. Non-small cell lung cancer: current treatment and future advances. Transl Lung Cancer Res 5(3): 288-300
  2. Lo DS, Zeldin RA, Skrastins R, et al. 2007. Time to treat: a system redesign focusing on decreasing the time from suspicion of lung cancer to diagnosis. J Thorac Oncol 2(11): 1001-6
  3. Pollock Michelle, Craig Rodger, Chojecki Dagmara, et al. 2018. Initiatives to accelerate the diagnostic phase of cancer care: An environmental scan. Edmonton: Institute of Health Economics
  4. Williams S, Davies P, Johnson B, et al. 2018. A fast track clinic improves diagnosis and treatment times for those investigated for lung cancer in Northland District Health Board. N Z Med J 131(1472): 29-37
  5. Probst HB, Hussain ZB, Andersen O. 2012. Cancer patient pathways in Denmark as a joint effort between bureaucrats, health professionals and politicians—A national Danish project. Health Policy 105(1): 65-70
  6. Jeyakumar HS, Wright A. 2020. Improving regional lung cancer optimal care pathway compliance through a rapid-access respiratory clinic. Internal Medicine Journal 50(7): 805-10
  7. Evison M, Hewitt K, Lyons J, et al. 2020. Implementation and outcomes of the RAPID programme: Addressing the front end of the lung cancer pathway in Manchester. Clin Med (Lond) 20(4): 401-05
  8. Nilssen Y, Brustugun OT, Tandberg Eriksen M, et al. 2019. Decreasing waiting time for treatment before and during implementation of cancer patient pathways in Norway. Cancer Epidemiology 61: 59-69
  9. Global Cancer Observatory. Cancer Today: Estimated number of incident cases worldwide, both sexes, all ages. Available here: https://gco.iarc.fr/today/ [accessed: March 2021]
  10. Cancer Research UK. 2018. Why is early diagnosis important? [Updated 26/06/18]. Available here: https://www.cancerresearchuk.org/about-cancer/cancer-symptoms/why-is-early-diagnosis-important [accessed: February 2019]
  11. Manchester University NHS Foundation Trust. RAPID Programme. Available here: https://mft.nhs.uk/wythenshawe/services/rapid-programme/ [accessed: March 2021]
  12. The Health Policy Partnership. 2021. Lung cancer screening: Building resilience and sustainability of healthcare systems. London: HPP
  13. Hennessy M, Ryan D, Clarke S, et al. 2020. Optimal Timing of CT Scanning in the Rapid Access Lung Cancer Clinic. Ir Med J 113(7): 121