Background: Chest x-ray (CXR) is the first line investigation for lung cancer in many countries. Previous research has suggested that lung cancer is not detected by CXR in approximately 20% of patients. The risk of lung cancer, with particular symptoms, following a negative CXR is not known. Aims: 1) To establish the sensitivity and specificity of CXR requested by symptomatic patients 2) To determine the positive predictive values (PPVs) of each presenting symptom of lung cancer following a negative CXR. Design & Setting: A prospective cohort study based on routinely collected data from a service which allowed patients with symptoms to request CXR. Methods: Symptom data was combined with a diagnostic category (positive or negative) for each CXR. Sensitivity and specificity of CXR for lung cancer was calculated. The positive predictive values (PPVs) of lung cancer associated with each symptom was estimated for those with negative CXR. Results: 114 (1.3%) out of 8996 patients were diagnosed with lung cancer within one year. Sensitivity was 75.4% and specificity was 90.2%. Risk of lung cancer following a negative CXR was low for all symptoms with the exception of haemoptysis, which had a positive predictive value of 2.9%. Conclusion: CXR has limited sensitivity. However, in a low prevalence population, its high specificity and negative predictive value means that lung cancer is very unlikely to be present following a negative result. The study also provides further evidence that supports guidance that unexplained haemoptysis warrants urgent referral, regardless of CXR result.

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Background: Chest x-ray (CXR) is the first line investigation for lung cancer in many healthcare systems. Understanding of the consequences of false negative CXRs on time to diagnosis, stage and survival is limited. Aims: To determine the sensitivity of CXR for lung cancer and to compare stage at diagnosis, time to diagnosis and survival between those with CXR which detected, or did not detect, lung cancer. Design & Setting: Retrospective observational study using routinely collected healthcare data. Methods: All patients diagnosed with lung cancer in a teaching hospital trust during 2008 – 2015 who had a GP requested CXR in the year before diagnosis were categorised based on the result of the earliest CXR performed in that period. We calculated sensitivity of CXR and performed analyses with respect to time to diagnosis, survival and stage at diagnosis. Results: CXR was negative for 18% of patients (n=376/2129). Median time from initial CXR to diagnosis was 43 days (IQR: 27-78) for those with positive CXR and 204 days (105-287) for those with negative CXR. Of those with positive CXR, 29% (95% CIs 27-31%) were diagnosed at either stage I/II, compared to 34% (95% CIs 29-39%) of those with a negative CXR. Conclusion: GPs should consider lung cancer in patients with persistent symptoms even when CXR is negative. Despite longer duration to diagnosis for those with ‘false negative’ CXRs, there was no evidence of adverse impact on stage at diagnosis or survival; however this comparison is likely to be affected by confounding variables.

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Introduction Lung cancer in never smokers (LCINS) accounts for 15% of lung cancers diagnosed in the UK, making it the 8th most common cancer. There are few robust studies specific to the LCINS population making data surrounding the incidence and mortality of LCINS incomplete, leaving many gaps in our understanding of the needs of this population. Methods To address a lack of research in this important area, the UK National Cancer Research Institute Lung Study Group (NCRI-LSG) undertook a national survey and hosted a research strategy day to define key research priorities. A wide cross section of stakeholders, including patient advocates, the charitable sector, basic and translational researchers, and multi-disciplinary healthcare professionals contributed highlighting their research priorities. Results One-hundred twenty-seven surveys were completed (52 by patients/patient advocates) prior to the strategy day. These identified themes for expert review presentations and subsequent workshop discussions at the national research strategy day, which registered 190 attendees (50 patients/patient advocates). The four key themes that emerged to form the basis of a research strategy for LCINS are (1) Raising awareness, (2) Risk assessment and early detection, (3) Disease biology, (4) Living with and beyond. Conclusion This paper summarises current evidence and important gaps in our knowledge related to LCINS. We present recommendations for a national research strategy aimed at improving outcomes for patients.

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