HSIB report: Missed detection of lung cancer on chest X-rays of patients being seen in primary care (14 October 2021)

Summary

The Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk caused by delays in diagnosing lung cancer. Lung cancer is the third most common cancer diagnosed in England, but accounts for the most deaths. Two-thirds of patients with lung cancer are diagnosed at an advanced stage of the disease when curative treatment is no longer possible, a fact which is reflected in some of the lowest five-year survival rates in Europe. Chest X-ray is the first test used to assess for lung cancer, but about 20% of lung cancers will be missed on X-rays. This results in delayed diagnosis that will potentially affect a patient’s prognosis.

The HSIB investigation reviewed the experience of a patient who saw their GP multiple times and had three chest X-rays where the possible cancer was not identified. This resulted in an eight-month delay in diagnosis and potentially limited the patient’s treatment options.

Content

The investigation:

• sought to understand the context and contributory factors influencing a delay in lung cancer diagnosis in a patient repeatedly attending primary care with non-specific symptoms.
• identified the systemic factors that help or hinder the detection of lung cancer on chest X-rays.
• considered the utility of chest X-ray to assess for lung cancer in symptomatic patients being seen in primary care.
• identified the implications of the findings for mitigating the risk of delayed diagnosis of lung cancer.

Safety recommendations

1. HSIB recommends that NHS England and NHS Improvement work with research partners to explore options for commissioning research to address whether low-dose computed tomography (CT) is clinically- and cost-effective for the diagnosis of lung cancer in symptomatic patients seen in primary care compared to chest X-ray.
2. HSIB recommends that the National Institute for Health and Care Excellence (NICE) reviews its current safety netting advice to healthcare professionals with respect to the investigation of possible lung cancer. The wording of the advice should be amended as required to make it clearer what should be offered to patients with ongoing, unexplained symptoms who have had a negative chest X-ray.
3. HSIB recommends that NHSX, in collaboration with relevant stakeholders such as The Royal College of Radiologists and The Society and College of Radiographers, develops guidance to support independent benchmarking and validation of artificial intelligence algorithms for the identification of lung diseases such as cancer.