New safety recommendations to avoid lung cancer being missed on chest X-rays

Independent HSIB investigation calls for more research into use of CT scans

Published: 14 October 2021 X-ray

The Healthcare Safety Investigation Branch (HSIB) has published its findings on delays resulting from missed detection of possible lung cancer on chest X-rays of patients seen in primary care.

The HSIB investigation considered the experience of Tracey, who saw her GP on multiple occasions with respiratory symptoms over the course of a year. Tracey had three chest X-rays during this time which did not identify a possible lung cancer.

Lung cancer is increasing in people who have never smoked, and media messaging highlighting the close link between lung cancer and smoking, as well as the often non-specific symptoms of lung cancer, have created a significant diagnostic challenge for GPs.

Although a chest X-ray is the recommended first test to assess whether a patient may have lung cancer, chest X-rays are difficult to interpret and about one in five cancers are missed.

An internal investigation by the hospital trust involved resulted in a key safety action that a CT scan should be requested if there is uncertainty regarding pathology instead of a lateral chest X-ray. If in exceptional circumstances a radiologist requests a lateral chest X-ray, the same radiologist should provide the report.

HSIB recommendations

The HSIB has now recommended that NHS England and NHS Improvement works with research partners to explore options for commissioning research to address whether low-dose CT is clinically and cost-effective for the diagnosis of lung cancer in symptomatic patients seen in primary care compared to chest X-ray.

NICE has also been asked to amend safety netting advice to make it clearer what should be offered to patients with ongoing, unexplained symptoms who have had a negative chest X-ray.

A statement from the SoR said: ‘The Society of Radiographers was pleased to be able to provide comments and suggestions to inform this important report. HSIB have taken into account the contribution and potential of reporting radiographers and available evidence base.

‘The report highlights the gaps which exist in terms of equipment and staffing levels in CT departments. It also highlights the low levels of existing knowledge with respect to the use of low dose-CT scan for chest screening and the use of AI – recommending further research. SoR welcome the opportunity to explore these areas.

‘SoR also applauds Tracey for sharing her story and evidence with HSIB. It is thanks to the power and dignity of people such as Tracey - patients, carers and families - that HSIB are able to highlight major problems in healthcare systems. We expect staff to follow the safety recommendations and observation, to take the range of actions necessary in their local organisations to prevent harm in the future.’

The case that triggered the investigation

Tracey contacted her general practice with symptoms of cough and shortness of breath which she had had for several months. She was initially prescribed antibiotics by a nurse practitioner for a presumed chest infection.

As Tracey’s symptoms did not improve, she saw a GP who referred her for a chest X-ray. This X-ray, and a subsequent one, did not identify a possible lung cancer. Tracey was at low risk of lung cancer because she was 49 years old and had never smoked.

Over the next seven months, Tracey was seen at the GP practice on multiple occasions with an ongoing cough and shortness of breath without a cause being identified.

Nine months after her first visit to the practice with respiratory symptoms, she saw a GP because she was experiencing central chest pain in addition to her worsening breathlessness.

The GP referred Tracey to the emergency department and ordered an urgent CT scan. Tracey had a chest X-ray in the emergency department; the report on this X-ray did not identify a possible lung cancer. The CT scan performed a few days later identified likely lung cancer which appeared to have spread throughout Tracey’s lungs.

Tracey was referred to the oncology team and, after further tests, began drug treatment for her cancer.