Investigating Symptoms of Lung Cancer

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Increasing age as a risk factor

The incidence of lung cancer increases with age. Over 75% of lung cancers are diagnosed in people aged 65 years and older.[1]

Gender as a risk factor

In 2021, it is estimated there will be a higher number of cases of lung cancer diagnosed in men compared to women in Australia (an estimated 7,460 men diagnosed compared to 6,350 women). [1]

The age standardised incidence rates for men and women for 2021 are:

Men: 48.8 cases per 100,000 men
Women: 37.4 cases per 100,000 women [1]

Risk of lung cancer in different populations

Aboriginal and Torres Strait Islander people are twice as likely to be diagnosed with lung cancer, almost twice as likely to die from the disease and less likely to survive 5-years after a diagnosis of lung cancer compared with non-Indigenous Australians [2].

Some Aboriginal and Torres Strait Islander people may have personal or cultural factors that affect the presentation and investigative pathway. Refer to the Optimal care pathway for Aboriginal and Torres Strait Islander people with cancer for detailed information.

Tobacco smoking as a risk factor

About 90% of lung cancer in males and 65% in females is estimated to be a result of tobacco smoking. [3]
The association of lung cancer with smoking can lead to lung cancer patients feeling stigmatised, contributing to delays in help-seeking for symptoms [4][5] and psychological distress. [6]
All current smokers should be offered smoking cessation advice and support to quit.

Passive smoking

Exposure to second-hand tobacco smoke (also known as passive smoking) at home and at the workplace is associated with an increased risk of lung cancer [7,8]. The risk of lung cancer increases with extent and duration of exposure [9]

Occupational exposures, e.g. asbestos, diesel exhaust, silica and radon

Occupational exposures, such as asbestos, diesel exhaust, silica and radon are associated with an increased risk of lung cancer. [10]
Lung cancer risk is increased following exposure to all types of asbestos, with increasing risk of all histological lung cancer sub-types associated with increased exposure. [11]
High exposure to diesel exhaust (e.g., workers who are miners, mechanics for agricultural machinery and diesel engines, and railway and road vehicle loaders) is associated with an increased risk of lung cancer. [12]
Occupational exposure to silica is associated with an increased risk of lung cancer. Those occupations leading to high exposure to silica in Australia include miners, construction workers, stone workers and plumbers. [13-16]
Radon exposure is consistently reported as a risk factor for lung cancer, however, in Australia, this is mainly due to radon exposure in uranium miners. [17]
Additional occupational risk factors include arsenic, beryllium, cadmium, chromium, nickel, polycyclic hydrocarbons, iron and steel founding and painting as an occupation. [17]

Air pollution

Outdoor air pollution comprises fine particulate matter and gases, mainly from urban pollution and vehicle exhaust, and increases a person’s risk of lung cancer. [7]
Indoor air pollution is also a risk factor for lung cancer. However, exposure at sufficient levels is uncommon in Australia, in part due to the National Construction Code of the Australian Building Codes Board in which it is a requirement for all buildings to have adequate ventilation. [18]
Known indoor air pollutants associated with an increased risk of lung cancer such as biomass fuel smoke are less relevant in Australia than in some other countries. [19]

Family history of lung cancer

Relatives of individuals with lung cancer may be at higher risk of lung cancer than the general population due to shared genetic, environmental, and behavioural characteristics. [7]
The increased risk for having a family history of lung cancer compared to no family history has been estimated as 1.85 (95% CI:1.71 – 1.99), the risk increasing from 1.55 (95% CI: 1.37 – 1.75) for one affected first-degree relative to 2.72 (95% CI:1.95 – 3.81) for two affected first-degree relatives. [20]

Chronic lung disease, e.g. COPD, pulmonary fibrosis

A history of chronic lung disease, including chronic obstructive pulmonary disease (COPD), pulmonary fibrosis and pulmonary tuberculosis, is associated with an increased risk of developing lung cancer. [10]

Personal history of cancer

A personal history of previous primary cancers including lung cancer, head and neck cancer, and bladder cancer, may increase the risk of developing lung cancer. [10]

Optimal imaging modalities for lung cancer

Low-dose CT (LDCT) scans have a lower radiation dose compared to conventional Chest CT scans, provide good clinical information and are more sensitive than Chest X-ray in the diagnosis of lung cancer. [23]
Be aware of the possibility of false-negative results for chest X-rays (up to 25%). [24-26]

Optimal imaging modalities for lung cancer

Low-dose CT (LDCT) scans have a lower radiation dose compared to conventional Chest CT scans, provide good clinical information and are more sensitive than Chest X-ray in the diagnosis of lung cancer. [24]

Optimal imaging modalities for lung cancer

Be aware of the possibility of false-negative results for chest X-rays (up to 25%). [24-26]

Superior vena caval obstruction

The result of the direct obstruction of the superior vena cava may be a consequence of compression or destruction by malignant tumours. It causes oedema of the face, neck and arms. [23]
Superior vena caval obstruction is present at diagnosis in 10% of patients with small cell lung cancer (SCLC) and 2% of patients with non-small cell lung cancer (NSCLC). [23]

Thrombocytosis

An adult with thrombocytosis has a 1.6% chance of the symptom being due to underlying lung cancer.
This positive predictive value increases when thrombocytosis has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 1.6% (95%CI: 0.8 – 3.1)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6

Cough

An adult reporting cough to their GP as a single symptom for the first time has a 0.4% chance of the cough being due to underlying lung cancer.
The positive predictive value increases when cough has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 0.40% (95%CI: 0.3 – 0.5)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6

Haemoptysis

If the patient presents with massive haemoptysis, immediately refer to the nearest Emergency Department.
An adult reporting haemoptysis to their GP as a single symptom for the first time has a 2.4% chance of haemoptysis being due to underlying lung cancer.
This positive predictive value increases when haemoptysis has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 2.4% (95%CI: 1.4 – 4.1)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6

Shortness of breath

An adult reporting dyspnoea to their GP as a single symptom for the first time has a 0.66% chance of the dyspnoea being due to underlying lung cancer.
This positive predictive value increases when dyspnoea has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 0.66% (95%CI: 0.5 – 0.8)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6

Chest pain

An adult reporting chest pain to their GP as a single symptom for the first time has a 0.82% chance of the chest pain being due to underlying lung cancer
This positive predictive value increases when chest pain has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 0.82% (95%CI: 0.6 – 1.1)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6

Weight loss

An adult reporting loss of weight to their GP as a single symptom for the first time has a 1.1% chance of the weight loss being due to underlying lung cancer
This positive predictive value increases when weight loss has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 1.1% (95%CI: 0.8 – 1.6)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6

Loss of appetite

An adult reporting loss of appetite to their GP as a single symptom for the first time has a 0.87% chance of loss of appetite being due to underlying lung cancer.
This positive predictive value increases when loss of appetite has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 0.87% (95%CI: 0.6 – 1.3)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6

Hoarseness of voice

The probability of a patient presenting with change in voice receiving a true positive lung cancer diagnosis within 1 year following a negative chest X-ray is 0.26% (95%CI: 0.01 to 0.51). [21]

Positive Predictive Values (PPV) for stridor

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Fatigue

An adult reporting fatigue to their GP as a single symptom for the first time has a 0.43% chance of fatigue being due to underlying lung cancer.
This positive predictive value increases when fatigue has been reported more than once, or in combination with other symptoms or signs, or risk factors.
Positive Predictive Value*: 0.43% (95%CI: 0.3 – 0.6)

*Positive Predictive Value (PPV): The chance of a patient having the disease of interest when they have reported the symptom.

Reference: [22] Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. British journal of cancer. 2009;101 Suppl 2:S80-6