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Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] It is also the leading cause of cancer death in patients of Māori descent.[[1,2]] A study by Gurney et al that analysed cases of cancer in New Zealand from 2007–2016 highlighted that Māori patients with lung cancer were 30% more likely to die than non-Māori with lung cancer.[[27]] Most patients with lung cancer present with advanced disease and are offered palliative treatment. Approximately 20% of New Zealand patients with newly diagnosed lung cancer are treated surgically.[[2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. Part of the recognised conundrum with accurately diagnosing lung cancer is the nonspecific symptoms.[[8]] Furthermore, the first step in imaging has traditionally been a chest radiograph which in turn has a high false negative rate for diagnosing lung cancer.[[20]] An incidental detection of lung cancer has been associated with improved survival.[[21]]

The Waikato Cardiothoracic Surgical Unit provides a lung cancer resection service to the Midland Region, with a population of 880,000 and with approximately 490 new cases of lung cancer diagnosed per year. Using a cohort of patients with lung cancer receiving curative surgery in Waikato Hospital, we aimed to review the presenting symptoms, the first diagnostic method of imaging and whether the diagnosis was incidental or non-incidental. The hypothesis for this study is that a number of cases of early-stage disease are diagnosed incidentally and subsequently offered curative surgery in the Midland Region. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis.

Methods

This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. This time frame was utilised as full medical records were available. Baseline characteristics included pre-operative patient variables as well as the tumour characteristics including date of cancer diagnosis, cancer stage (grouped into I, II, III and IV) and cancer cell type. We categorised the cell types into 6 groups: non-small cell lung cancer (NSCLC), NSCLC-others, small cell, carcinoid (including typical and malignant carcinoid), low grade mucoepidermoid carcinoma, and others.

Symptoms and signs at time of diagnosis were confirmed by cross referencing the original handwritten and electronic patients files. Two authors reviewed all these notes and achieved concordance to ensure correct data collection. Symptoms or signs recorded as directly caused by lung cancer were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. Based on the subsequent patient management by treating physician (not symptoms), the lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance. Regardless, if the patients had symptoms at diagnosis or not, if patients were not under surveillance (regular surveillance of previously identified lung nodules) and were detected because of an incidental investigation of another presenting health issue, they were recorded as incidentally detected lung cancers.

The mode of clinical imaging included chest radiograph (CXR), computed tomography (CT), positron emission tomography (PET), or magnetic resonance imaging (MRI). Statistical analysis between incidental and non-incidental patient cohorts for patient characteristics, mode of detection and symptomatology was undertaken with chi-square tests and a p-value of less than 0.05 was used to define whether the difference was significant or not.

Institutional approval was given for this project and classed as an audit and ethics approval was not required as deemed negligible risk.

Results

Between January 2010 and June 2018, 310 patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital, including 78 (25.2%) Māori patients and 232 (74.8%) non-Māori patients (Table 1).

Mean age was 66 years, and 55.5% were female. Two hundred and sixty-one (84.2%) patients were either current or ex-smokers. The predominant lung cancer was NSCLC with two hundred and ninety cases (93.5%). There was no significant difference between Māori and non-Māori patients whether the diagnosis was incidental or not (Table 1). Our study, however, only has 78 Māori patients and a nationwide study would be more powered in order to highlight any disparities to diagnosis for a Māori patient population. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician, and 96 (31%) patients were asymptomatic. These asymptomatic patients were diagnosed on either routine check-up imaging via a chest radiograph or diagnosed upon imaging investigating an unrelated disease process. Patients were determined as an incidental diagnosis if the detection occurred because of an investigation of another presenting health issue. Incidental diagnosis was demonstrated in 121 (39.4%) patients and 189 (60.6%) accurately investigated for lung cancer (Table 2).

View Tables 1 & 2.

The use of CXR was still the most common form of imaging modality utilised to diagnosis lung cancer (Table 3). However, the rate of detection with CT was higher in the incidental diagnosis cohort with 38% of patients identified incidentally with lung cancer via CT compared with only a rate of 11.1% non-incidental patients diagnosed via CT. Of the 46 patients who had an incidental diagnosis via CT, 22 patients (47%) had a normal chest radiograph prior.

Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12), and 28% chest pain (n=12) (Table 4). Although these patients presented with symptoms, they are identified as incidental diagnoses, as the investigations were not undertaken with the intent of diagnosing lung cancer. There were 18 patients who had no symptoms and classed as non-incidental (Table 4). Fourteen of these patients were under surveillance imaging for malignancy. Although the remaining four patients did not have primary symptoms, the request for imaging directly queried lung cancer due to their risk factors from clinical history as determined by the treating physician. Patients were determined as an incidental diagnosis if the detection occurred because of an investigation of another presenting health issue. Of those diagnosed incidentally despite symptomatology of lung cancer, 35 patients (79.6%) were diagnosed on an acute admission to hospital, whereas only nine patients (20.4%) were diagnosed in a primary care community setting. Of those 35 patients diagnosed in the hospital, we did not have access to primary care community case notes to determine whether these symptoms had been present but not highlighted to be linked to lung cancer.

View Tables 3 & 4.

Discussion

The five-year survival within New Zealand and Australia is extremely poor at 11 and 17%, respectively.[[23]] Furthermore, surgical resection of lung cancer is associated with improved survival.[[28]] The most recent 2021 New Zealand lung cancer quality improvement report, however, does not ascertain survival differences between surgical and non-surgical patients.[[29]] This study has shown that of patients undergoing curative resection for lung cancer at Waikato Hospital, 121 (39%) patients were discovered because of incidental findings on imaging for other reasons. The remainder were diagnosed following the investigations of symptoms, or because of ongoing surveillance of patients with lung nodules. A population control study from the United Kingdom on lung cancer symptoms demonstrated that often lung cancer diagnosis is not the primary differential when investigating patients.[[8]] A population study from Australia identified that only a small proportion of patients recognise the signs and symptoms of lung cancer, even if a current smoker.[[9]] In our study, 69.4% of patients had symptoms that could be attributable to lung cancer at the time of diagnosis. Of these, cough, dyspnoea and chest pain were the most common presenting symptoms with 44.2%, 20% and 18.1% of patients, respectively. This is consistent with other literature available on the presenting symptoms on diagnosis of lung cancer.[[10–12]]

The difficulty that is faced when cough or dyspnoea are the main presenting symptoms is that other differential diagnoses, such as a respiratory tract infection or cardiovascular disease, are explored as the first diagnosis. A large retrospective study of 2,293 patients by Kocher et al identified that cardiovascular disease and COPD were present in 62.1 and 62% of patients, respectively.[[14]] Furthermore, it has been hypothesised that co-morbidities and suspicion of more benign disease can be isolated as one of the reasons between initial onset of symptoms and a lack of urgency to undertake medical investigation.[[13]] Other literature reports constitutional symptoms as being a main presenting symptom, particularly in an aging population.[[9]] This difference between our cohort could be contributed, by splitting constitutional symptoms into weight loss and fatigue in order to get a more specific representation of presenting symptoms. In terms of the association of a particular symptom and lung cancer, a systematic review of lung cancer diagnosis symptoms by Shim et al demonstrated that haemoptysis had the highest positive predictive value of 2.4–7.5%.[[18]]

In our single centre cohort, the incidental rate of lung cancer was 39%. It has been reported that up to 30–54% of a unit’s thoracic surgical patients are diagnosed incidentally. [[3-5]] Another large retrospective cohort study of 1,279 patients only found an incidental diagnosis in 9.1%.[[6]] This discrepancy between our cohort and other literature could be due to how Kocher et al only included asymptomatic patients as an incidental diagnosis.[[6]] In our analysis, if the intention for diagnosis was not related to lung cancer, then this was classified as an incidental finding. Therefore, in our cohort there are patients who are symptomatic, but an incidental diagnosis of lung cancer has been made. For example, a patient with chest pain has been investigated but lung cancer was not suspected. It has been observed that those patients with lung cancer who are diagnosed incidentally have an improved survival rate.[[3,5,6]] Furthermore, those patients who have been diagnosed incidentally with the imaging modality of CT, have a prognostic survival benefit.[[3,7]] In our cohort, of the 46 patients who had an incidental diagnosis via CT, 22 patients (47%) had a normal chest radiograph prior.  

The significant disparity in survival for Māori patients with lung cancer when compared to non-Māori population should warrant investigation into the feasibility of a targeted screening program for at high-risk Māori patients. The New Zealand national lung cancer working group has stated that more research is required on screening for lung cancer.[[24]] A study undertaken to examine the cost-effectiveness of a low-dose CT screening program in New Zealand stated that it is likely to be cost-effective in the high-risk group of Māori patients.[[26]] In comparison, the Australian Government have stated that a lung cancer screening program, regardless of whether a patient population is at high-risk for lung cancer, is not currently supported.[[25]] Overseas, the current European position on lung cancer promotes the use of low-dose CT for lung cancer screening,[[17]] and the American National Lung Screening Trial also demonstrates a survival benefit for those diagnosed with low-dose CT.[[18]] The NELSON trial has demonstrated that in high-risk patients, mortality from lung cancer was significantly lower among those who were detected on CT screening.[[22]] However, there have been concerns over the extrapolation of these results into an Indigenous population.[[16]]

The majority of patients diagnosed with lung cancer will initially be detected following general practitioner-initiated investigations.[[19]] However, access to primary healthcare in New Zealand is an ongoing challenge. A low-dose CT screening program is likely to improve outcomes from lung cancer in New Zealand, but patient participation is vital for success. In a small cohort study in the USA by Raz et al, of 185 current smokers deemed high-risk, only 18.9% of the cohort had accessed lung cancer screening services, with the remaining 81.1% completely unaware of the available program.[[15]]

Conclusion

This is the first local experience from the Midland Region documenting the symptomatology and route of diagnosis for lung cancer. Furthermore, this cohort study has demonstrated that in a New Zealand population, a large amount of lung cancer is still diagnosed incidentally. The common symptoms are cough, dyspnoea and chest pain. Despite patients presenting with symptoms, lung cancer is still not one of the initial differential diagnoses that are investigated despite having symptoms consistent with lung cancer. A number of patients are diagnosed with lung cancer despite having a normal chest radiograph. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Summary

Abstract

Aim

Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis.

Method

This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. Symptoms or signs recorded were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. The lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance.

Results

Three hundred and ten patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician and 96 (31%) patients were asymptomatic. Incidental diagnosis was demonstrated in 121 (39.4%) patients. Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12) and 28% chest pain (n=12).

Conclusion

In New Zealand, a large amount of lung cancer is still diagnosed incidentally with symptoms of cough, dyspnoea and chest pain. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Author Information

Damian Gimpel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Andrew Pan: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Venughanan Manikavasagar: Newcastle University, Newcastle upon Tyne, United Kingdom. Chunuan Lao: Medical Research Centre, The University of Waikato, Hamilton, New Zealand. Leonie Brown: Waikato Medical Research Centre, The University of Waikato, Level 3 Hockin building, Waikato Hospital, Hamilton, New Zealand. David J McCormack: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Zaw Lin: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Felicity Meikle: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Paul Conaglen: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Doug Stephenson: Department of Veterans Affairs, Prescott VAMC, Prescott Arizona, United States of America. Ross Lawrenson: Strategy and Funding, Waikato District Health Board, Hamilton, New Zealand; Medical Research Centre, The University of Waikato, Hamilton, New Zealand. Adam El-Gamel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, Auckland University, Auckland, New Zealand.

Acknowledgements

The results of this project were published in the NZMJ for the proceedings of the 2018 Waikato Clinical Campus Biannual Research Seminar.

Correspondence

Damian Gimpel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand.

Correspondence Email

gimpeldamian@gmail.com

Competing Interests

Nil.

1) Ministry of Health. Cancer: New registrations and deaths 2013. Wellington: Ministry of Health, 2016.

2) Stevens W, Stevens G, Kolbe J, Cox B. Lung cancer in New Zealand: patterns of secondary care and implications for survival. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer 2007; 2(6): 481-93.

3) Orrason AW, Sigurdsson MI, Baldvinsson K, et al. Incidental detection by computed tomography is an independent prognosti factor for survival in patients operated for non small cell lung carcinoma. ERJ Open Res 2017; 3: 00106-2016 [https://doi.org/10.1183/ 23120541.00106-2016].

4) Raz DJ, Glidden DV, Odisho AY, et al. Clinical characteristics and survival of patients with surgically resected, incidentally detected lung cancer. J Thorac Oncol 2007; 2: 125–130.

5) Quadrelli S, Lyons G, Colt H et al. Clinical characteristics and prognosis of incidentally detected lung cancers. Int J Surg Oncol. 2015;2015:287604.

6) Kocher F, Lunger F, Seeber A, et al. Incidental diagnosis of asymptomatic non-small cell lung cancer: A registry based analysis. Clinical Lung Cancer 2015; 17;62-67

7) Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with lowdose computed tomographic screening. N Engl J Med 2011; 365:395-409.

8) Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case control study. Thorax. 2005;60:1059-65.

9) Jiwa M, Arnet H, Halkett G et al. Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms? A pilot study in Western Australia. BMC Fam Pract. 2009; 10:16

10) Smith SM, Campbell NC, MacLeod U et al. Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study. Thorax. 2009;64:523-31.

11) Buccheri G, Ferrigno D. Lung cancer: clinical presentation and specialist referral time. Eur Respir J. 2004;24:898-904.

12) Lövgren M, Leveälahti H, Tishelman C, et al. Time spans from first symptom to treatment in patients with lung cancer- -the influence of symptoms and demographic characteristics. Acta Oncol. 2008;47:397-405.

13) Simpson CB, Amin MR. Chronic cough: state-of-the-art review. Otolaryngol Head Neck Surg. 2006;134:693-700.

14) Kocher F, Hilbe W, Seeber A et al. Longitudional analysis of 2293 NSCLC patients: A comprehensive study from the TYROL registry. Lung Cancer 2015; 87 (2): 193-200

15) Raz D, Wu G, Nelson R et al. Pereception and utilization of lung cancer screening among smoker enrolled in a tobacco cessation program. Clinical lung cancer 2019; 20 (1); 115-122

16) Koo H, Choi C, Park S et al. Chest radiography surveillance for lung cancer: results from a national health insurance database in South Korea. Lung Cancer; 128; 120-126

17) Oudkerk M, Devaraj A, Vliegenthart R et al. European position statement on lung cancer screening. Lancet Oncol 2017; 18; (12) 754-766

18) Shim J, Brindle L, Simon M, George S. A systematic review of symptomatic diagnosis of lung cancer. Fam Pract. 2014;31(2):137–48.

19) Bradley S, Kennedy M, Neal R. Recognising lung cancer in primary care. Advances in Therapy 2019: 36 (1); 19-30.

20) Stapley S, Sharp D. Negative chest x-rays in primary care patients with lung cancer. Br. J. Gen. Pract. 2006;56:570-575

21) Quadrelli S, Lyons G, Colt H et al. Clinical characteristics and prognosis of incidentally detected lung cancers. Int J Surg Oncol. 2015;2015:287604.

22) De Koning H, Van Der Aalst C, De Jonh P et al. Reduced lung cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513

23) Manners D, Dawkins P, Pascoe D et al. Lung cancer screening in Australia and New Zealand: the evidence and the challenge. Internal Medical Journal. 2021;51:436-441

24) National Lung Cancer Working Group. 2016. Standards of Service Provision for Lung Cancer Patients in New Zealand (2nd edn). Wellington: Ministry of Health.

25) Australian Government Department of Health’s Standing Committee on Screening. Position Statement: Lung Cancer Screening Using Low-Dose Computed Tomography 2015. Canberra: Australian Department of Health; 2015. Last Updated 2019 [cited 2021 Jul 29].

26) Jaine R, Kvizhinadze G, Nair N, Blakely T. Cost-effectiveness of a low dose computed tomography screening programme for lung cancer in New Zealand. Lung Cancer. 2020;144:99-106

27) Gurney J, Stanley J, McLeod M, Koea J et al. Disparities in cancer-specific survival between Maori and Non Maori New Zealanders. JCO Glocal Oncology. 2020;6:766-774

28) Che K, Shen H, Qu X, et al. Survival Outcomes for Patients with Surgical and Non-Surgical Treatments in Stages I-III Small-Cell Lung Cancer. J Cancer. 2018;9(8):1421-1429.

29) Te Aho o Te Kahu. 2021. Lung Cancer Quality Improvement Monitoring Report 2021. Wellington: Cancer Control Agency

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Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] It is also the leading cause of cancer death in patients of Māori descent.[[1,2]] A study by Gurney et al that analysed cases of cancer in New Zealand from 2007–2016 highlighted that Māori patients with lung cancer were 30% more likely to die than non-Māori with lung cancer.[[27]] Most patients with lung cancer present with advanced disease and are offered palliative treatment. Approximately 20% of New Zealand patients with newly diagnosed lung cancer are treated surgically.[[2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. Part of the recognised conundrum with accurately diagnosing lung cancer is the nonspecific symptoms.[[8]] Furthermore, the first step in imaging has traditionally been a chest radiograph which in turn has a high false negative rate for diagnosing lung cancer.[[20]] An incidental detection of lung cancer has been associated with improved survival.[[21]]

The Waikato Cardiothoracic Surgical Unit provides a lung cancer resection service to the Midland Region, with a population of 880,000 and with approximately 490 new cases of lung cancer diagnosed per year. Using a cohort of patients with lung cancer receiving curative surgery in Waikato Hospital, we aimed to review the presenting symptoms, the first diagnostic method of imaging and whether the diagnosis was incidental or non-incidental. The hypothesis for this study is that a number of cases of early-stage disease are diagnosed incidentally and subsequently offered curative surgery in the Midland Region. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis.

Methods

This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. This time frame was utilised as full medical records were available. Baseline characteristics included pre-operative patient variables as well as the tumour characteristics including date of cancer diagnosis, cancer stage (grouped into I, II, III and IV) and cancer cell type. We categorised the cell types into 6 groups: non-small cell lung cancer (NSCLC), NSCLC-others, small cell, carcinoid (including typical and malignant carcinoid), low grade mucoepidermoid carcinoma, and others.

Symptoms and signs at time of diagnosis were confirmed by cross referencing the original handwritten and electronic patients files. Two authors reviewed all these notes and achieved concordance to ensure correct data collection. Symptoms or signs recorded as directly caused by lung cancer were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. Based on the subsequent patient management by treating physician (not symptoms), the lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance. Regardless, if the patients had symptoms at diagnosis or not, if patients were not under surveillance (regular surveillance of previously identified lung nodules) and were detected because of an incidental investigation of another presenting health issue, they were recorded as incidentally detected lung cancers.

The mode of clinical imaging included chest radiograph (CXR), computed tomography (CT), positron emission tomography (PET), or magnetic resonance imaging (MRI). Statistical analysis between incidental and non-incidental patient cohorts for patient characteristics, mode of detection and symptomatology was undertaken with chi-square tests and a p-value of less than 0.05 was used to define whether the difference was significant or not.

Institutional approval was given for this project and classed as an audit and ethics approval was not required as deemed negligible risk.

Results

Between January 2010 and June 2018, 310 patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital, including 78 (25.2%) Māori patients and 232 (74.8%) non-Māori patients (Table 1).

Mean age was 66 years, and 55.5% were female. Two hundred and sixty-one (84.2%) patients were either current or ex-smokers. The predominant lung cancer was NSCLC with two hundred and ninety cases (93.5%). There was no significant difference between Māori and non-Māori patients whether the diagnosis was incidental or not (Table 1). Our study, however, only has 78 Māori patients and a nationwide study would be more powered in order to highlight any disparities to diagnosis for a Māori patient population. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician, and 96 (31%) patients were asymptomatic. These asymptomatic patients were diagnosed on either routine check-up imaging via a chest radiograph or diagnosed upon imaging investigating an unrelated disease process. Patients were determined as an incidental diagnosis if the detection occurred because of an investigation of another presenting health issue. Incidental diagnosis was demonstrated in 121 (39.4%) patients and 189 (60.6%) accurately investigated for lung cancer (Table 2).

View Tables 1 & 2.

The use of CXR was still the most common form of imaging modality utilised to diagnosis lung cancer (Table 3). However, the rate of detection with CT was higher in the incidental diagnosis cohort with 38% of patients identified incidentally with lung cancer via CT compared with only a rate of 11.1% non-incidental patients diagnosed via CT. Of the 46 patients who had an incidental diagnosis via CT, 22 patients (47%) had a normal chest radiograph prior.

Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12), and 28% chest pain (n=12) (Table 4). Although these patients presented with symptoms, they are identified as incidental diagnoses, as the investigations were not undertaken with the intent of diagnosing lung cancer. There were 18 patients who had no symptoms and classed as non-incidental (Table 4). Fourteen of these patients were under surveillance imaging for malignancy. Although the remaining four patients did not have primary symptoms, the request for imaging directly queried lung cancer due to their risk factors from clinical history as determined by the treating physician. Patients were determined as an incidental diagnosis if the detection occurred because of an investigation of another presenting health issue. Of those diagnosed incidentally despite symptomatology of lung cancer, 35 patients (79.6%) were diagnosed on an acute admission to hospital, whereas only nine patients (20.4%) were diagnosed in a primary care community setting. Of those 35 patients diagnosed in the hospital, we did not have access to primary care community case notes to determine whether these symptoms had been present but not highlighted to be linked to lung cancer.

View Tables 3 & 4.

Discussion

The five-year survival within New Zealand and Australia is extremely poor at 11 and 17%, respectively.[[23]] Furthermore, surgical resection of lung cancer is associated with improved survival.[[28]] The most recent 2021 New Zealand lung cancer quality improvement report, however, does not ascertain survival differences between surgical and non-surgical patients.[[29]] This study has shown that of patients undergoing curative resection for lung cancer at Waikato Hospital, 121 (39%) patients were discovered because of incidental findings on imaging for other reasons. The remainder were diagnosed following the investigations of symptoms, or because of ongoing surveillance of patients with lung nodules. A population control study from the United Kingdom on lung cancer symptoms demonstrated that often lung cancer diagnosis is not the primary differential when investigating patients.[[8]] A population study from Australia identified that only a small proportion of patients recognise the signs and symptoms of lung cancer, even if a current smoker.[[9]] In our study, 69.4% of patients had symptoms that could be attributable to lung cancer at the time of diagnosis. Of these, cough, dyspnoea and chest pain were the most common presenting symptoms with 44.2%, 20% and 18.1% of patients, respectively. This is consistent with other literature available on the presenting symptoms on diagnosis of lung cancer.[[10–12]]

The difficulty that is faced when cough or dyspnoea are the main presenting symptoms is that other differential diagnoses, such as a respiratory tract infection or cardiovascular disease, are explored as the first diagnosis. A large retrospective study of 2,293 patients by Kocher et al identified that cardiovascular disease and COPD were present in 62.1 and 62% of patients, respectively.[[14]] Furthermore, it has been hypothesised that co-morbidities and suspicion of more benign disease can be isolated as one of the reasons between initial onset of symptoms and a lack of urgency to undertake medical investigation.[[13]] Other literature reports constitutional symptoms as being a main presenting symptom, particularly in an aging population.[[9]] This difference between our cohort could be contributed, by splitting constitutional symptoms into weight loss and fatigue in order to get a more specific representation of presenting symptoms. In terms of the association of a particular symptom and lung cancer, a systematic review of lung cancer diagnosis symptoms by Shim et al demonstrated that haemoptysis had the highest positive predictive value of 2.4–7.5%.[[18]]

In our single centre cohort, the incidental rate of lung cancer was 39%. It has been reported that up to 30–54% of a unit’s thoracic surgical patients are diagnosed incidentally. [[3-5]] Another large retrospective cohort study of 1,279 patients only found an incidental diagnosis in 9.1%.[[6]] This discrepancy between our cohort and other literature could be due to how Kocher et al only included asymptomatic patients as an incidental diagnosis.[[6]] In our analysis, if the intention for diagnosis was not related to lung cancer, then this was classified as an incidental finding. Therefore, in our cohort there are patients who are symptomatic, but an incidental diagnosis of lung cancer has been made. For example, a patient with chest pain has been investigated but lung cancer was not suspected. It has been observed that those patients with lung cancer who are diagnosed incidentally have an improved survival rate.[[3,5,6]] Furthermore, those patients who have been diagnosed incidentally with the imaging modality of CT, have a prognostic survival benefit.[[3,7]] In our cohort, of the 46 patients who had an incidental diagnosis via CT, 22 patients (47%) had a normal chest radiograph prior.  

The significant disparity in survival for Māori patients with lung cancer when compared to non-Māori population should warrant investigation into the feasibility of a targeted screening program for at high-risk Māori patients. The New Zealand national lung cancer working group has stated that more research is required on screening for lung cancer.[[24]] A study undertaken to examine the cost-effectiveness of a low-dose CT screening program in New Zealand stated that it is likely to be cost-effective in the high-risk group of Māori patients.[[26]] In comparison, the Australian Government have stated that a lung cancer screening program, regardless of whether a patient population is at high-risk for lung cancer, is not currently supported.[[25]] Overseas, the current European position on lung cancer promotes the use of low-dose CT for lung cancer screening,[[17]] and the American National Lung Screening Trial also demonstrates a survival benefit for those diagnosed with low-dose CT.[[18]] The NELSON trial has demonstrated that in high-risk patients, mortality from lung cancer was significantly lower among those who were detected on CT screening.[[22]] However, there have been concerns over the extrapolation of these results into an Indigenous population.[[16]]

The majority of patients diagnosed with lung cancer will initially be detected following general practitioner-initiated investigations.[[19]] However, access to primary healthcare in New Zealand is an ongoing challenge. A low-dose CT screening program is likely to improve outcomes from lung cancer in New Zealand, but patient participation is vital for success. In a small cohort study in the USA by Raz et al, of 185 current smokers deemed high-risk, only 18.9% of the cohort had accessed lung cancer screening services, with the remaining 81.1% completely unaware of the available program.[[15]]

Conclusion

This is the first local experience from the Midland Region documenting the symptomatology and route of diagnosis for lung cancer. Furthermore, this cohort study has demonstrated that in a New Zealand population, a large amount of lung cancer is still diagnosed incidentally. The common symptoms are cough, dyspnoea and chest pain. Despite patients presenting with symptoms, lung cancer is still not one of the initial differential diagnoses that are investigated despite having symptoms consistent with lung cancer. A number of patients are diagnosed with lung cancer despite having a normal chest radiograph. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Summary

Abstract

Aim

Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis.

Method

This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. Symptoms or signs recorded were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. The lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance.

Results

Three hundred and ten patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician and 96 (31%) patients were asymptomatic. Incidental diagnosis was demonstrated in 121 (39.4%) patients. Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12) and 28% chest pain (n=12).

Conclusion

In New Zealand, a large amount of lung cancer is still diagnosed incidentally with symptoms of cough, dyspnoea and chest pain. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Author Information

Damian Gimpel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Andrew Pan: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Venughanan Manikavasagar: Newcastle University, Newcastle upon Tyne, United Kingdom. Chunuan Lao: Medical Research Centre, The University of Waikato, Hamilton, New Zealand. Leonie Brown: Waikato Medical Research Centre, The University of Waikato, Level 3 Hockin building, Waikato Hospital, Hamilton, New Zealand. David J McCormack: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Zaw Lin: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Felicity Meikle: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Paul Conaglen: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Doug Stephenson: Department of Veterans Affairs, Prescott VAMC, Prescott Arizona, United States of America. Ross Lawrenson: Strategy and Funding, Waikato District Health Board, Hamilton, New Zealand; Medical Research Centre, The University of Waikato, Hamilton, New Zealand. Adam El-Gamel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, Auckland University, Auckland, New Zealand.

Acknowledgements

The results of this project were published in the NZMJ for the proceedings of the 2018 Waikato Clinical Campus Biannual Research Seminar.

Correspondence

Damian Gimpel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand.

Correspondence Email

gimpeldamian@gmail.com

Competing Interests

Nil.

1) Ministry of Health. Cancer: New registrations and deaths 2013. Wellington: Ministry of Health, 2016.

2) Stevens W, Stevens G, Kolbe J, Cox B. Lung cancer in New Zealand: patterns of secondary care and implications for survival. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer 2007; 2(6): 481-93.

3) Orrason AW, Sigurdsson MI, Baldvinsson K, et al. Incidental detection by computed tomography is an independent prognosti factor for survival in patients operated for non small cell lung carcinoma. ERJ Open Res 2017; 3: 00106-2016 [https://doi.org/10.1183/ 23120541.00106-2016].

4) Raz DJ, Glidden DV, Odisho AY, et al. Clinical characteristics and survival of patients with surgically resected, incidentally detected lung cancer. J Thorac Oncol 2007; 2: 125–130.

5) Quadrelli S, Lyons G, Colt H et al. Clinical characteristics and prognosis of incidentally detected lung cancers. Int J Surg Oncol. 2015;2015:287604.

6) Kocher F, Lunger F, Seeber A, et al. Incidental diagnosis of asymptomatic non-small cell lung cancer: A registry based analysis. Clinical Lung Cancer 2015; 17;62-67

7) Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with lowdose computed tomographic screening. N Engl J Med 2011; 365:395-409.

8) Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case control study. Thorax. 2005;60:1059-65.

9) Jiwa M, Arnet H, Halkett G et al. Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms? A pilot study in Western Australia. BMC Fam Pract. 2009; 10:16

10) Smith SM, Campbell NC, MacLeod U et al. Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study. Thorax. 2009;64:523-31.

11) Buccheri G, Ferrigno D. Lung cancer: clinical presentation and specialist referral time. Eur Respir J. 2004;24:898-904.

12) Lövgren M, Leveälahti H, Tishelman C, et al. Time spans from first symptom to treatment in patients with lung cancer- -the influence of symptoms and demographic characteristics. Acta Oncol. 2008;47:397-405.

13) Simpson CB, Amin MR. Chronic cough: state-of-the-art review. Otolaryngol Head Neck Surg. 2006;134:693-700.

14) Kocher F, Hilbe W, Seeber A et al. Longitudional analysis of 2293 NSCLC patients: A comprehensive study from the TYROL registry. Lung Cancer 2015; 87 (2): 193-200

15) Raz D, Wu G, Nelson R et al. Pereception and utilization of lung cancer screening among smoker enrolled in a tobacco cessation program. Clinical lung cancer 2019; 20 (1); 115-122

16) Koo H, Choi C, Park S et al. Chest radiography surveillance for lung cancer: results from a national health insurance database in South Korea. Lung Cancer; 128; 120-126

17) Oudkerk M, Devaraj A, Vliegenthart R et al. European position statement on lung cancer screening. Lancet Oncol 2017; 18; (12) 754-766

18) Shim J, Brindle L, Simon M, George S. A systematic review of symptomatic diagnosis of lung cancer. Fam Pract. 2014;31(2):137–48.

19) Bradley S, Kennedy M, Neal R. Recognising lung cancer in primary care. Advances in Therapy 2019: 36 (1); 19-30.

20) Stapley S, Sharp D. Negative chest x-rays in primary care patients with lung cancer. Br. J. Gen. Pract. 2006;56:570-575

21) Quadrelli S, Lyons G, Colt H et al. Clinical characteristics and prognosis of incidentally detected lung cancers. Int J Surg Oncol. 2015;2015:287604.

22) De Koning H, Van Der Aalst C, De Jonh P et al. Reduced lung cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513

23) Manners D, Dawkins P, Pascoe D et al. Lung cancer screening in Australia and New Zealand: the evidence and the challenge. Internal Medical Journal. 2021;51:436-441

24) National Lung Cancer Working Group. 2016. Standards of Service Provision for Lung Cancer Patients in New Zealand (2nd edn). Wellington: Ministry of Health.

25) Australian Government Department of Health’s Standing Committee on Screening. Position Statement: Lung Cancer Screening Using Low-Dose Computed Tomography 2015. Canberra: Australian Department of Health; 2015. Last Updated 2019 [cited 2021 Jul 29].

26) Jaine R, Kvizhinadze G, Nair N, Blakely T. Cost-effectiveness of a low dose computed tomography screening programme for lung cancer in New Zealand. Lung Cancer. 2020;144:99-106

27) Gurney J, Stanley J, McLeod M, Koea J et al. Disparities in cancer-specific survival between Maori and Non Maori New Zealanders. JCO Glocal Oncology. 2020;6:766-774

28) Che K, Shen H, Qu X, et al. Survival Outcomes for Patients with Surgical and Non-Surgical Treatments in Stages I-III Small-Cell Lung Cancer. J Cancer. 2018;9(8):1421-1429.

29) Te Aho o Te Kahu. 2021. Lung Cancer Quality Improvement Monitoring Report 2021. Wellington: Cancer Control Agency

For the PDF of this article,
contact nzmj@nzma.org.nz

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Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] It is also the leading cause of cancer death in patients of Māori descent.[[1,2]] A study by Gurney et al that analysed cases of cancer in New Zealand from 2007–2016 highlighted that Māori patients with lung cancer were 30% more likely to die than non-Māori with lung cancer.[[27]] Most patients with lung cancer present with advanced disease and are offered palliative treatment. Approximately 20% of New Zealand patients with newly diagnosed lung cancer are treated surgically.[[2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. Part of the recognised conundrum with accurately diagnosing lung cancer is the nonspecific symptoms.[[8]] Furthermore, the first step in imaging has traditionally been a chest radiograph which in turn has a high false negative rate for diagnosing lung cancer.[[20]] An incidental detection of lung cancer has been associated with improved survival.[[21]]

The Waikato Cardiothoracic Surgical Unit provides a lung cancer resection service to the Midland Region, with a population of 880,000 and with approximately 490 new cases of lung cancer diagnosed per year. Using a cohort of patients with lung cancer receiving curative surgery in Waikato Hospital, we aimed to review the presenting symptoms, the first diagnostic method of imaging and whether the diagnosis was incidental or non-incidental. The hypothesis for this study is that a number of cases of early-stage disease are diagnosed incidentally and subsequently offered curative surgery in the Midland Region. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis.

Methods

This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. This time frame was utilised as full medical records were available. Baseline characteristics included pre-operative patient variables as well as the tumour characteristics including date of cancer diagnosis, cancer stage (grouped into I, II, III and IV) and cancer cell type. We categorised the cell types into 6 groups: non-small cell lung cancer (NSCLC), NSCLC-others, small cell, carcinoid (including typical and malignant carcinoid), low grade mucoepidermoid carcinoma, and others.

Symptoms and signs at time of diagnosis were confirmed by cross referencing the original handwritten and electronic patients files. Two authors reviewed all these notes and achieved concordance to ensure correct data collection. Symptoms or signs recorded as directly caused by lung cancer were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. Based on the subsequent patient management by treating physician (not symptoms), the lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance. Regardless, if the patients had symptoms at diagnosis or not, if patients were not under surveillance (regular surveillance of previously identified lung nodules) and were detected because of an incidental investigation of another presenting health issue, they were recorded as incidentally detected lung cancers.

The mode of clinical imaging included chest radiograph (CXR), computed tomography (CT), positron emission tomography (PET), or magnetic resonance imaging (MRI). Statistical analysis between incidental and non-incidental patient cohorts for patient characteristics, mode of detection and symptomatology was undertaken with chi-square tests and a p-value of less than 0.05 was used to define whether the difference was significant or not.

Institutional approval was given for this project and classed as an audit and ethics approval was not required as deemed negligible risk.

Results

Between January 2010 and June 2018, 310 patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital, including 78 (25.2%) Māori patients and 232 (74.8%) non-Māori patients (Table 1).

Mean age was 66 years, and 55.5% were female. Two hundred and sixty-one (84.2%) patients were either current or ex-smokers. The predominant lung cancer was NSCLC with two hundred and ninety cases (93.5%). There was no significant difference between Māori and non-Māori patients whether the diagnosis was incidental or not (Table 1). Our study, however, only has 78 Māori patients and a nationwide study would be more powered in order to highlight any disparities to diagnosis for a Māori patient population. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician, and 96 (31%) patients were asymptomatic. These asymptomatic patients were diagnosed on either routine check-up imaging via a chest radiograph or diagnosed upon imaging investigating an unrelated disease process. Patients were determined as an incidental diagnosis if the detection occurred because of an investigation of another presenting health issue. Incidental diagnosis was demonstrated in 121 (39.4%) patients and 189 (60.6%) accurately investigated for lung cancer (Table 2).

View Tables 1 & 2.

The use of CXR was still the most common form of imaging modality utilised to diagnosis lung cancer (Table 3). However, the rate of detection with CT was higher in the incidental diagnosis cohort with 38% of patients identified incidentally with lung cancer via CT compared with only a rate of 11.1% non-incidental patients diagnosed via CT. Of the 46 patients who had an incidental diagnosis via CT, 22 patients (47%) had a normal chest radiograph prior.

Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12), and 28% chest pain (n=12) (Table 4). Although these patients presented with symptoms, they are identified as incidental diagnoses, as the investigations were not undertaken with the intent of diagnosing lung cancer. There were 18 patients who had no symptoms and classed as non-incidental (Table 4). Fourteen of these patients were under surveillance imaging for malignancy. Although the remaining four patients did not have primary symptoms, the request for imaging directly queried lung cancer due to their risk factors from clinical history as determined by the treating physician. Patients were determined as an incidental diagnosis if the detection occurred because of an investigation of another presenting health issue. Of those diagnosed incidentally despite symptomatology of lung cancer, 35 patients (79.6%) were diagnosed on an acute admission to hospital, whereas only nine patients (20.4%) were diagnosed in a primary care community setting. Of those 35 patients diagnosed in the hospital, we did not have access to primary care community case notes to determine whether these symptoms had been present but not highlighted to be linked to lung cancer.

View Tables 3 & 4.

Discussion

The five-year survival within New Zealand and Australia is extremely poor at 11 and 17%, respectively.[[23]] Furthermore, surgical resection of lung cancer is associated with improved survival.[[28]] The most recent 2021 New Zealand lung cancer quality improvement report, however, does not ascertain survival differences between surgical and non-surgical patients.[[29]] This study has shown that of patients undergoing curative resection for lung cancer at Waikato Hospital, 121 (39%) patients were discovered because of incidental findings on imaging for other reasons. The remainder were diagnosed following the investigations of symptoms, or because of ongoing surveillance of patients with lung nodules. A population control study from the United Kingdom on lung cancer symptoms demonstrated that often lung cancer diagnosis is not the primary differential when investigating patients.[[8]] A population study from Australia identified that only a small proportion of patients recognise the signs and symptoms of lung cancer, even if a current smoker.[[9]] In our study, 69.4% of patients had symptoms that could be attributable to lung cancer at the time of diagnosis. Of these, cough, dyspnoea and chest pain were the most common presenting symptoms with 44.2%, 20% and 18.1% of patients, respectively. This is consistent with other literature available on the presenting symptoms on diagnosis of lung cancer.[[10–12]]

The difficulty that is faced when cough or dyspnoea are the main presenting symptoms is that other differential diagnoses, such as a respiratory tract infection or cardiovascular disease, are explored as the first diagnosis. A large retrospective study of 2,293 patients by Kocher et al identified that cardiovascular disease and COPD were present in 62.1 and 62% of patients, respectively.[[14]] Furthermore, it has been hypothesised that co-morbidities and suspicion of more benign disease can be isolated as one of the reasons between initial onset of symptoms and a lack of urgency to undertake medical investigation.[[13]] Other literature reports constitutional symptoms as being a main presenting symptom, particularly in an aging population.[[9]] This difference between our cohort could be contributed, by splitting constitutional symptoms into weight loss and fatigue in order to get a more specific representation of presenting symptoms. In terms of the association of a particular symptom and lung cancer, a systematic review of lung cancer diagnosis symptoms by Shim et al demonstrated that haemoptysis had the highest positive predictive value of 2.4–7.5%.[[18]]

In our single centre cohort, the incidental rate of lung cancer was 39%. It has been reported that up to 30–54% of a unit’s thoracic surgical patients are diagnosed incidentally. [[3-5]] Another large retrospective cohort study of 1,279 patients only found an incidental diagnosis in 9.1%.[[6]] This discrepancy between our cohort and other literature could be due to how Kocher et al only included asymptomatic patients as an incidental diagnosis.[[6]] In our analysis, if the intention for diagnosis was not related to lung cancer, then this was classified as an incidental finding. Therefore, in our cohort there are patients who are symptomatic, but an incidental diagnosis of lung cancer has been made. For example, a patient with chest pain has been investigated but lung cancer was not suspected. It has been observed that those patients with lung cancer who are diagnosed incidentally have an improved survival rate.[[3,5,6]] Furthermore, those patients who have been diagnosed incidentally with the imaging modality of CT, have a prognostic survival benefit.[[3,7]] In our cohort, of the 46 patients who had an incidental diagnosis via CT, 22 patients (47%) had a normal chest radiograph prior.  

The significant disparity in survival for Māori patients with lung cancer when compared to non-Māori population should warrant investigation into the feasibility of a targeted screening program for at high-risk Māori patients. The New Zealand national lung cancer working group has stated that more research is required on screening for lung cancer.[[24]] A study undertaken to examine the cost-effectiveness of a low-dose CT screening program in New Zealand stated that it is likely to be cost-effective in the high-risk group of Māori patients.[[26]] In comparison, the Australian Government have stated that a lung cancer screening program, regardless of whether a patient population is at high-risk for lung cancer, is not currently supported.[[25]] Overseas, the current European position on lung cancer promotes the use of low-dose CT for lung cancer screening,[[17]] and the American National Lung Screening Trial also demonstrates a survival benefit for those diagnosed with low-dose CT.[[18]] The NELSON trial has demonstrated that in high-risk patients, mortality from lung cancer was significantly lower among those who were detected on CT screening.[[22]] However, there have been concerns over the extrapolation of these results into an Indigenous population.[[16]]

The majority of patients diagnosed with lung cancer will initially be detected following general practitioner-initiated investigations.[[19]] However, access to primary healthcare in New Zealand is an ongoing challenge. A low-dose CT screening program is likely to improve outcomes from lung cancer in New Zealand, but patient participation is vital for success. In a small cohort study in the USA by Raz et al, of 185 current smokers deemed high-risk, only 18.9% of the cohort had accessed lung cancer screening services, with the remaining 81.1% completely unaware of the available program.[[15]]

Conclusion

This is the first local experience from the Midland Region documenting the symptomatology and route of diagnosis for lung cancer. Furthermore, this cohort study has demonstrated that in a New Zealand population, a large amount of lung cancer is still diagnosed incidentally. The common symptoms are cough, dyspnoea and chest pain. Despite patients presenting with symptoms, lung cancer is still not one of the initial differential diagnoses that are investigated despite having symptoms consistent with lung cancer. A number of patients are diagnosed with lung cancer despite having a normal chest radiograph. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Summary

Abstract

Aim

Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis.

Method

This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. Symptoms or signs recorded were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. The lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance.

Results

Three hundred and ten patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician and 96 (31%) patients were asymptomatic. Incidental diagnosis was demonstrated in 121 (39.4%) patients. Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12) and 28% chest pain (n=12).

Conclusion

In New Zealand, a large amount of lung cancer is still diagnosed incidentally with symptoms of cough, dyspnoea and chest pain. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Author Information

Damian Gimpel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Andrew Pan: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Venughanan Manikavasagar: Newcastle University, Newcastle upon Tyne, United Kingdom. Chunuan Lao: Medical Research Centre, The University of Waikato, Hamilton, New Zealand. Leonie Brown: Waikato Medical Research Centre, The University of Waikato, Level 3 Hockin building, Waikato Hospital, Hamilton, New Zealand. David J McCormack: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Zaw Lin: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Felicity Meikle: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Paul Conaglen: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand. Doug Stephenson: Department of Veterans Affairs, Prescott VAMC, Prescott Arizona, United States of America. Ross Lawrenson: Strategy and Funding, Waikato District Health Board, Hamilton, New Zealand; Medical Research Centre, The University of Waikato, Hamilton, New Zealand. Adam El-Gamel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, Auckland University, Auckland, New Zealand.

Acknowledgements

The results of this project were published in the NZMJ for the proceedings of the 2018 Waikato Clinical Campus Biannual Research Seminar.

Correspondence

Damian Gimpel: Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand.

Correspondence Email

gimpeldamian@gmail.com

Competing Interests

Nil.

1) Ministry of Health. Cancer: New registrations and deaths 2013. Wellington: Ministry of Health, 2016.

2) Stevens W, Stevens G, Kolbe J, Cox B. Lung cancer in New Zealand: patterns of secondary care and implications for survival. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer 2007; 2(6): 481-93.

3) Orrason AW, Sigurdsson MI, Baldvinsson K, et al. Incidental detection by computed tomography is an independent prognosti factor for survival in patients operated for non small cell lung carcinoma. ERJ Open Res 2017; 3: 00106-2016 [https://doi.org/10.1183/ 23120541.00106-2016].

4) Raz DJ, Glidden DV, Odisho AY, et al. Clinical characteristics and survival of patients with surgically resected, incidentally detected lung cancer. J Thorac Oncol 2007; 2: 125–130.

5) Quadrelli S, Lyons G, Colt H et al. Clinical characteristics and prognosis of incidentally detected lung cancers. Int J Surg Oncol. 2015;2015:287604.

6) Kocher F, Lunger F, Seeber A, et al. Incidental diagnosis of asymptomatic non-small cell lung cancer: A registry based analysis. Clinical Lung Cancer 2015; 17;62-67

7) Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with lowdose computed tomographic screening. N Engl J Med 2011; 365:395-409.

8) Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case control study. Thorax. 2005;60:1059-65.

9) Jiwa M, Arnet H, Halkett G et al. Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms? A pilot study in Western Australia. BMC Fam Pract. 2009; 10:16

10) Smith SM, Campbell NC, MacLeod U et al. Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study. Thorax. 2009;64:523-31.

11) Buccheri G, Ferrigno D. Lung cancer: clinical presentation and specialist referral time. Eur Respir J. 2004;24:898-904.

12) Lövgren M, Leveälahti H, Tishelman C, et al. Time spans from first symptom to treatment in patients with lung cancer- -the influence of symptoms and demographic characteristics. Acta Oncol. 2008;47:397-405.

13) Simpson CB, Amin MR. Chronic cough: state-of-the-art review. Otolaryngol Head Neck Surg. 2006;134:693-700.

14) Kocher F, Hilbe W, Seeber A et al. Longitudional analysis of 2293 NSCLC patients: A comprehensive study from the TYROL registry. Lung Cancer 2015; 87 (2): 193-200

15) Raz D, Wu G, Nelson R et al. Pereception and utilization of lung cancer screening among smoker enrolled in a tobacco cessation program. Clinical lung cancer 2019; 20 (1); 115-122

16) Koo H, Choi C, Park S et al. Chest radiography surveillance for lung cancer: results from a national health insurance database in South Korea. Lung Cancer; 128; 120-126

17) Oudkerk M, Devaraj A, Vliegenthart R et al. European position statement on lung cancer screening. Lancet Oncol 2017; 18; (12) 754-766

18) Shim J, Brindle L, Simon M, George S. A systematic review of symptomatic diagnosis of lung cancer. Fam Pract. 2014;31(2):137–48.

19) Bradley S, Kennedy M, Neal R. Recognising lung cancer in primary care. Advances in Therapy 2019: 36 (1); 19-30.

20) Stapley S, Sharp D. Negative chest x-rays in primary care patients with lung cancer. Br. J. Gen. Pract. 2006;56:570-575

21) Quadrelli S, Lyons G, Colt H et al. Clinical characteristics and prognosis of incidentally detected lung cancers. Int J Surg Oncol. 2015;2015:287604.

22) De Koning H, Van Der Aalst C, De Jonh P et al. Reduced lung cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513

23) Manners D, Dawkins P, Pascoe D et al. Lung cancer screening in Australia and New Zealand: the evidence and the challenge. Internal Medical Journal. 2021;51:436-441

24) National Lung Cancer Working Group. 2016. Standards of Service Provision for Lung Cancer Patients in New Zealand (2nd edn). Wellington: Ministry of Health.

25) Australian Government Department of Health’s Standing Committee on Screening. Position Statement: Lung Cancer Screening Using Low-Dose Computed Tomography 2015. Canberra: Australian Department of Health; 2015. Last Updated 2019 [cited 2021 Jul 29].

26) Jaine R, Kvizhinadze G, Nair N, Blakely T. Cost-effectiveness of a low dose computed tomography screening programme for lung cancer in New Zealand. Lung Cancer. 2020;144:99-106

27) Gurney J, Stanley J, McLeod M, Koea J et al. Disparities in cancer-specific survival between Maori and Non Maori New Zealanders. JCO Glocal Oncology. 2020;6:766-774

28) Che K, Shen H, Qu X, et al. Survival Outcomes for Patients with Surgical and Non-Surgical Treatments in Stages I-III Small-Cell Lung Cancer. J Cancer. 2018;9(8):1421-1429.

29) Te Aho o Te Kahu. 2021. Lung Cancer Quality Improvement Monitoring Report 2021. Wellington: Cancer Control Agency

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