STEP 2: Presentation, initial investigations and referral
This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
The following unexplained, persistent signs and symptoms require investigation, if lasting more than three weeks, or earlier in patients with known risk factors or with more than one sign or symptom:
- new or changed cough
- chest or shoulder pain
- shortness of breath
- hoarseness
- weight loss or loss of appetite
- persistent or recurrent chest infection
- fatigue
- deep vein thrombosis
- abnormal chest signs
- finger clubbing
- cervical or supraclavicular lymphadenopathy
- features suggesting lung cancer metastasis (e.g. brain, bone, liver or skin)
- pleural effusion
- thrombocytosis (Cancer Australia 2020b).
The following signs and symptoms require urgent referral for a chest CT scan and concurrent referral (within two weeks) to a specialist linked to a lung cancer multidisciplinary team:
- persistent or unexplained haemoptysis
- signs of superior vena caval obstruction
- high clinical suspicion of lung cancer
- imaging findings that suggest lung cancer (Cancer Australia 2020b).
The following signs or symptoms require immediate referral to an emergency department:
- massive haemoptysis
- stridor (Cancer Australia 2020b).
The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of lung cancer.
Presenting symptoms should be promptly and clinically triaged with a health professional.
General practitioner examinations and investigations should include:
- thorough medical history
- urgent chest x-ray for unexplained, persistent symptoms and signs (lasting more than three weeks, or earlier in patients with known risk factors or with more than one symptom or sign – if the chest x-ray is normal and symptoms persist, repeat the chest x-ray at six weeks)
- chest CT scan – this should be offered if there is a strong clinical suspicion of lung cancer, persistent or unexplained haemoptysis, signs of superior vena caval obstruction or imaging findings suggest lung cancer. Complete within two weeks of the patient presenting with symptoms. The CT scan should be delivered with contrast unless contraindicated. Concurrently, refer the patient to a specialist linked to a lung cancer multidisciplinary team (consider immediate telephone contact) (Cancer Australia 2020b).
Presenting symptoms should be addressed based on the advice provided above.
Patients should be provided with tests results within one week of presenting to their general practitioner.
The patient’s general practitioner should refer the patient to a specialist (with expertise in lung cancer, who is affiliated with a multidisciplinary team) for treatment if the diagnosis is confirmed or to make the diagnosis if the diagnosis is not conclusive (Cancer Australia 2020b).
See Lung Foundation Australia’s, ‘Lung Cancer Multidisciplinary Team’ directory for institutions that have multidisciplinary teams with expertise in lung cancer.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Patients in some rural or remote locations may access specialists via telehealth services. General practitioners working in remote or rural locations should be aware of such facilities before referral.
Referral for suspected or diagnosed lung cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resource – Checking for cancer and Cancer from the Cancer Australia website.
The first specialist appointment should take place within two weeks of the initial general practitioner referral.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific challenges and needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties (consider referral to a clinical psychologist and connecting the patient to a face-to-face, online or telephone lung cancer support group)
- management of physical symptoms including pain, fatigue, cough and breathlessness
- physical distress caused by breathlessness and coughing – this may be alleviated through a referral to allied health professionals (physiotherapy, occupational therapy, exercise physiology or pulmonary rehabilitation); non-pharmacological strategies may be beneficial in breathlessness management (CareSearch 2019a)
- haemoptysis (CareSearch 2019b) – ensure patients understand how to manage haemoptysis and obtain medical support
- stigma related to smoking, which may exacerbate distress and cause delays in presentation and lead to isolation (people with non-smoking-related lung cancer may also be affected by stigma, including erroneous assumption of smoking status [Gonzalez & Jacobsen 2012])
- smoking cessation care – this should be implemented from the initial patient visit and offered at all stages of the cancer care continuum including palliative and end-of-life care
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
- supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
