PassFinals
Respiratory

Lung Cancer

A malignant lung tumour can obstruct airways, invade local structures or spread distantly; the high-yield pathway is rapid recognition, tissue and molecular diagnosis, stage and fitness assessment, multidisciplinary treatment and early supportive care.

In a nutshell

Suspect lung cancer with persistent or changing cough, haemoptysis, unexplained weight loss, breathlessness, chest pain or recurrent pneumonia. Use NICE referral criteria, stage with CT and PET-CT when curative treatment is possible, obtain tissue with relevant molecular and biomarker testing, and let the MDT select treatment according to stage, histology, fitness and patient priorities.

Classic presentation

A current or former smoker with persistent cough, haemoptysis, weight loss, breathlessness or a recurrent chest infection in the same region.

Key points

  • Refer people aged 40 or over with unexplained haemoptysis through the suspected-cancer pathway; use urgent chest X-ray criteria for other symptom combinations.
  • A normal chest X-ray does not end investigation when symptoms persist or clinical suspicion remains high.
  • CT defines the primary and possible spread before biopsy; choose bronchoscopy, image-guided sampling or EBUS/EUS according to lesion and nodal anatomy.
  • Tissue should support subtype, relevant molecular testing and biomarker assessment because these results can change systemic treatment.
  • Early NSCLC may be treated with surgery or radical radiotherapy; locally advanced disease needs an MDT multimodality plan.
  • Advanced NSCLC treatment must follow current NICE technology appraisals and NHS genomic eligibility rather than a static drug list.
  • SCLC usually needs prompt thoracic-oncology assessment and systemic treatment, with radiotherapy according to stage and response.
  • Screening invitations are risk-based and do not replace diagnostic assessment of symptoms.

First-line investigation

Urgent chest X-ray using NICE NG12 criteria, followed by contrast CT and appropriately selected tissue and staging investigations through the lung cancer team.

Management

Recognise and refer

  • Use NICE NG12 for urgent chest X-ray or suspected-cancer referral, safety-net persistent symptoms and escalate airway compromise, major haemoptysis, superior vena cava obstruction or suspected spinal or brain complications.6,2

Stage and obtain tissue

  • Arrange contrast CT before biopsy, use PET-CT when curative treatment is possible and choose the safest tissue route that can also support nodal, molecular and biomarker assessment.7,3

Assess fitness and support

  • Assess performance status, respiratory and cardiovascular reserve, smoking status, comorbidity and patient priorities; provide a lung cancer clinical nurse specialist and symptom support from diagnosis.1,4

Treat by stage and biology

  • Use the MDT to select surgery or radical radiotherapy for appropriate early NSCLC, multimodality treatment for locally advanced disease, current NICE technology-appraisal pathways for advanced NSCLC and prompt systemic treatment for SCLC.4,3,8

Support and prevent delay

  • Offer smoking-cessation, palliative and psychological support alongside anticancer treatment, give clear follow-up and safety-netting, and use the NHS Lung Cancer Screening Programme only for its risk-based invitation pathway.1,5,8

Exam traps

  • A normal chest X-ray cannot safely exclude lung cancer in a persistent or high-risk presentation.
  • Horner syndrome with shoulder or arm symptoms suggests an apical tumour and needs a cancer pathway.
  • A recurrent or non-resolving pneumonia in the same area can reflect endobronchial obstruction.
  • Do not start advanced NSCLC systemic treatment without checking the current biomarker and NICE technology-appraisal pathway.
  • SCLC is not managed by default as resectable NSCLC; it spreads early and needs rapid oncology assessment.
  • Screening is for eligible asymptomatic risk groups and must not delay investigation of symptoms.

Illustrations

Central versus peripheral tumour anatomyDiagram showing a centrally arising bronchial tumour causing obstruction versus a peripheral tumour invading the pleura or chest wall.PassFinals · original
Pancoast tumour and Horner syndromeIllustration of an apical lung tumour invading the brachial plexus and sympathetic chain, producing arm pain and Horner syndrome.PassFinals · original
Left perihilar lung cancer on chest X-rayPosteroanterior chest radiograph showing an irregular left perihilar lung mass, marked by the red arrow, due to primary lung cancer.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE NG122: Lung cancer: diagnosis and management (NICE guideline for lung cancer diagnosis, staging, MDT care, support, follow-up and treatment; last updated March 2024 and reviewed February 2026.)
  2. NHS: Lung cancer and diagnosis (Current NHS information on symptoms, chest X-ray limitations, specialist diagnosis and treatment factors.)
  3. NHS England: National Genomic Test Directory (Current NHS England directory specifying commissioned genomic tests and eligibility criteria; page updated July 2026.)
  4. NICE NG122: Management recommendations (Current NICE recommendations for curative NSCLC treatment, multimodality pathways, advanced NSCLC technology-appraisal links and SCLC management.)
  5. NHS England: Earlier diagnosis and the NHS Lung Cancer Screening Programme (Current NHS England information on lung health checks for people aged 55 to 74 who smoke or used to smoke and low-dose CT for those assessed as high risk.)
  6. NICE NG12: Suspected cancer: recognition and referral (Current NICE referral criteria for unexplained haemoptysis and symptom-based urgent direct-access chest X-ray; last updated April 2026.)
  7. NICE NG122: Diagnosis and staging recommendations (Current NICE recommendations for CT before biopsy, tissue sampling, EBUS-TBNA, PET-CT, brain imaging, MDT referral and clinical nurse specialist support.)
  8. BNF online: current prescribing information relevant to lung-cancer supportive and systemic care (Use current BNF and local oncology protocols for prescribing, interactions, renal and hepatic adjustment, toxicity management and monitoring; no fixed drug regimen is reproduced here.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.