Covid-19: Lung Cancer Pathway

James Daly Excerpts

Wednesday 2nd December 2020 Westminster Hall

[Derek Twigg (Halton) (Lab)]

I beg to move,

That this House has considered the effect of the covid-19 outbreak on the lung cancer pathway.

The effect of the covid-19 outbreak on the lung cancer pathway is of real concern and has been brought into sharp focus by the UK Lung Cancer Coalition’s report, “Covid-19 Matters”. I will refer to that report as well as to discussions with Martin Grange, Professor Mick Peake OBE and Dr Robert Rintoul from the coalition.

When we discuss health matters in Parliament, we often focus on policies, funding and statistics. Of course, those are important, and I will discuss them later, but when we speak about a specific disease that most people will have little knowledge of, we should explain its impact on patients and their loved ones. In doing that, I will share a real example of a lung cancer case. The patient concerned had a persistent cough for a few weeks. After prompting from their family, they went to see the GP. The GP prescribed some medication and advised them to come back in two weeks if the cough persisted. It did. The GP sent the patient for an X-ray and, the next day, called the patient in to see him. It did not look good—there appeared to be a large tumour in the right lung, and it had spread.

The patient was given an urgent referral to the local acute hospital. Tests were done, and they confirmed stage 4 small cell lung cancer, which had also spread to the rib, liver and lymph glands. The consultant told the family as sensitively as he could that it was terminal and that, at best, the patient would have six to nine more months of life. The oncologist said he wanted the patient to try some chemotherapy, but it had risks. If a patient gets an infection, it could cause serious complications. Unfortunately, the patient developed an infection and was rushed to hospital the following day, very poorly and in great pain.

The hospital gets the pain management wrong. The patient is admitted, but it is another 24 hours before the pain management team sees the patient to get control of the situation. A “no resuscitation” form is signed, but the patient recovers from the infection and goes home. However, more infection occurs in the lung. The lung collapses and the infection gets worse, filling the lung with pus, and the smell is awful. The patient must go to another hospital to have a drain inserted into their chest, but it does not always drain the pus in the way intended, so the patient needs to return to the hospital on several occasions to have the drain looked at. As the lung has filled up with so much fluid, it occasionally needs to be drained by the brilliantly caring specialist nurse practitioners. Despite all that, the patient finds some inner strength in the final few weeks and manages a bit of travel to tick off a couple of things on their bucket list. They then give a knowing nod to the family to say, “I assured you that I could do it.”

Then there is the inevitable weight loss, loss of appetite and puffing up of the face from steroids. After being reduced by one course of chemotherapy, the cancer comes back with a vengeance and quickly spreads to many parts of the body. The family feel helpless and just want to do everything they can to help support the patient and show their love. The patient is brave and more concerned about the impact on their children than on themselves. The pain management and care from the GPs and district nursing team is exceptional. Eventually, in just 48 hours, matters take a turn for the worse. On the final day, in a matter of hours, the patient slips into unconsciousness. The end comes, just over six months from diagnosis. The family feel numb, and the intense grief and sadness take over. This is the reality of lung cancer.

Lung cancer is the leading cause of death in the UK. Approximately 35,000 people die every year with lung cancer, which is more than the figure for breast cancer and bowel cancer combined. Despite the high mortality associated with lung cancer, it is not the most common cancer in the country. Breast cancer is the most common cancer but is generally diagnosed earlier—by stage 2—resulting in a much higher survival rate. That is not the case for lung cancer. Some 49% of lung cancer patients are diagnosed at stage 4. Late diagnosis is the main reason why lung cancer is the cause of most cancer deaths in the UK. Patients present so late because symptoms do not appear until stages 3 or 4

Like other cancers, the earlier the detection, the more likely the survival. Only 19% of lung cancer patients will survive beyond one year if they are diagnosed when the disease has spread. We know that the people most likely to suffer with lung cancer are 55 and over. They are likely to live in an area with high pollution levels and to have been a smoker at some point in their life. As the lungs are so large, symptoms often become apparent only in the latter stages, which results in small tumours, cancerous or benign, having no instant impact on the person. It is only when the tumour grows larger that it begins to affect the lungs’ ability to function, which is when and why the coughing begins. Something as simple as a cough is often the first symptom when a patient sees their GP, but they might be sent away with antibiotics. As symptoms present so late, the speed of diagnosis is of the utmost importance. As we exit the pandemic, it is likely that we will see a backlog of lung cancer cases.

[James Daly (Bury North) (Con)]

The hon. Gentleman is giving a very powerful and articulate description of the appalling disease that is cancer. The petition that forms the basis of today’s debate comes from my constituent Andrew Jenkinson, whose wife Emma sadly died of brain cancer during the pandemic. His concern regards the ongoing issue of patients receiving cancer treatment during the difficult period that we are in. Will the hon. Gentleman join me in paying tribute to Mr Jenkinson for the tireless work he has done to bring this issue to people’s attention not only at the local level in my constituency of Bury North, but nationally?

[Derek Twigg]

I will of course pay tribute to Mr Jenkinson, and I offer him my condolences on his loss. The hon. Gentleman raises a very important point about the impact of the pandemic on cancer treatment and survival, and I will shortly address that in more detail.



It is vital that we do not take risks with people’s health and that we ensure that a proactive approach is taken. There is widespread concern that, during the covid-19 pandemic, there have been too few face-to-face appointments. Lung cancer experts have told me that they believe that face-to-face appointments are important for referring people for urgent fast-track checks, and that they should resume as soon as possible. GPs need to see patients and patients need to know that they are receiving a full and thorough examination when they present to their doctor with problems.

My constituency has one of the highest lung cancer rates in the country. It is also a hotspot for other respiratory diseases such as chronic obstructive pulmonary disease and asthma. Widnes and Runcorn are old industrial towns that are famous for their former Imperial Chemical Industries plants. Many of the older generation suffer from the pollution that they inhaled as children and young adults. Those people, who were also encouraged to smoke in the 1950s and 1960s, are most likely to suffer from lung cancer. Simply, the situation that they find themselves in, through an accident of birth, puts them at a higher risk of developing lung cancer.

It is not widely known that people who have never smoked can also be the subject of the disease. In fact, non-smoker lung cancer is the eighth biggest cancer killer in the country and is responsible for about 6,000 deaths a year—I was shocked to find that out. We have come to believe that only people who have smoked can develop lung cancer, but that is simply not the case.

In an article for the Journal of the Royal Society of Medicine, Anand Bhopal, Michael Peake, David Gilligan and Paul Cosford discuss never-smoker lung cancer, which they note is increasing in absolute and relative terms compared with the decline in smoking. Their research shows that, although second-hand smoking is a contributing factor, it is not the main reason for that. They also note that never-smokers feel a stigma about their diagnosis. We must work to destigmatise lung cancer, particularly as the number of never-smoker patients rises. At the same time, publicity campaigns would help to raise the profile of that silent killer among never-smokers. As we know, there has been some good progress in the battle against second-hand smoking.

[Yvonne Fovargue in the Chair]

It is not only never-smoker lung cancer patients who need to be destigmatised, but smokers and ex-smokers, who can feel blamed for having lung cancer. As I said, decades ago—for a generation of people—it was acceptable to smoke. There needs to be more support and positive encouragement to quit. The message should ultimately be that it is better to be safe than sorry.

GPs need to make more referrals for chest X-rays to increase the chance of early diagnosis. They should screen patients to target those most at risk, and the Government should provide them with more resources. X-rays are relatively inexpensive and quick for the NHS to perform. They are often available in the local community, as is the case in my constituency, so they cause little if any inconvenience to the patient.

The pandemic will have adversely affected the detection of lung cancer. As we know, a new continuous cough is one of the main symptoms of covid-19. It is not unreasonable to suggest that people out there could have been suffering with, and potentially died from, lung cancer during the pandemic without any diagnosis or treatment. They could also have presented too late. It is vital that people who have had a cough for longer than three weeks see their GP.

There was a staggering 75% drop in the number of patients urgently referred to lung cancer specialists during the first wave of the pandemic. During that time, 55% of UK lung cancer specialist nurses or team members were redeployed or unable to work as a result of covid-19. It is estimated in the UK Lung Cancer Coalition’s “Covid-19 Matters” report that at least one third of lung cancer patients have already died since the beginning of the pandemic. There is also a chance that some of those deaths were labelled as covid-19 due to similar symptoms.

The Government should heed the advice of the UK Lung Cancer Coalition and pilot a “Be clear on lung cancer and covid-19” campaign to increase awareness of potential lung cancer symptoms and increase the confidence of the public across the UK to engage with the healthcare system early. The UK Lung Cancer Coalition also wants national NHS bodies to support the resumption of lung cancer screening programmes at the earliest opportunity. When will they resume? There was a report in the Health Service Journal yesterday of a shortage of equipment and staff.

The UK Lung Cancer Coalition pushed to increase the five-year survival rate from 16.2% in 2017 to 25% by 2025. It felt that target was achievable, but now believes that is unattainable by 2025 because of the pandemic. It is clear that the pandemic has had, and will continue to have, a detrimental effect on lung cancer patients.

Lung cancer patients are also at particular risk of contracting viral infections such as covid-19 because of their underlying condition and the immunosuppression associated with many lung cancer treatments. The Health Service Journal reported yesterday that, since the start of the financial year, two-week wait referrals for lung cancer stand at 18,400, down 42% from 32,000, in the same period last year.

Paula Chadwick, the chief executive of the Roy Castle Lung Cancer Foundation, told me that since the start of the pandemic it has seen the requirement for support significantly increase. Calls to its Ask the Nurse helpline have risen by 93%, with patients and carers understandably anxious, with questions about shielding, diagnosis and treatments. Recognising the effect of covid on lung cancer, the foundation took action, accelerating and extending its activity for the Lung Cancer Awareness Month campaign. It also launched the Still Here campaign, with the aim of increasing awareness of the disease and symptoms—as the foundation says, for example, a cough does not just mean covid—and encouraging those with symptoms to contact their GP.

Going forward, we need a strategy that gets us back on target to achieve the five-year survival rate of 25% set by the Lung Cancer Coalition. We need campaigns to encourage people to visit their GP if they have symptoms of lung cancer, especially if they live in high-risk areas. The battle to end lung cancer will be a long and painful journey. Every year that we fail to reach the 25% target, people will be dying who would have had a longer life. Memories that could have been made will be taken away. Families that could have been spared grief will have to endure the pain of losing a loved one. That needs urgent action, before that progress turns out to have been made in vain.

In summary, lung cancer should be a top priority as we move out of the pandemic. A shocking 75% fall in urgent referrals is deeply worrying. We must ensure that urgent referrals are at the pre-pandemic level as soon as possible. We need the return of face-to-face consultations, so that patients can have confidence in the treatment they are receiving and the right diagnosis. We need to ensure that places such as Halton, which has a high prevalence of lung cancer, are prioritised for a programme of targeted screening and chest X-rays.

That would mean targeted campaigns, such as those suggested by the UK Lung Cancer Coalition, to encourage those at risk to see their GP, while also encouraging GPs to take a more cautious approach, when someone in an at-risk group presents with a cough, in the years and months to come.

[The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)]

It is a pleasure to serve under your chairmanship, Ms Fovargue. I congratulate the hon. Member for Halton (Derek Twigg) on securing the debate and sharing patients’ stories, showing not only the huge care delivered by the NHS workforce but the challenges for patients, as they struggle to get a diagnosis and navigate the system. In the patient’s story that the hon. Gentleman articulated, there was already spread: not only was the disease at stage 4 but was metastatic, so affected different sites in the body.

All these things pose a challenge, and the hon. Gentleman very articulately laid out the challenges of late diagnosis and how we can improve. The UK Lung Cancer Coalition report articulated how we must not lose the progress that we have seen over the past 10 to 15 years, but must absolutely focus on the aim to extend survival up to 2025. I hope I can reassure him that the initial measures that we took at the beginning of the pandemic, because we did not know what we were dealing with, have not been the focus since June, when we began to refocus and double our efforts on trying to ensure that cancer patients can have full access to services.

There are still some challenges. I have had conversations with thoracic surgeons. There are particular challenges with the trajectory of this disease, because of where it is on the body and some of the aerosol-generating procedures that are needed in diagnosis and so on. I can say to the hon. Member frankly and honestly that we are aware of those issues and we are working hard to get back not just to where we were, but, as I think Professor Peake said, to a normal that is better than what we had at the start.

I also pay tribute to the constituent of my hon. Friend the Member for Bury North (James Daly), Andrew Jenkinson, and add my condolences for the sad loss of his wife. I congratulate him on his energy in campaigning. It is often the biggest tribute someone can give to a person they love, to try to drive forward and make things better for others.

[James Daly]

I thank the Minister for those kind comments, which will mean a lot to Mr Jenkinson. His petition is titled:

“Ensure access to treatment and screening for all cancer patients during Covid-19”.

We know there have been challenges and the pandemic has thrown up things we never dreamt we would be dealing with. Will my hon. Friend offer some assurance that the issues that Mr Jenkinson highlights in his petition are being addressed and that there are positive signs going forward?

[Jo Churchill]

I will indeed come to that, and hopefully give him and others the reassurance that we are focusing hard on making sure that we not only deliver, but learn from the pandemic. That was highlighted in the Lung Cancer Coalition report as well. Where we can make improvements to speeding up delivery of diagnoses or treatment, we need to make sure that we do so.

Lung cancer is one of the country’s most invidious cancers and it is important that it is diagnosed as early as possible, for treatment to be successful. As the hon. Member for Halton highlighted, it is one of the worst cancers for being diagnosed too late, largely at stage 4, and it has often spread. The challenge then is that treatment options are reduced because of the grade of the cancer.

When someone does present, it is vital that they are referred swiftly for further diagnostics, remembering that we are in a pandemic with a disease that attacks the respiratory system as much as anything. I have stood here talking about teenage cancers and diagnostics and treatments already this week. Not all cancers are the same; they all need a bespoke approach. It is important to remember that.

I spoke to a thoracic surgeon at the cancer hub during the summer. He explained to me in some detail the challenges, but also the opportunities now before us. I thank the cancer workforce for all that they have done through the pandemic and their continued effort to restore services. It has been a herculean effort and they have really flexed the service, joining together in cancer hubs and ensuring that areas are covid-secure for patients. Part of the challenge is to encourage patients to come forward for tests. If someone has a persistent cough, or signs of other cancers, they need to do something about it.

I spoke in the debates yesterday and this morning, and I know only too well the devastation that Mr Jenkinson must be feeling. The particular concern with lung cancer is the overlap with covid-19 symptoms. That was highlighted in the Lung Cancer Coalition report and by a plethora of clinicians. To that end, we have updated 111 protocols. If somebody has received a negative covid test but has a persistent cough, it may indicate lung cancer and they are directed to appropriate clinical care. One challenge has been a sustained fall in people coming forward for lung checks, with the number of people seeking checks at only 76% of pre-pandemic levels. This is about ensuring that we encourage people to come forward, driving forward campaigns such as the Greater Manchester Cancer Alliance and the Northern Cancer Alliance’s campaign “Do It For Yourself”. Ensuring that people are aware of the signs and symptoms is really important, and has an impact on the number of lung cancers diagnosed and treatments started. I cannot stress enough that if individuals do not come forward, we cannot get them into the optimal pathway, which has shown real improvements in how we can help people through their cancer journey.

I was pleased with the £150 million of capital funding issued to regions in October to invest in diagnostic equipment such as MRI and CT scanners. Again, that was very much called for. I know that instant referral to a CT scan is an objective of the report, but getting the equipment so that we can start to deliver quicker routes is part of the issue. The further £325 million for new diagnostic equipment in the spending review, once we know exactly how it is going to be allocated, will, I hope, result in more delivery of diagnostics into cancer care. It is vital that we use that money to maximise equipment in as many places as possible so that individuals can be treated as rapidly as possible.

We know that access to earlier diagnostic screening improves clinical outcomes and that the late stage is really one of the challenges. That is why I am really pleased to see the hugely successful pilots of the targeted lung health check programme rolled out. Those pilots offered places such as supermarket car parks and lorries where people could easily access a check, particularly in areas of high prevalence or high inequalities, making it as simple as possible for somebody to get a check. There were dramatic improvements in those attending and huge upturns in the number of people diagnosed. The pilots were paused due to covid-19, but I am really keen that we turbo-charge them now that we have them back on track, so that they operate more broadly as soon as is safely possible. The programme will be rolled out to 23 clinical commissioning groups, focused on areas with some of the highest rates of mortality from lung cancer.

Because I am short of time, I will not repeat what the hon. Member for Halton said, but we know that we have regional variation, and we need to target more effectively for lung cancer where we have those problems. It is important that we do that geographically in the light of the need to minimise trips to the hospital, particularly for people who may be more vulnerable to covid-19. Radiotherapy services have made use of fewer fraction protocols as evidence has emerged.

The focus on recovery has been on embedding the use of hypofractionated treatment. In addition, the NHS is supporting providers to accelerate the delivery of stereotactic ablative body radiotherapy for non-small cell lung cancer and oligometastatic indications, starting with the treatment of non-small cell lung cancer. In some cases, that is an alternative to surgery. Again, I think the report picked up on that. The challenge is that if someone gets covid-19 at the same time as they are having the surgery, it dramatically increases the mortality rate.

It was right to react at speed. Where clinicians say, “We need to be doing it this way,” we have tried to give the direction so that they can. Individuals can safely go to their GPs. If people have worrying symptoms that could be cancer, GPs are open for business and ready to help patients. It is about ensuring that the “Help us help you” campaign from earlier in the year delivers and gets more people coming through the door so that we can treat them quicker.