Lung Cancer/Thoracic Malignancy

• Suspected primary thoracic cancer with any of the following concerning features:
  • Large volume haemoptysis defined as expectoration of 200-250ml (1cup) within 24 hours
  • Suspected large airway obstruction (stridor, tachypnoea, increased work of breathing, decreased air entry on auscultation, hoarseness)
  • Severe dyspnoea
  • Clinical signs and symptoms of SVC obstruction
  • Hypercalcaemia/hyponatremia with confusion
  • Large significantly symptomatic pleural effusion
  • Neurological features of spinal cord compression

• Suspected primary thoracic cancer
• Nodule of any size associated with hilar lymphadenopathy, distal atelectasis or pleural effusion
• Significant growth/change of a noncalcified pulmonary nodule on serial chest CT

NB: Best practice is for patients to be seen within 14 days

To contact the relevant service, see Clinician Assist WA: Acute Respiratory assessment (external site).

• The following findings not in setting of acute/chronic pulmonary infection, embolism, sepsis/trauma/febrile illness or outside of another clinical reason:
  • mass ≥ 3cm on chest CT scan
  • significant growth/change of a noncalcified pulmonary nodule on serial chest CT
  • noncalcified pulmonary nodule of any size associated with hilar lymphadenopathy, distal atelectasis or pleural effusion
• Anterior mediastinal mass
• Pleural based mass

Referrals missing 'mandatory information' with no explanation provided may not be accepted by site. If 'mandatory information' is not included, the explanation must be provided in the body of the referral (e.g. patient unable to access test in regional or remote areas or due to financial reason).

This information is required to inform accurate and timely triage. If unable to attach reports, please include relevant information/findings in the body of the referral and advise where (provider) investigation/imaging was completed.

• Relevant history, onset, duration, and severity of symptoms
• Smoking/vaping status and history
• Current medication list
• Any known allergies
• Personal cancer history (including skin cancers)

• Nil

•  Chest CT scan (contrast not required; thin sections preferred ≤1.25mm slice width): please include reports from private providers

• Patient aware of reason for referral
• Patient ability to give informed consent
• Family history of lung cancer
• Ethnicity
• Asbestos and/or other occupational exposures

• Nil

• Any previous chest imaging
• Any other relevant pathology/biopsy results
• FBC in last month
• U&Es in last month
• LFTs in last month
• Coagulation profile in last month
• Calcium in last month
• ECOG/Functional Status

Category 1

Appointment within 30 days

• Significant or enlarging mediastinal/hilar lymphadenopathy requiring investigation
• Metastatic disease to thorax requiring sampling for management decisions

Category 2

Appointment within 90 days

• No defined category 2 criteria

Category 3

Appointment within 365 days

•  No defined category 3 criteria

Excluded condition for the following:

• Pulmonary nodules not requiring ongoing surveillance
  • Pulmonary nodule is defined as a lung lesion <30mm diameter surrounded by lung parenchyma with no associated hilar lymphadenopathy, distal atelectasis or pleural effusion
  • Stable pulmonary nodules are defined as no change/growth detected on CT surveillance in solid nodules ≥ 2 years and subsolid ≥ 5 years
  • Perifissural nodule <10mm that demonstrates characteristic morphology (triangular or oval shape in the axial plane, and a flat or lentiform morphology in the sagittal and coronal planes)
  • Completely calcified pulmonary nodules
• Pulmonary nodule in acutely unwell patient:
  • Detection of an incidental lung nodule in acute clinical setting such as CT chest performed for other scenarios such as pulmonary infection/sepsis/pulmonary embolism/ cardiac failure/trauma etc
  • In this scenario, if no prior chest CT imaging available for comparison, recommend repeat short-term interval chest CT (6-12 weeks) to reassess lesion
  • If lesion persistent on short term interval CT OR has worrisome CAT 1 features refer according to Noncalcified pulmonary nodules indicative triage category
• Pulmonary masses/nodules suspicious of metastases in patients with suspected non-thoracic primary malignancy
  • Refer to most appropriate specialist service for primary cancer
• New pulmonary nodules/masses in patients with known current thoracic or non-thoracic malignancy
  • Refer to clinician/oncologist currently treating the known malignancy

• Referrals for previously treated lung cancer with suspected recurrence should be sent to patients treating clinician/oncologist in first instance
• Please ensure all private radiology is uploaded/available in public imaging system
• Outpatient appointments via telehealth may be considered (on a case-by-case basis)
• When writing the referral, it is useful for the referrer to note in the referral that the patient is aware:
  1. The referral has been made
  2. The underlying clinical concern
  3. If there has been multiple referrals made (i.e. to the public and private outpatients)
  4. For country patient, indicating the patient has also been referred to the Rural Cancer Nurse for suspected cancer work up

Clinician resources

• The Eastern Cooperative Oncology Group (ECOG): Performance Status Scale
• Cancer Australia: Investigating symptoms of lung cancer
• Cancer Victoria: Optimal care pathway for people with lung cancer
• Cancer Victoria: Optimal care pathway for people with lung cancer: Quick reference guide