When Charlie, 44, returned from holiday with a niggling back pain, she assumed she had pulled a muscle carrying her heavy luggage. But despite never smoking, it was stage four lung cancer

A persistent cough. A hoarse voice that lingers for weeks. Losing your appetite. For most otherwise fit and healthy people – and for most doctors – these symptoms would not ring alarm bells.

But one of Britain’s leading oncologists warns that these all-too-easily dismissed signs could indicate lung cancer – the deadly disease increasingly being diagnosed in younger people.

Speaking at the annual meeting of the European Society for Medical Oncology (ESMO) in Madrid, Dr James Wilson is among experts calling for changes to referral guidelines amid concerns that too many patients are being diagnosed only after their cancer has spread. 

The private cancer specialist at the prestigious Cromwell Hospital in London believes any adult – regardless of age or smoking history – with a persistent cough that fails to improve after two to three weeks should be offered a chest X-ray.

Most will not have cancer, he says, but it is a quick, relatively inexpensive way to investigate symptoms that might otherwise be dismissed.

Currently, NHS guidelines recommend an urgent chest X-ray for people aged 40 and over who have an unexplained cough and have smoked, or who have never smoked but have other symptoms, such as breathlessness, fatigue or weight loss. But there is no equivalent recommendation for younger adults, even those with a history of smoking.

And, in recent years, the profile of lung cancer patients has shifted.

Smoking and advancing age remain the biggest risk factors for lung cancer. Yet specialists are also seeing patients in their 20s and 30s – some of whom have never smoked – presenting with advanced disease.

This has prompted concerns that current referral guidelines, which focus on older adults, could mean younger patients are missing out on a lifesaving early diagnosis.

‘Lung cancer does not discriminate based on age,’ Dr Wilson tells The Mail on Sunday. ‘Anybody can get it and we need people to know that lung cancer is not uncommon in people who don’t smoke.

‘It’s easy to think that you’ve just been shouting too much, or are coming down with a virus, but if it’s persistent and worsening, it needs to be checked.

‘Don’t let your GP fob you off. If you have any new symptoms – including a cough, chest pain, breathlessness, hoarse voice – that are persistent and worsening, you should be sent for a chest X-ray, no matter your age.’

Certainly, lung cancer was the last thing on Charlie Maxwell’s mind when she first noticed a twinge of pain in her left ribs and back.

The 44-year-old was returning from holiday and assumed she had simply pulled a muscle lugging around her heavy backpack.

But the pain didn’t go and she had difficulty even blowing her dog whistle or sleeping on her left side.

‘The fact that it didn’t hurt when I moved, but did when I blew air into a whistle, or laughed, was strange,’ she says. ‘But as a former rugby player, I knew there’s nothing you can do for rib pain, so I left it.’

Then, visiting her sister in Spain, Charlie found herself suddenly breathless while walking up a flight of stairs. She says: ‘I had been swimming and walking earlier that day with no issues, but when I went up even just one flight of steps I had to stop to catch my breath. I made a note to check with my GP.’

Her doctor was very concerned. But because Charlie was young and had never smoked, she could not be referred for further scans on the two-week cancer pathway. Instead, she was advised to go straight to A&E, where she was eventually given a chest X-ray. While at first given the all-clear, and told to return home, Charlie received an urgent call two weeks later – a radiologist checking her file had found a shadow on her lung. Within days she received the official diagnosis: stage four lung cancer that had already spread to her rib.

Today, Charlie is doing well – her disease, while incurable, has shrunk and is stable. But she wishes she had listened to her strange and unexplained symptoms earlier.

‘I didn’t understand then how far cancer can get before you feel it,’ she says. ‘Now I encourage everyone that if you have something that doesn’t feel right, to get it checked. Don’t assume that pain or changes are normal.’

Lung cancer is Britain’s biggest cancer killer, causing about 33,000 deaths a year with some 50,000 people diagnosed annually.

It is overwhelmingly a disease of older people. Almost half of patients are 75 or over when diagnosed, with rates highest among those aged 80 to 84.

But about 15 per cent of lung cancers occur in people who have never smoked – accounting for an estimated 6,000 deaths a year. And these patients are more likely to be younger – in rare cases, just 25.

An analysis of lung cancer patients at Guy’s and St Thomas’ Hospital in London found that 16 per cent of those who had never smoked were under 50, compared with just 5 per cent of patients with a smoking history.

Crucially, catching lung cancer early can make an enormous difference. About 65 per cent of those diagnosed at an early stage – before it has spread beyond the lungs – survive at least five years, compared with just 5 per cent of those whose disease is advanced.

In an effort to detect the disease before symptoms appear, the NHS is rolling out a screening programme in England for people aged 55 to 74 who have smoked.

Those invited undergo an assessment, with those considered most at risk offered a CT scan which can detect tumours while they are still small and before they spread to other areas – known medically as metastatic.

Dr Wilson says the proportion of patients he sees at his clinic who have never smoked has been increasing and now account for nearly a third of his cases, with a marked increase among under-50s.

‘We know from a growing pool of patients that a 30-year-old non-smoker with a persistent cough could have lung cancer – and yet it can take weeks, if not months, for them to be referred for a chest X-ray,’ Dr Wilson adds.

‘And in this time, if they do have cancer, the disease can, and often will, progress. Often I see patients who have been given repeated courses of antibiotics. Sometimes that’s what they want because it means they can keep working.

‘They may also have young children and feel that they don’t have the time to make an appointment.

‘Unfortunately, by the time we see them, it’s metastatic disease.’

Younger, fitter patients may also be better able to tolerate the early symptoms of the disease, meaning they can go unnoticed for longer.

Adenocarcinoma, which develops from glandular cells in the lung, is the most common type of lung cancer among people who have never smoked. It often develops in the outer regions of the lungs, where tumours may grow without initially irritating the larger airways.

For some patients, the first obvious symptom may be breathlessness caused by fluid collecting around the lung.

‘This is known as a pleural effusion,’ Dr Wilson explains. ‘Somebody who is fit and healthy can build up a surprising amount before becoming breathless.’

So if smoking isn’t responsible, what is causing lung cancer in these patients?

Scientists say that air pollution is a factor. According to Cancer Research UK, it is responsible for about 8 per cent of lung cancer cases in Britain. And a study published last year found that people who had never smoked but had been exposed to higher levels of air pollution had more cancer-related genetic changes in their lung tumours.

Other recognised risk factors include second-hand cigarette smoke, exposure to asbestos and radon – a natural radioactive gas that can accumulate in buildings. However, in many patients, no obvious cause can be identified. Research suggests women who have never smoked are more than twice as likely to develop lung cancer than men who have never smoked. It is not clear why.

Under NHS targets, 85 per cent of patients should begin cancer treatment within 62 days of an urgent suspected cancer referral – a standard the health service has failed to meet for years.

But Dr Wilson argues that even this time-frame may be too long for some patients.

‘We know the longer it takes from symptoms to treatment, the greater the chance the cancer can spread,’ he says.

‘And there is a very real chance that somebody can move from curable to incurable disease during that diagnostic pathway.’

Some 40 per cent of patients referred on an urgent suspected lung cancer pathway do not start treatment within 62 days.

Dr Wilson believes the stigma surrounding lung cancer can also contribute to delays, with some patients reluctant to seek help because of the assumption that they have brought the disease on themselves through smoking.

Others downplay their smoking history when speaking to doctors.

‘I don’t care if somebody smokes,’ he says. ‘The damage has already been done. But I need to know because it can change the course of treatment.’

The delays are concerning given dramatic advances in lung cancer treatment. New targeted drugs and immunotherapies have transformed the outlook for patients.

‘When I was training, if somebody was diagnosed with advanced lung cancer you were often talking about survival measured in months,’ Dr Wilson says. ‘Now we’re talking about years.’

But those advances depend on patients receiving the right diagnosis and prompt treatment.

‘The message is simple,’ says Dr Wilson. ‘If you’ve got a symptom that isn’t going away, don’t ignore it. And don’t assume you’re too young for it to be serious.’