Diagnostic intervals and imaging use in lung cancer: a national real-world study in England

Timely diagnosis is critical for improving lung cancer outcomes, yet diagnostic pathways in England remain complex and variable. Real-world evidence examining imaging use, delays and emergency care during the diagnostic interval is limited.

We conducted a national retrospective cohort study using linked Hospital Episode Statistics and Diagnostic Imaging Dataset for adults newly diagnosed with lung cancer between April 2018 and March 2019. Diagnostic intervals were defined from first chest imaging to diagnosis. We assessed imaging utilisation, diagnostic pathways and A&E attendance, with subgroup analyses by ethnicity, deprivation and diagnostic interval.

Among 21 052 patients, the median diagnostic interval was 56 days: 25% experienced intervals ≥113 days. Patients underwent a median of three chest scans, and 25% received four or more. Multimodality imaging was strongly associated with prolonged intervals. One-third of patients attended A&E during the diagnostic pathway, rising to 45% among those with the longest intervals. Asian patients experienced the longest diagnostic intervals (median: 67 days). Patterns were consistent across deprivation quintiles, with diagnostic intervals and high A&E attendance observed across all strata, indicating systemic gaps in coordinated diagnostic pathways.

A substantial proportion of patients with lung cancer in England experience prolonged diagnostic intervals, often accompanied by high emergency care utilisation. Prolonged diagnostic intervals may reflect underlying differences in patient pathways. Multimodality imaging was associated with longer diagnostic timelines, which could represent clinical complexity, diagnostic challenges or possibly fragmentation of diagnostic pathways. These findings highlight the need for streamlined imaging processes, timely follow-up after initial chest imaging and stronger primary care engagement to support earlier diagnosis and alignment with the National Optimal Lung Cancer Pathway.