The burden of lung disease

Short abstract

A timely reminder of the needs of people with respiratory disease in the UK

The range of clinical conditions included under the umbrella of “respiratory medicine” is wide. From cancers to obstructive sleep apnoea, interstitial lung disease to airways disease, occupational lung disease to respiratory infections, there is a variety present in respiratory medicine not seen in other hospital based specialties. This diversity makes respiratory medicine a deeply rewarding specialty in which to work, but also means that it is not easy to quantify the full impact of lung disease on the health of the British public.

For this reason, the British Thoracic Society has produced the second edition of “The Burden of Lung Disease” which includes a number of statistics that may be startling to the casual reader and of interest to those involved in resource allocation in the NHS.¹ For example, of the 580 000 deaths each year in the UK, one in five is due to respiratory disease with 35 000 deaths from lung cancer, 34 000 from pneumonia, and 27 000 from COPD. Respiratory disease now accounts for more than 845 000 hospital admissions each year and is second only to injury and poisoning as a cause of emergency admission to hospital. Asthma remains the most common chronic illness in children. The estimated cost to the UK of respiratory disease in 2004 was a staggering £6.6 billion. Clearly, the impact of lung disease is huge.

The report also provides evidence of health inequalities in lung disease. The socioeconomic gradient in death rates from respiratory disease is steeper than that for all cause mortality, highlighting the great potential to prevent deaths from lung disease. Worryingly, the report also suggests that respiratory medicine in the UK is falling behind other specialties and other countries. For example, the death rate from ischaemic heart disease in the UK has halved over the last 20 years, but that due to respiratory disease is essentially unchanged and death rates from lung cancer in the UK are among the worst in Europe.

The scale of the problem of lung disease detailed in the report is impressive, but is still likely to be an underestimate because data are just not available for some important respiratory diseases. For example, we know that in some populations obstructive sleep apnoea is common and associated with a range of morbidities, but we still need information on the full public health impact of this condition.²,³,⁴ We have data from death registrations that the incidence of idiopathic pulmonary fibrosis is rising steeply, but that these data underestimate greatly the true frequency of the disease.⁵,⁶ There is still a considerable amount of research required to allow the third edition of “The Burden of Lung Disease” to describe the impact of the full spectrum of lung disease.

In his foreword John Macfarlane comments that the “report confirms that we urgently need to provide an improved NHS service for those with lung disease”. I would echo these thoughts and add that we also need an improved up to date evidence base. The challenge now is how best to make progress.

In the long term, the solution to preventing deaths from lung cancer and COPD lies with drastically reducing the prevalence of smoking in the UK. This would also remove much of the socioeconomic gradient for respiratory mortality and have a beneficial impact on a wide range of other respiratory diseases.⁷ Since respiratory medicine has more to gain by reducing the prevalence of smoking than other areas of medicine, it is vital that our specialty takes a lead in promoting and widening access to smoking cessations services. We should also take a leading role in research to improve the efficacy of smoking cessation treatments and to determine how best to deliver services to all sectors of society.

We also urgently need to improve the care for our patients presenting with lung disease now. In some areas more research is needed, but in others the evidence is already strong and the problem is one of service provision. Examples where a strong evidence base already exists, but where many centres have struggled for resources to provide services, include pulmonary rehabilitation for patents with COPD and continuous positive airways pressure for patients with obstructive sleep apnoea.⁸,⁹ These examples highlight the need for a coordinated approach to provide these effective but relatively low cost interventions to all the people who need them wherever they live. An example where additional clinical evidence would have a large clinical impact is that of surgical resection rates for lung cancer. Surgical resection rates for lung cancer in the UK are lower than those in Europe, partly because people in the UK present later with more advanced disease.¹⁰ At the moment we do not know the most effective way to diagnose cases of lung cancer earlier, but possible approaches include publicity/education campaigns and screening programmes, perhaps using low dose spiral CT scanning.¹¹ The challenge to the research community it to determine which is the most cost effective approach. With this in mind, lung cancer needs more than the 4% of the UK cancer research budget that it currently receives. The equivalent figures for breast cancer, colon cancer and ovarian cancer are 17%, 11% and 6%, although collectively these three cancers kill fewer people each year than lung cancer.¹² The disproportionately low funding for lung cancer extends into other areas of respiratory medicine and this has been recognised as a problem by the Medical Research Council (www.mrc.ac.uk).

In summary, the second edition of “The Burden of Lung Disease” is a timely reminder of the needs of people with respiratory disease in the UK. The report highlights areas where more evidence is required. This means that researchers working in respiratory medicine need to maximise their ability to secure the limited research funding available by working together to produce high quality proposals to answer clinically relevant questions. In many areas we already have enough clinical evidence to help reduce the mortality and morbidity of patients with lung disease, but the current service provision is fragmented. Here we need a coordinated effort from the whole of the respiratory community to push for the services our patients deserve.