Table 1.

Patient pathways before diagnosis of lung cancer

#	Interval	From first symptoms to diagnosis
8	2 weeks	An X-ray was ordered for this patient upon consultation with a physiatrist for tendinitis of the arm: “Actually… It was odd. I mean, because it was a long time that I’d been having… that I was aware of symptoms. But I just attributed it to fatigue.” (p. 4) “I had terrible pain in my back, but since it was in my back, I didn’t think it had anything to do with my chest. But in fact, it was because there was a tumour just opposite it… and I was… I was getting out of breath, I couldn’t go very far, but you know, I had things I needed to get done. I just put it all down to fatigue. So I told myself that if I just rested, everything would be okay… Meanwhile… I had a pretty bad tendinitis in my left arm. I was referred to a physiatrist because, you know, well. And then he started looking me over. It’s coming back to me… I don’t know how… He looked at me and he said… Maybe I had on a sweater that was a bit more [inaudible 0:04:54.8]. He said: ‘On that side, there, it’s bigger than on the other side.’ And then, he had a little lamp, and he said ‘I see a shadow.’ I didn’t understand! Then he said, ‘I think…’ He said, ‘Has it been a long time since you’ve had an X-ray?’ ‘Ah’, I said, ‘it’s been at least… 3 or 4 years.’ He said, ‘If I were you, I’d go right away. It’s worrisome.’” (44, p. 4) Soon after that, in a private radiology clinic, the patient had an X-ray whose results were positive. The results were transmitted the next day and the radiologist prescribed a scan. The patient managed to accelerate the transmission of the scan results to her family physician.
6	1.5 months	This person suffered from restless leg syndrome and very quickly her symptoms worsened to the point that she had difficulty sleeping. Following a worsening of her symptoms, she went to the emergency room of a hospital where she had a contact. She was diagnosed with lung cancer the next day, after being admitted to hospital. “And then, my daughter-in-law had a friend who was an emergency physician at the hospital. So my husband called her. He called her, and [name of daughter-in-law], and he said, ‘You need to try, to see if your friend could… » (p. 6) “So then, I went to see her (at the ER),… and on the 14th, they sent me to neurology, and four or five people came to see me, and they told me I had two cancers: one in the brain, and one in the lungs. Then I called my husband.”
4	2 months	This person, very athletic and active, experienced respiratory problems related to activity. “Then, at a certain point, a Sunday, after the holidays, I had a cough that was dry, dry, dry. I’d been having frequent dry coughs, so much that… I said, I’m choking… on my saliva, you know. What’s wrong with me? A dry, dry, dry cough… And one that had been going on for a long time, and had irritated my throat, and I had spit up some blood. Then I said, Oh! What’s [inaudible 0:07:39.6] you know, ah, either it’s… But me, I hadn’t thought about bronchial tubes. I was thinking more that I had irritated my respiratory tract, anyway. I put it out of my mind, to some extent. It had scared me a little, but one of my friends said, ‘No, no, you need to see a doctor, now, really,…’ ‘OK, I will.’ But then January came along… We went for a hike on the mountain, and as I was climbing the stairs, I was, like…. Me, I described it sort of like bronchospasms. All of a sudden, I couldn’t breathe, I was out of breath, air wasn’t getting through there. […] I called that week, I think, for an appointment with my doctor and got one….” (261, p. 7) She contacted her family physician for her activity-related respiratory problems. The patient, a nurse, thought it was asthma. In addition to prescribing inhalers, her family physician ordered an X-ray and referred her for to a respirologist. After an initial positive X-ray, the physician thought it was early pneumonia and prescribed antibiotic treatment and another lung X-ray. After a second positive result, more advanced investigations were undertaken: a scan and bronchoscopy.
5	3 months	Two or three months before her diagnosis, this person had a first case of bronchitis, which was treated. At that time she had a lung X-ray, which was normal (October 2011). She had bronchitis again a few weeks later. Her family physician ordered a second X-ray. Following those results, he referred her to the hospital for further evaluation.
7	3.5 months	This person felt a lump when washing herself. After several months, seeing that the lump was not going away, she tried making an appointment with her family physician. Because the appointment she was given was two to three weeks away, she went to a walk-in clinic. The physician there sent her immediately for X-rays, read the results the same day, and ordered a scan, which the patient underwent two or three days later. Following the scan results, the physician ordered a biopsy and referred her to a respirologist.
1	4 months	This person experienced symptoms of shortness of breath in November 2012. She had three mechanical valves, one of which habitually leaked. She thought her shortness of breath was related to a problem with her valve. She had a scheduled appointment with her family physician in December. She told him about the problem. Her physician referred her to a surgeon, who saw a hematoma. He gave her an appointment for March 14. After the consultation, the surgeon referred her to the emergency cardiology service (swollen hematoma + patient turning blue). The patient underwent a scan and an MRI. The physician told her the problem was not related to her valves and sent her to the emergency room at the general hospital. At the ER, on March 18, the physicians suspected cancer. The patient was hospitalized. She then underwent several tests and surgeries (four bronchoscopies, a biopsy, a mediastinoscopy) before receiving a diagnosis on May 10.
3	4 months	This person said she experienced shortness of breath (in May). She consulted at a nearby clinic. Her physician sent her for a lung X-ray. Even though the radiologist indicated that it was urgent that the patient be referred for further investigation, the physician did not notify the patient. It was only at a later consultation, for acute respiratory problems, that the results of the diagnostic X-ray conducted several months earlier were read and communicated to the patient. The patient then went immediately to the emergency room, and two days after going to the ER, she received a cancer diagnosis.
2	5 months	This person experienced unusual shortness of breath in the autumn. After returning from a trip she had taken over the holidays, she made an appointment with a physician. On January 15 a physician accepted her on his patient roster. The patient underwent an X-ray and blood tests. Her physician referred her to a respirologist, whom she saw at the end of February. That specialist noted the presence of a mass and prescribed a bronchoscopy and pulmonary function testing. The diagnosis was reached on March 7th. The interval between first symptoms and making an appointment with a physician was rather long. Once the patient was in consultation, the time to diagnosis was between one and a half and two months.