Lung cancer pathway inequalities for adults with severe mental health conditions: A mixed-methods analysis of barriers to screening and care pathways in South East London

Background

Adults with severe mental health conditions (often referred to as severe mental illness – SMI) experience 15–20-year mortality gap relative to the general population, with lung cancer a significant contributor. National cancer policy targets earlier diagnosis but does not explicitly address how pathways function for this group.

Aims

This study aimed to describe lung cancer risk, prevalence, screening eligibility, referral activity and diagnostic pathway performance for adults with SMI in South East London (SEL), and to examine where along the pathway inequalities arise.

Methods

Co-designed with experts with lived experience and voluntary sector, this exploratory mixed-methods service evaluation combined quantitative analysis of routinely collected data from the Quality Outcomes Framework (QOF), SMI Register and Cancer Waiting Times Record (April 2023-March 2024) with semi-structured qualitative interviews (n=11 clinical staff) and focus groups (n=6 adults with lived experience of SMI). Quantitative and qualitative data were analysed using descriptive statistics and framework-based thematic analysis respectively, and findings were integrated using a joint display approach, organised by the Consolidated Framework for Implementation Research (CFIR).

Results

Lung cancer prevalence was approximately double among adults with SMI (0.17% vs 0.09% in the general population). Despite Urgent Suspected Cancer (USC) referral rates being more than twice as high in the SMI population (63 vs 28 per 100,000), fewer cancers were detected via planned general practice (GP) routes (11% vs 20%), the 28-day Faster Diagnosis Standard was not met for any SMI patient diagnosed with lung cancer during the study period; overall FDS performance was 76% in the SMI population compared with 84% in the general population; and appointment non-attendance was more than double that in the general population (6% vs 3%). Qualitative findings identified individual, service and system-level mechanisms – including stigma, diagnostic overshadowing, fragmented coordination, and rigid pathway protocols – that compound disadvantage across lung cancer pathway stages.

Conclusions

Inequality in lung cancer outcomes for adults with SMI accumulates across the pathway rather than arising at a single point of failure. Addressing this requires proportionate adaptations within existing cancer pathways, alongside routine reporting of cancer outcomes stratified by SMI population.

Significance of this study

What is already known on this subject?

• People with severe mental health conditions (often referred to as severe mental illness - SMI) experience substantially worse cancer outcomes, including higher mortality from lung cancer.

• Inequalities are driven by multi-level barriers, including reduced access to screening, diagnostic delay, and fragmented care across physical and mental health services.

• However, there is limited empirically grounded evidence on how these barriers operate within lung cancer pathways, and how they can be addressed in practice.

What are the new findings?

• This study identifies multi-level barriers and enablers to the National Health Service Lung Cancer Screening (NHS LCS) programme and care for people with SMI, spanning individual, service, and system domains.

• Barriers include fragmentation between services, unclear care coordination, and challenges navigating screening pathways, even when eligibility is met.

• Findings are theoretically informed by three implementation science frameworks and validated through multi-stakeholder engagement, including clinicians and people with lived experience.

• The study generates co-produced, actionable recommendations to address these barriers across the pathway.

How might this impact on clinical practice in the foreseeable future?

• Provides an evidence-informed basis for redesigning lung cancer pathways to improve access, engagement, and continuity of care for people with SMI.

• Supports targeted service and system interventions to address identified barriers and improve early diagnosis.

• Offers practical, co-produced recommendations for clinicians and system leaders working to reduce inequalities.

• Findings have direct relevance to ongoing national and regional efforts to reduce cancer inequalities and improve outcomes for people with SMI.