Aim: The aim of this study was to examine the frequency of lung cancers presenting with misleading chest X-rays in primary care. Background: Lung cancer is a common cause of cancer death. Misleading chest x rays are resulting in delay in the diagnosis and thereby increasing the mortality. Early diagnosis can help in curative treatment and thereby decreasing the mortality rate. Design of study and setting: this study is a prospective study. It is carried out in 52 lung cancer patients, who were diagnosed in the department of pulmonary medicine between june2012 to august 2014. Method: All diagnosed cases of lung cancer patients in MIMS medical college were included in the study. Chest X-rays and radiologist reports of the patient’s were analyzed. Chest X-rays were categorized into two groups depending on the primary care physician’s notes and radiologist’s report: abnormal but no malignancy suspected (unsuspected malignancy cases); or abnormal with possible malignancy. Results: Of the 52 patients, in 30 patients chest x ray presentation was atypical, not suggestive of malignancy. 22 cases presented with typical radiological features of malignancy. Pneumonia (n=9, 17.3%) was the most common misdiagnosis of lung cancer followed by Collapse (n=7), Pleural effusion (n=6), Lymphadenopathy (n=3), Lung abscess/Cavitation (n=5). Conclusion: Chest X-rays of more than half of malignancy cases are negative. Further investigation is warranted with continuing or changing symptoms, even if the X-ray is not suggestive of malignancy.