Recent articles in the media, published after a study by cancer research on 135,000 people. Medical education teaches GPs to “live with uncertainty” because of the need to ration resources effectively. The access to sophisticated tests is rationed by hospital trusts who wish to limit demand as they have inadequate capacity. If we want earlier diagnosis we have to accept greater expense, more technology, more false positives, and more hopeful and unnecessary treatments…..
“The study by Cancer Research UK found that just 37 per cent of all cancer diagnoses in England involved patients who had been given an urgent referral by their GP, because the disease was suspected. Just 32 per cent of diagnoses for bowel cancer and 28 per cent of diagnoses for lung cancer were identified this way.” Many other news media repeated the problem including The Yorkshire Post
David Oliver opines in the BMJ: David Oliver: Don’t blame GPs for late cancer diagnoses BMJ 2019;366:l4625
Being a GP isn’t easy. Under-resourcing, workforce gaps, the rising complexity and volume of work, and a media narrative too often laden with blame add to the challenges. On 28 June the Daily Telegraph ran a column entitled, “GPs failing to spot two thirds of cancers.”1 The article was more measured than the headline. But readers’ fear and anger are rarely tempered by less conspicuous details.
It reported a Cancer Research UK study, which had focused on two common cancers (lung and bowel), analysing 135 000 cases.2 The Telegraph mentioned “average waits of more than eight weeks for diagnosis,” adding that “the vast majority of cases that turned out to be cancer were never suspected by family doctors.”
The study, based on data from 2014-15, had concluded that only 37% of all cancers had been diagnosed after urgent referral by a GP suspecting or wanting to rule out the disease. This was true in 32% of bowel cancer cases and 28% of lung cancer cases. Patients who had not been referred for urgent assessment waited weeks longer for diagnosis. And 35% of lung cancer cases and 28% of bowel cancer cases were diagnosed only when patients presented to hospitals as an emergency.
GPs see a whole range of conditions, often in early stages with undifferentiated symptoms that could easily be many things other than newly presenting cancer. The 2015 NICE guidelines on recognising and referring suspected cancer lowered the positive predictive value threshold for referring cases from 5% to 3%.3 Cancer Research’s Cancer in the UK 2019 report showed that, even in 2015-16, only 19% of cancers were diagnosed as emergencies (and only 6% through screening programmes)—so most were in fact diagnosed through GP assessment and referral.4
The data on Public Health England’s bespoke GP profiles illustrate that cancer still represents only a small percentage of a GP’s overall caseload.5 And some patients, with vague symptoms of cancer not specific to any one organ, risk being sent urgently down the wrong specialist route.
Patients’ own circumstances or care preferences also play a part in delayed diagnosis. A study by Abel and colleagues on 4647 NHS patients with a cancer diagnosis from presenting as an emergency found that 29% reported no prior GP consultation. Percentages were substantially higher in older, male, and deprived patients.6
Also consider that, if more patients were referred as urgent cases, our hospital services in radiology, specialty medicine, oncology, and surgery, which already have their own major workforce and workload challenges, would struggle to cope. Indeed, they’re already struggling, not least in balancing patients with suspected cancer against those with equally pressing clinical (if not target) priorities.
A Nuffield Trust analysis7 of performance against cancer waiting time targets showed that, since measurement started in 2009, we’ve generally maintained the operational standard of at least 94% of patients who are referred by GPs as “urgent” being seen within two weeks, with only a recent dip in performance. However, it also showed that the metric of at least 85% of such patients starting treatment within six weeks of referral has been breached for the past four years and has recently declined further. NHS England’s clinical review of national access standards is ongoing,8 partly in response to such issues.
Cancer Research UK has a fantastic track record of raising awareness, in line with its charitable mission. It’s just a shame that, in this case, the resulting media narrative placed excessive blame on GPs, using old data. I’m not sure that this helps patients or doctors.