March 2010 – Cancer: Early Diagnosis
Update from Macmillan GP Advisers
Welcome to the March edition of Macmillan Cancer Support's newsletter for GPs to update you on activities in primary care. This edition we will be focussing primarily on the early diagnosis of cancer.
Macmillan produces this newsletter for the benefit of Macmillan GPs, Primary Care Cancer Leads, and our wider GP and primary care colleagues to keep you informed of developments within Macmillan Cancer Support that may interest you. Further information can be obtained from your local Macmillan GP Adviser (details below) or by responding to this email address: Macmillan_primary_care@macmillan.org.uk
In this edition:
It is often stated that the UK has a poor record in cancer outcomes compared with other European countries. Quite why this should be so is difficult to say. In recent years the focus for this poor performance has increasingly been on diagnosis, rather than on treatment. Some impressive calculations have suggested 10,000 to 12,000 British lives are lost each year from late diagnosis. These have even been broken down by cancer site, with nearly 1,000 extra lung cancer deaths when compared with the average EU country (it much worse when you compare with the best). These figures, plus a lot of excellent papers covering the whole subject of the UK's cancer record are in a free online supplement of the British Journal of Cancer.
What does this mean to GPs? Firstly, it is not yet known which parts of the cancer diagnostic journey in the UK are the problem ones. Are the problems before the GP is involved (in which case the solutions are primarily those of public awareness of symptoms, plus a little on access to primary care)? Or are the delays in we GPs being slow in considering cancer as a possibility? Or is out our unwillingness to test when the chance of finding a cancer is low? Or are tests simply too hard to get hold of? Or are the problems in secondary care, even though the two-week clinics have created an apparently simple route for investigation? The truth is we don’t know which of these matter, or whether they all do. For my money, I’d say all were possible causes for some cancers, but that probably patient awareness of cancer symptoms and unwillingness to test/unavailability of tests are the main explanations.
We have made considerable progress in estimating the risk of cancer for specific presentations to primary care (which I review in the supplement above) but are still jostling around the much more tricky concept – just what level of cancer risk warrants urgent investigation? We hope to get closer to an answer for this from a recently started programme of research, the DISCOVERY programme. This will poll general practice patients by giving them various scenarios, equating to different risks of cancer and simply asking them if they would want investigation. That sounds facile: it’s not – my wife says she’d refuse a colonoscopy if she were told the risk of an underlying colorectal cancer was (only) 2%. Others would ask for investigation at any level of risk. This decision is central to how we provide cancer diagnostic services in the UK – particularly with the forthcoming expansion of such testing. Most GPs and their patients will welcome increased provision of testing but we must be careful in not overdoing it. Take one example: something like 4% of MRI brain scans in ‘healthy’ people are abnormal, showing a haemangioma similar. These generally lead to repeat scanning – which is hardly reassuring – for anyone. So, we will need to assemble guidance for testing, even if the absolute threshold for investigation falls.
All pieces written by researchers end up with the line, ‘More research is needed’ – this piece is no exception!
Willie Hamilton, MD, FRCP, FRCGP consultant senior lecturer University of Bristol
The Cancer Reform Strategy in 2007 identified the need to look at barriers to early diagnosis, and late presentation. In response to this a primary care audit was developed which was based in the Scottish Directly Enhanced Service. The audit was designed to look retrospectively at a number of aspects of the diagnostic pathway including:
The Anglia Cancer Network conducted this audit from July 2009. It was decided to retrospectively audit patients with a new cancer diagnosis (excluding non-melanoma skin cancers and screening detected cancers) made between April 2008 and April 2009.
124 surgeries were recruited with population of over 1,000,000 people (40% of the population of the network)!
75% of the returns have been quality assured and analysed and already there are significant trends emerging.
Overall feedback from this audit has been very positive with the only real complaints being around the inclusion and exclusion of certain types of cancers and the omission of 'urgent' as a referral option. Further work is being undertaken to look at how best to use the information gathered within the network.
Dr David Plume-Macmillan GP Adviser LASER
Many of you reading this newsletter will be involved in primary care audit. On the basis of returns so far there are some common themes and lessons to be learnt. Below is a first attempt to summarise some of these into tips that may help all of us involved in primary care. These will be updated as the project progresses. We would be grateful for any comments and suggestions you may have.
GPs are sometimes criticised about their referral behaviour, particularly when a diagnosis of cancer is involved. It can be a difficult task to achieve the fine balance between causing unnecessary anxiety in our patients, overwhelming the system with unnecessary referrals for investigations or specialist opinion and ensuring that, amongst the array of presentations we see, the worrying symptoms and signs are recognised and acted upon. Here are some questions to ask yourself about how you manage this and what you might be able to do to achieve that balance – these are not meant to be critical, but just some simple points to help reflection.
* Be aware that smoking puts people at risk of types of cancer in addition to lung; obesity, excessive alcohol consumption and sun exposure increases risk of cancer. Know the environmental carcinogens to which people may be exposed and that some infections increase the risk of cancer (e.g. HPV, Hepatitis B and C, Epstein Barr virus, herpes simplex, chronic syphilis, Helicobacter and schistosomiasis)
*Please note this list is not exhaustive.
We are very excited to tell you about our new partnership with Boots. Much more than just a fundraising partnership, we will be working together to reach everyone in the UK affected by cancer and provide them with the information and support they need. There is much more information to come, but in the meantime if you have any questions, contact Steven Wibberley on 020 7840 4942 or firstname.lastname@example.org
The venue for this year’s conference has been confirmed. The event will be held at:
Thistle Barbican Hotel
Website which includes link to map:
We are currently finalising the programme of events for the conference. Registration for the event will open in early April and will be in contact shortly to advise on how to register.
Learn Zone gives you free and easy access to a wide variety of online resources, e-learning programmes, professional development tools and information about Macmillan's latest learning and development opportunities. Learn Zone is open to Macmillan professionals, other healthcare professionals and members of the public. We hope you've enjoyed reading this update from Macmillan GP Advisers. Please feel free to send us your comments by responding to Macmillan_primary_care@macmillan.org.uk
Dr Steven Beaven
Want to know more about who we are and what we do? Visit www.macmillan.org.uk/goodday today and see our latest awareness campaign to help us reach and support even more people affected by cancer.
Around 25 patients per 1,000 on your list are living with cancer – do you know who they are?
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