It is too early to say exactly how cancer outcomes are going to be affected by COVID, but what we do know is there was a dramatic reduction in urgent referrals for suspected cancer during the early phase of COVID, and referral numbers have been slow to recover. Although we are close to (but not back to) usual referral numbers for suspected cancer, it is important for us to be aware that data analysed by Cancer Research UK shows referrals for suspected lung cancer were still only ~60% of usual by the end of September (as reported in a recent BMJ article - BMJ 2020;371:m3958). A recent BJGP study (BJGP 2020; 70 (692)) shows that cough and breathlessness are now the commonest presenting features of lung cancer. These symptoms could easily be put down to COVID so we need to remember, particularly in at risks groups, to think ‘could this actually be lung cancer?’ Kate wrote a blog in September on the tricky issue of differentiating between COVID and lung cancer which is well worth a read.
This was a common question that cropped up over the evening. It highlighted one of the many changes that had to be made during COVID to risk stratify people, as hospitals and diagnostic services had to make significant changes to normal cancer pathways (e.g. dramatic reduction in colonoscopies due to risk of COVID spread during procedures). Guidance was produced by both NHS England and Scotland on the use of FIT tests in symptomatic people during COVID. Cancer Research UK have an excellent web page dedicated to support for health professionals during COVID, which includes links to this guidance, as well as other useful information including the tricky area of diagnosis of lung cancer in the COVID era.
There are a number of cancer risk assessment tools now including the RAT, Q-cancer and the Macmillan cancer decision support tool (further detail on these can be found on the Cancer Research UK webpage on cancer decision support tools). A recent BJGP systematic review on decision support tools (BJGP 2019; 69 (689)) concluded that three studies showed improvements in decision making for cancer diagnosis, one study found a reduction in time to cancer diagnosis, and three studies demonstrated positive effects on secondary outcomes such as referral practice. Questions still remain around usability and acceptability, and the quality of coding will inevitably influence accuracy.
The evidence for RDCs is now compelling. These clinics/centres may be known under different names (e.g. Multidisciplinary Clinics/MDCs, vague symptom pathway, etc.). They do have slightly different models, but the principle they all share is to allow patients with vague and non-specific but potentially worrying symptoms, who do not fit traditional urgent cancer pathways to be referred urgently for further investigation. They pick up many of the difficult to diagnose cancers more promptly, which under current systems often have long times to diagnosis (e.g. lung cancer, upper GI cancers including pancreatic). Evidence from B J Cancer July 2020 evaluating the RDCs showed the strongest predictor for cancer was inevitably age, but importantly the only other strong predictor of cancer was GP clinical suspicion - this highlights increasing evidence confirming that GP ‘gut feeling’ is a crucial factor in cancer diagnosis and should not be ignored. One of NHS England’s ambitions in the Long Term Plan is to create RDCs across the country, so patients displaying symptoms that may be due to cancer can be assessed and diagnosed quickly. Plans and funding for the rollout of RDCs have been affected by the pandemic, but services continue to be set up, led by cancer alliances. The initial hope was that by 2024/25 RDCs would be in place across the country, but
these timelines may slip given the impact of COVID.
This is such a tricky area isn’t it and is very much where General Practice becomes an art, not a science. As many of you rightly pointed out in the evening when we presented a case, patient wishes and shared decisions should always be part of any consultation, especially when considering referrals for potentially invasive investigations. There is no right answer to this, and it will very much dependent on the individual patient, but a very good BJGP editorial from a couple of months ago (BJGP 2020; 70 (696) is well worth a read on this subject.
For those in England look at the Fingertips data from PHE. It only runs to data up to 2018/19, but can give you some benchmarking against both national figures, but also practices locally and within your CCG. In other areas of the UK, no such resource exists yet, but other sources may be available locally. In Scotland, information may be available at Board level and/or HSPC level. In Wales, some information is available from the Welsh Cancer Intelligence and Surveillance Unit (WCISU), though not at practice level.
Alternatively, you may consider undertaking an audit. The National Cancer Diagnosis Audit (NCDA) provides an evidence-based set of questions to review cancer assessment and referral pathways in primary care - click here for more information from CRUK but please note the page is currently being updated. A template is available to undertake this audit internally between national cycles. And don’t forget focussed internal practice audits can be really useful too. How about reviewing cases of lung cancer given the concerns around the impact of COVID? Or the number of people with confirmed cancer that presented as emergencies to A&E/ED or via acute hospital admissions and see if there were any delays that could have avoided?
It is definitely worth speaking to your colleagues within your PCN – many of whom will have tackled QI QOF work last year, your federation, or your CCG – where there may already be a designated QI lead or QI team. The BMJ published a short yet super article last year worth a read: ‘How to get started in quality improvement’. And for examples, case studies, and ‘starter’ tools then I would also recommend visiting the RCGP QI Ready page.
A run chart is a graph of variable data over time. For example, the number of 2ww referrals generated by your practice each week, or the percentage of patients who take up cervical screening each month. Run charts display how the data varies so that you can better understand your ‘normal’ pattern. This is important as you will need to know if improvements are genuine or if they are part of normal (or ‘common cause’) variation.
All the revised QOF information for 2020/21 can be found within this document, including the QI information. The reporting template is towards the bottom of the document in section 6.1.
Safety netting has never been more important than it is currently due to a number of factors. Our switch to predominantly remote consultations, patients not wanting to be referred to hospitals due to concerns over COVID, diagnostic tests not being available or patients being downgraded all mean the potential for them getting lost in the system. A literature review in BJGP 2019; 69 (678) highlighted a number of key components for us, notably communicating uncertainty with patients particularly around investigations - patients (and clinicians) can get falsely reassured by normal results. Given the concerns raised above about lung cancer ‘hiding’ in the COVID era it is important to be aware of systematic review evidence from BJGP 2019; 69 (689) that at best chest X-rays are only about 80% sensitive for lung cancer, so a normal CXR does not adequately rule lung cancer out. Cancer Research UK have an excellent webpage dedicated to supporting health professionals during COVID, including safety netting during the COVID recovery.
Dr Rob Walker and Dr Kate Digby from NB Medical, with thanks again to Jana Witt and the Cancer Research UK team and Dr Mike Jones for their help and input into this webinar.
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