Hot Topics Blog
Julie was 60 and presented with some cramping low abdominal pains and bloating. She had lost some weight and feels tired. She was a smoker. I did a CXR and some bloods. The CXR was fine, but she had a slight anaemia and raised platelets. I was worried that she may have cancer and wanted to urgently refer her, but to where? I referred her to colorectal, they did a colonoscopy and then referred her to upper GI. Nothing found. I then referred her to gynae and it was at this point, now about 6 weeks in from my original referral, that she started coughing up blood…Quick change of direction, and to respiratory she went where her lung cancer was diagnosed on CT scan. For poor Julie this was an avoidable delay in diagnosis. Recent data from the National Cancer Diagnosis Audit published in BJGP2018;68:e63 shows that a third of all avoidable diagnostic delays are not due to clinician or patient, but system related factors. We have all had patients like Julie, who as referrals have become pathway driven have fallen through the gaps between these pathways.
Improving early diagnosis of cancer has been a Hot Topic ever since the NICE NG12 suspected cancer guidance of 2015, and it has become more so as it is a key priority in the NHS Longterm Plan (LTP) published in 2019. At the moment in the UK, 50% of cancers are diagnosed at stage 1 or 2. The LTP has set an ambitious target to raise that figure to 75% over the next decade. They estimate this will lead to 50,000 more people each year surviving their cancer for more than 5 years. For GPs in England, NHSE have made early cancer diagnosis a major new QI domain in QOF for2020/21.
The NICE NG12 guideline is arguably the national guideline that has had most impact on clinical care and referral, and it is enshrined in most regions’ local urgent cancer referral pathways. It has many positive aspects and hopefully it will have led to many more patients having an early diagnosis of cancer, but it also re-enforces a tick-box pathway model and there are two fundamental problems with this. Firstly, as every GP knows, sometimes patients just don’t tick all the boxes and yet significant clinical concern remains. Secondly, patients like Julie may tick boxes on several different pathways but it is not clear where to refer her. This problem is compounded by the fact that we no longer refer to a clinician who will take clinical responsibility for the case, but to a nameless diagnostic pathway of an individual body system. Once cancer in that particular ‘silo’ has been ruled out, the patient is sent back to you and the process has to restart. Patients, like Julie, frequently fall then between the gaps and this can lead to significant diagnostic delays.
The NHS Longterm Plan (LTP) plans that there will be many more Rapid Diagnostic Centres (RDCs, sometimes called Multidisciplinary Centres or MDCs) across the country so that patients with possible cancer can be assessed and diagnosed in a single 'one stop shop' visit. These are now being rolled out (and already in place in some areas) to refer patients to who have non-specific symptoms that are concerning but do not 'fit' with a specific diagnosis. The longer-term plan however is for ALL suspected cancer referrals with suspected cancer to go through this single point of access to prevent patients falling through the gaps between different pathways.
A recent pilot study , funded by CRUK and published in the BJGP January 2020 has just reported, looking at outcomes from a rapid diagnostic centre in Port Talbot, Wales. Patients were referred to the RDC if they did not fulfil criteria for a specific urgent cancer referral pathway, but had non-specific symptoms which their GP was worried may be due to cancer. They were matched with control patients not referred to the RDC. The RDC reduced mean time to diagnosis from 84 days in usual care to 6 days if a diagnosis was made in the RDC clinic, and if further investigations were needed from the initial RDC appointment the diagnostic delay was halved to 41 days.
These are very significant results and interestingly NICE have now announced that NG12 will not be updated, as we move towards a change in service delivery with RDCs at the centre of this (although outcomes from further pilot studies are awaited).
It’s too late for Julie, but hopefully over the next few years these changes will lead to fewer patients falling through the gaps and suffering avoidable delays in their cancer diagnosis. Ticking boxes may be helpful for to do lists and shopping, but for diagnosis of cancer we need a more subtle, flexible, thoughtful, clinical and above all holistic approach to diagnosis.
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