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COVID-19 and the potential cancer time bomb

Dr Kate Digby - 14 May, 2020

I am sure you will agree that in the last 2 months life has become somewhat strange. Within the space of a week, we redesigned our way of working, discovered IT skills we never knew we had, and began to work remotely as much as possible. Herculean amounts of planning and an unprecedented volume of email traffic followed to ensure that not only were we looking after our staff, but we were also looking after our patients as best we could while the Covid-19 pandemic unfolded. As the pandemic continues to unfold, the collateral damage is starting to emerge and at the forefront is the time bomb of missed and delayed cancer diagnoses.

For example, at the start of the pandemic, I had a call from a 50 year old chap who was feeling very itchy. He had been lucky enough to have squeezed in a holiday just before the lockdown began. We agreed his symptoms were most likely due to dry skin/dermatitis and I advised he buy some OTC emollients. The next call he made was to a colleague 2 weeks later, the problem persisted and the itching was driving him crazy. In addition to the emollient, an antihistamine was advised and a steroid cream prescribed. The 3rd call to the practice came 2 weeks after that….his skin looked yellow and his urine had turned brown…cholangiocarcinoma has subsequently been diagnosed mid-lockdown.

The Government’s clear message of ‘Stay Home, Protect the NHS, Save Lives,’ went down well. Our patients have been brilliant, doing as asked, and staying away from the surgery as much as possible. We have become more confident in telephone consulting, video consulting, and managing problems remotely. But there is a flip side to this new way of interacting with our patients…what about the un-done work? Just because there is a pandemic going on doesn’t mean that all other problems have decided to take a break. Cancer did not receive a memo at the start of the pandemic asking it to stop developing for a while whilst we address the Covid-19 issue. Yet urgent (2WW) referrals to secondary care for suspected cancer have dropped by 75% since the pandemic began. This is in part due to fewer people contacting their GP with new symptoms and partly due to a reluctance on the part of healthcare professionals to refer patients to secondary care for investigation, or reluctance from patients to visit their local hospitals for fear of catching the virus. Cancer Research UK (CRUK) estimate that this dramatic reduction in referrals will miss over 2,000 new and as yet undiagnosed cancers per week in England alone.

Couple this with the fact that screening services for bowel, breast, and cervical cancer have been paused during the pandemic. Over 200,000 people per week are not being screened, reducing the chances of early diagnosis whilst asymptomatic. The C-bomb is ticking and we will be counting the costs of the COVID pandemic on our early diagnosis and survival statistics for years to come.

So, what can we do? The NICE NG12 guideline & Scottish Referral Guidelines for Suspected Cancer both provided clear symptom-driven recommendations on when we should consider referral or investigation. Even in these strange times, it is worth remembering those recommendations to prompt early referral or at least a discussion of your concerns with your patients.

Your clinical IT system may support the use of a cancer Risk Assessment Tool such as Q-cancer. If it is not embedded into your clinical system, the Q-cancer tool is available for use online. It is also worth checking with your local departments to see if they are still able to process diagnostic tests such as a FIT tests or XR requests, which could help in your diagnostic quest.

Of course, we all know that in practice many patients present to us with vague, undifferentiated symptoms. If improving early diagnosis/referral rates for suspected cancer was tricky in conventional times, it is a massive challenge when working remotely. Finding that elusive needle in a haystack has never been more complicated.

There has been a lot of research published on how we can better manage these vague presentations (in non-pandemic times) and one consistent recommendation is the use of careful safety netting measures. At least this is something that we can still do during remote consultations.

Re-assessing patients if their symptoms do not resolve, documenting clearly the advice that you have given, and explaining the likely time to resolution of symptoms (and the need to call again if they persist) are key parts to safety netting. Trying to avoid the false reassurance of normal results (CXRs are normal in about 20% of lung cancers) and ‘seeing through’ the co-morbidities that may be masking the sinister symptoms are other considerations. I am a firm believer of the ‘3 strikes and you are in’ approach – if a patient presents with the same problem 3 times, it is time to ask someone else for an opinion.

CRUK Insight have several useful advisory publications on managing vague symptoms and safety netting. Most recently CRUK has published recommendations for safety netting during the Covid-19 pandemic as well as a useful resource for patients, both are worth a read.

The later diagnosis of cancer with its prognostic implications is going to affect our patients for years to come. If we can mitigate the impact and reduce the number of cases where we feel that opportunities for earlier diagnosis were missed, it would not only be good for our patients but would be great for us and our mental wellbeing. I firmly believe we are all doing our absolute best at the moment. We now need to consider how we can sustain this way of working going forwards whilst resuming some of our key diagnostic duties such as increasing the referral rates for suspected cancer.

Dr Kate Digby

NB Medical Education, Cancer Lead

GP in Gloucestershire

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