In a drive to improve England’s record on cancer survival, Jeremy Hunt recently announced that he will 'name and shame' low-referring GPs. It’s clear that improving early diagnosis of cancer could improve survival. But it’s not clear how shaming GPs into referring more patients will solve the problem of delayed diagnosis.
Our study published this week in the British Journal of Cancer sheds some light on this question for bowel cancer. We focused on bowel cancer because we know that survival is much better if it’s caught early. However, less than one in five patients are diagnosed at the earliest stage and a quarter of cases are not diagnosed until a patient reaches A&E with symptoms.
We looked at anonymised GP, hospital and cancer records on just under 1,000 colorectal cancer cases in north east London. We tracked back their GP and hospital use before their diagnosis to see what distinguished those referred by GPs from those diagnosed as emergencies.
Firstly, we wanted to know whether patients diagnosed as emergencies were even seeing a GP before they were diagnosed. In our study, nine out of 10 patients – both GP-referred and emergency cases – saw their GP in the year before diagnosis. However, we also saw that emergency patients tended to see the GP later and visit the GP less often those GP-referred patients.
Secondly, we wanted to know: were those seeing the GP coming with anything we might reasonably expect a GP to pick up as a possible cancer and refer for specialist investigation? We know that GPs will only see a small number of cancer cases in any one year, so it’s possible they are not used to spotting cases.
We found that patients diagnosed through different routes saw the GP with different symptoms: rectal bleeding was more common in GP-referred patients but emergency patients were more likely to consult with abdominal pain or constipation.
Rectal bleeding, a 'red flag' symptom for bowel cancer, is in NICE guidance for fast-track referrals. In contrast, abdominal pain or constipation are not. So, this evidence suggests that getting GPs to refer more patients using NICE referral criteria won’t tackle the problem of emergency presentations in those with abdominal pain or constipation. Instead, sensitising GPs to atypical presentations may be more helpful to tackle these cases.
The study also illustrates the value of linked, routinely collected data – i.e. information that GPs and hospitals have already recorded – to tell us more about the diagnostic process.
Without access to linked data we wouldn’t be able to conduct these studies.
As shown in this audio slideshow we saw individual patient pathways where:
- patients had little or no contact with health services before diagnosis: it is hard to see how encouraging GP referrals could affect these patients’ outcomes.
- patients repeatedly visited the GP before their diagnosis. This occurred in emergency and also in GP fast-track referrals: did GPs miss opportunities for an earlier referral, thus delaying diagnosis?
- patients had repeated outpatient and A&E visits as well as GP appointments: were patients referred more than once? Were there any missed opportunities for diagnosis in secondary care?
Rather than shaming GPs to refer more, I think we still need GPs and hospital doctors to look back at certain cancer cases to identify what happened and work out if anything could have been done differently. It’s not practical or productive to look back in all cases, or across all services.
Pathways constructed from linked data can tell us whether GPs, or health care professionals in other health services, are missing cancer symptoms. This study illustrates the potential for using linked data to direct which cases to investigate and which health care services to involve.
This article was also posted on the Inside Commissioning website.
Sheringham J (2014) ‘Improving cancer diagnosis: is there a better way than naming and shaming?’. Nuffield Trust comment, 30 July 2014. https://www.nuffieldtrust.org.uk/news-item/improving-cancer-diagnosis-is-there-a-better-way-than-naming-and-shaming