Diagnosing cancer earlier – challenges from a primary care perspective
In this blog, Dr Anthony Cunliffe discusses the challenges around early diagnosis of cancer and the essential role primary care givers play in ensuring people are diagnosed with cancer as early as possible.
The route to a cancer diagnosis can be complex, from identification of cancers through the National screening programmes, routine and urgent referrals from Primary Care or diagnosis in secondary care; either as an emergency in A+E or being spotted in appointments for routine concerns. However, in the UK, most people who are diagnosed with cancer, first present with their symptoms to Primary Care and so Health Care professionals working in Primary Care have an essential role in ensuring people are diagnosed with cancer as early as possible.
Most GPs will see multiple patients every day with symptoms that, in most cases, will be caused by a benign condition but that could represent an underlying cancer; yet a full time GP will, on average, only diagnose about 6-8 new cancers each year. This leaves Primary Care clinicians with the challenging job of identifying the people who do need urgent investigations, whilst trying not to send patients for unnecessary tests which can cause unwarranted worry and excess strain on the healthcare system.
Urgent suspected cancer pathways
Cancer can present in a myriad of different ways, sometimes with typical symptoms that would always raise concern but, more often, with non-specific or ‘vague’ symptoms that in most cases are caused by much less concerning diagnoses. But a GP has to be alert to when it could potentially be a flag that something more serious is going on.
In the UK, we have Urgent Suspected Cancer (USC) pathways in place which a Primary Care Clinician can utilise if a patient’s symptoms meet a specific set of criteria. In these situations, once referred, the patient will be seen in a strict timed period for investigations to try and ensure that they are either diagnosed or reassured as early as possible. Also ensuring that if diagnosed, their treatment is started as soon as is appropriate. These pathways are in place across the UK but have some differences in their referral criteria and in the time by which a patient needs to be seen, investigated and treatment started.
For example, in England these is a new standard called the Faster Diagnosis Standard (FDS) meaning that from the point at which a patient is referred, the system has 28 days to either diagnose a cancer or reassure the patient and GP that all efforts have been made to rule out cancer based on the symptoms with which they have presented.
Regarding starting treatment, all the UK Nations have a target ensuring all patients need to have started treatment for cancer by 62 days after the date they were referred.
Testing in primary care
For people who don’t meet these criteria, but the GP has concerns about a possible cancer, they need to consider alternative ways to investigate the patients’ symptoms.These include tests they can do directly including blood or urine tests or diagnostic imaging such as XRAYs or scans including CT scans, ultrasound, or MRIs. NHSE have recently increased the focus on allowing GPs direct access to a wider range of diagnostic imaging tests as a way of driving forward the earlier diagnosis of cancer.
New clinics are being set up in England called Community Diagnostic Centres (CDCs) which will create greater access for Primary Care to be able to be able to more effectively investigate people, in some cases away from hospital sites.
Rapid diagnostic clinics
Another way to facilitate getting people diagnosed with cancer earlier that has been introduced in the last few years are clinics specifically set up to investigate people who are presenting with the ‘vaguer’ symptoms that have been discussed. In England these are referred to as Rapid Diagnostic Clinics (RDCs) and they provide GPs with a referral route for patients in whom they may suspect a cancer diagnosis but who don’t present with the clinical criteria for the Urgent Suspected `Cancer pathways.So, for patients seeing their GP with persistent symptoms such as weight loss, abdominal pain or fatigue for which a cause hasn’t been identified, the GP can refer to these clinics for the patients to be reviewed and investigated quickly so that a cause can be found and, if a cancer is diagnosed, they can be referred on the treatment pathway. These clinics are a useful way to get people diagnosed with cancer earlier but are also ways that other serious illnesses can be diagnosed or, just as importantly, reassurance can be given. Similar clinics are available, or being developed, in Scotland, Wales and Northern Ireland.
Diagnosing cancer early is key to improving outcomes and all 4 UK Nations have programmes in place to try and ensure as many people as possible are diagnosed with cancer at an early stage. Although expedited pathways in secondary care are vital, Primary Care remains key to identifying the right people who need to be tested and getting people investigated as early as possible. Although there are challenges, currently more people than ever are being referred onto urgent suspected cancer pathways by their GP, which hopefully will lead to improved outcomes.
This is how Macmillan can help you
At Macmillan we want to ensure everyone is having their needs met by high quality services from the point of diagnosis, and education is fundamental in delivering this.
We are here to support Primary Care Clinicians in not only diagnosing people with cancer as early as possible but also in enabling them to support people living with cancer as fully as possible. Free resources such as the Macmillan Learning Hub or Gateway C which is available to all Primary Care professionals in England and Wales, are essential sources of education.
There are also many resources to support GPs on our website, such as the early diagnosis toolkit, rapid referral guidelines and guidance on the Cancer Decision Support tool.
This is how Macmillan can help your patients
We also understand that waiting for tests and diagnosis can be a very stressful time for patients, and they may have a lot of questions. There is a lot of information you can signpost patients to around going for tests and waiting for results.
Our freephone support line is also a great place to signpost patients to, as they are open every day and are able to offer confidential support to patients and their loved ones.