Viewpoint - Improving cancer survival by earlier diagnosis

Delayed diagnosis is a major contributor to poorer cancer survival rates in the UK. By Professor Mayur Lakhani.

Cancer is the leading cause of mortality in people under the age of 75 years in the UK.1 Each year, about 230,000 people in England will be diagnosed with cancer and about 125,000 will die from the disease.

With modern treatments, there are thousands of relatively healthy cancer survivors. There is much to be proud of, but improvement scan still be made.

Rare cancer, such as myeloma, can be difficult to diagnose (DU CANE MEDICAL IMAGING LTD / SCIENCE PHOTO LIBRARY)

Improving outcomes
Although cancer outcomes have been gradually improving since the 1990s, figures for 2006 showed the UK ranked ninth of 28 European nations for male cancer mortality and 22nd for female cancer mortality.

One of the main reasons for this worrying finding is late diagnosis.

It is now recognised that late presentation and delayed diagnosis are major contributors to poorer survival rates in the UK.

In 2007, the DoH published its Cancer Reform Strategy, an ambitious five-year plan to ensure world-class cancer services and outcomes by 2012 (see box).

Cancer Reform Strategy has established a National Awareness and Early Diagnosis Initiative (NAEDI). The National Patient Safety Agency (NPSA) has also established a programme of work in cancer, including a stream of early diagnosis, as part of the NAEDI.

Understanding delays
High quality research from Denmark tells us that delay can fall into one of three categories: patient, doctor (GP) or system.2

Initial analysis suggests that patient and primary care delays are the major reasons for the UK's poorer cancer survival rates. This understanding is crucial in devising strategies for improvement.

There is some evidence to suggest that barriers to access deter some patients from seeking help. When they do present, it is imperative that they experience high- quality and consistent primary care that will correctly evaluate symptoms, undertake relevant investigations and fast-track appropriate patients.

Crucial to this are effective doctor-patient communication, high evidence-based clinical standards, access to investigations and imaging, and co-ordination of care with tracking of results and appointments.

A rare or less common condition can be very difficult for GPs to diagnose because cardinal symptoms have low predictive values. A rare disease is defined as a condition that affects five or fewer people in every 10,000 population, but collectively, they represent 6-8 per cent of cancer cases in Europe.

About half of children and young people with cancer visit their GP with symptoms four times before being referred to a specialist. Cancer is normally not suspected until symptoms persist or pain worsens.

Cancer reform strategy
Six key areas of action in the care of cancer patients

  • Prevention
  • Diagnosing cancer earlier
  • Ensuring better treatment
  • Supporting survivors
  • Addressing inequalities
  • Delivering care in the most appropriate setting

Learning from incidents
Reporting of patient safety incidents can help significantly in understanding risks and developing solutions.

The NPSA has a national reporting and learning system for patient safety incidents. Thousands of reports are made, but most come from secondary care.

General practice, where there is perhaps the greatest potential to learn from missed diagnoses, only contributes to 0.4 per cent of all national reports.

GPs have their own system of reporting, the significant event audit (SEA). This is widely practised and is part of the quality and outcomes framework. Primary healthcare teams have to undertake a review of 12 events, including new cancer diagnoses, over three years.

SEA has many strengths. However, there are concerns that its promise has not been fulfilled because the quality of SEA varies, there is no systematic sharing of learning and the level of reporting to local and national systems is low.

There is a need for more standardisation and improvement in the practice of SEA.

Although GPs are in the spotlight over the question of late diagnosis, it is important to see them as part of the solution. Most GPs are not complacent and recognise that cancer is a leading cause for concern for the public and that prompt diagnosis is important to patients and doctors.3

Greater vigilance is needed, but it is also important to avoid routinely over-investigating or making inappropriate referrals.

Action is necessary
Greater vigilance is required by GPs to fast-track more appropriate patients, because it is well recognised that a significant proportion of patients who have cancer are diagnosed outside the two-week system, that is, in general clinics, A&E or acute wards.

Striving for even higher quality communication with patients is also crucial.

All providers must ask how good the practice system is at dealing with test results. Can it detect overdue and missing results? Can it highlight if serious pathology or significant results are expected?

It is necessary to stretch the limits of the two-week wait. If a GP strongly suspects a patient has cancer, I would suggest that a three-day fast-track would be appropriate.

Finally, the essential ingredients for improving cancer survival, as ever, include leadership, measurement and the engagement of front-line clinicians, working with patients and making the best use of information and technology.

Timing and context are vital in managing this matter aggressively. I would therefore urge all local health communities and leaders to create a process for addressing late diagnosis of cancer and to take concerted action, including the development of better service delivery models.

  • Professor Lakhani is a GP and former chairman of the RCGP. He chairs the NPSA early diagnosis cancer safety subcommittee. The views expressed here are his own

Further resources

References

1. DoH. Cancer Reform Strategy. HMSO, London, 2007. Available from www.dh.gov.uk

2. Hansen R P, Olesen F, Sorensen H T et al. Socioeconomic patient characteristics predict delay in cancer diagnosis. BMC Health Serv Res 2008; 8: 49.

3. RCGP. In Safer Hands. 2004.

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