Increased focus on primary care’s role in early diagnosis
The upcoming QOF quality improvement (QI) module on cancer early diagnosis in England and the Single Cancer Pathway in Wales both recognise the pivotal role that GPs play in diagnosing cancer earlier. Alongside this, from 1 April in England, PCNs will be required to take reasonable steps to improve rates of early diagnosis for their registered populations, as set out in the new GP contract.
The UK lags behind comparable countries when it comes to cancer outcomes and for some types of cancer, more late stage disease is a key factor. With most cancers diagnosed via the GP rather than via screening in England,1 it makes sense to work closely with primary care, to bring the evidence around early diagnosis of cancer into practice and drive improvements for cancer patients.
But it isn’t always easy. The role of primary care is getting ever more demanding and cancer is complex, with patient presentation varying widely. It can be difficult to detect cancer early when patients present with non-specific symptoms or co-morbidities. The key thing is to be alert to the risk of cancer in your patients and to use guidelines and tools to support clinical decision making.
Investigate even when symptoms are non-specific
A study published in January this year found that patients with non-specific but concerning symptoms were more likely to be diagnosed at a later stage and via an emergency presentation, had more multiple pre-referral GP consultations and primary care-led diagnostics, and had higher odds of having longer primary care intervals than those with at least one alarm symptom.2
There is strong evidence to support investigation even when symptoms are non-specific.
A study involving more than 215,000 patients and their practices found that those practices with a high referral ratio and a high detection rate (16% of all analysed) had reduced cancer mortality, and their patients’ hazard of death was 4% lower compared with patients from practices with intermediate referral ratios and detection rates.3
The NICE NG12 cancer referral guideline is one of the best resources to help support timely recognition and referral of suspected cancer. The guideline is organised by cancer site and by symptoms – the latter reflecting the way patients present to GPs; many of which are non-specific and not indicative of one cancer site only.
It suggests primary care investigations that are needed, safety netting practices that can help, and when urgent referral may be warranted. Underpinning it all is acknowledgement that the GP’s clinical judgement is key, and a suspicion of cancer is a reason for referral.
Below are some considerations for GPs when managing patients who present with non-specific symptoms.
The risk threshold for urgent referrals and direct access investigations is low. NG12 recommends urgently referring patients at a 3% or more positive predictive value (PPV) threshold, and a lower threshold is recommended for children and young people, and for primary care tests, e.g. blood tests and X-rays.
Use a vague symptom pathway
In some areas, pathways for non-specific symptoms, also known as rapid diagnostic centres (RDCs) are being established to manage these patients. Contact your local Cancer Alliance or CCG in England, or health board in Wales, to find out what is available in your area.
Implement safety-netting practices
Practise robust safety netting by monitoring patients you don’t refer until signs and/or symptoms are explained or resolved. Use EMIS and SystmOne safety-netting templates where available.
Act on clinical suspicion
Guidance should not override a GP’s clinical judgement
Tools and support
For more information on the above and for support with decision making and navigation of the guidelines, there are different support tools available:
- Arrange free tailored support and training for your GP surgery with a CRUK Facilitator visit (if available in your area), visit cruk.org/Facilitators
- Electronic cancer decision support tools, such as QCancer and Risk Assessment Tools, are often integrated into GP software and may aid with decision-making visit cruk.org/decisionsupporttool
- Download our NG12 referral guidelines summaries including desk easels and posters at cruk.org/NICEsummary
- Complete the GatewayC one-hour module on improving the quality of referral (England only)
Information for GPs in England and Wales
GPs can download Cancer Research UK's Cancer Insight for GPs: Managing patients with non-specific signs or symptoms of cancer here. This is a practical guide on how to use NICE NG12 cancer referral guidelines and includes a poster summarising guidelines for suspected cancer by organ system.
This article was funded by Cancer Research UK for GP Connect
- National Cancer Registration and Analysis Service (NCRAS), Routes to Diagnosis (2016)
- Pearson C, Poirier V, Fitzgerald K, et al. Cross-sectional study using primary care and cancer registration data to investigate patients with cancer presenting with non-specific symptoms. BMJ Open 2020;10:e033008. doi: 10.1136/bmjopen-2019-033008
- Møller H, Gildea C, Meechan D, Rubin G, Round T, Vedsted P et al. Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study. BMJ 2015; 351: h5102