According to yesterday’s headlines, GPs are ‘failing an estimated 32,000 cancer patients a year’ in England.
The reports follow a study we funded from a team of scientists based at UCL, The University of Cambridge, The University of Exeter and Public Health England. And while the researchers looked for the number of people diagnosed as an ‘emergency’ who had or hadn’t previously seen a GP, the findings didn’t show that GPs were mostly to blame for these diagnoses by ‘ignoring’ or ‘rejecting’ patients. Or that patients themselves had done anything wrong.
The study included 4647 patients who took part in the 2010 English Cancer Patient Experience Survey and were diagnosed with cancer as an emergency. Researchers then asked if patients had previously seen a GP about their symptoms. And if so, how many times.
The results show that around a third of these patients (34%) hadn’t seen their GP before being diagnosed as an emergency. These ‘emergency’ diagnoses are complicated, as we’ve written about before, and don’t just include people diagnosed after visiting A&E.
Understanding more about cancers diagnosed as an emergency is important, because these patients tend to have later stage disease, and therefore poorer outcomes.
GPs aren’t to blame for most emergency diagnoses
Most of yesterday’s headlines focused on just one of the findings of the study. It states that nearly a quarter of all patients (23%) who were diagnosed as an emergency had seen their GP 3 or more times prior to their diagnosis.
The headlines then suggest that these diagnoses were the fault of the GPs by either missing the patient’s symptoms, or turning them away.
But this is not what this study found. The researchers didn’t look at the reasons behind why these patients were diagnosed as an emergency, or what happened in each GP consultation. In fact the researchers believe the data suggest the opposite is the case. They say the findings don’t represent major failings by GPs because there are many factors at play, which makes diagnosing cancer in these cases incredibly difficult.
Of the 18 different types of cancer included in this study, patients with multiple myeloma (a cancer of the bone marrow) were most likely to have seen their GP 3 or more times. Myeloma symptoms can include persistent back pain, breathlessness and recurrent infections. These are common symptoms that a GP might see a lot and are usually caused by things other than cancer.
So Multiple visits to the GP might be expected, as the GP needs to perform a number of tests to work out what’s going on and rule out other causes.
And for cancers such as breast and endometrial cancer, which can be easier to spot due to more obvious ‘alarm’ symptoms, an emergency diagnosis could also be explained.
The researchers believe that emergency diagnoses in these cases (which represent a small group of patients with those cancers) could be due to them having rarer, less typical symptoms of those cancers.
A third of people diagnosed as an emergency hadn’t seen their GP
But the media coverage missed an equally important finding. This was the previously mentioned third of patients diagnosed as an emergency who hadn’t seen their GP.
Cancer is also a disease with many different types. And sadly many patients, even with common cancers, don’t have symptoms that give much away, until sometimes they become ill and need urgent help
– Dr Georgios Lyratzopoulos
Patients who hadn’t seen their GP prior to an emergency diagnosis were more likely to be male, older (≥85) and from poorer backgrounds. This might suggest that these groups are less likely to see their GP about symptoms. But other research has suggested that’s not the case.
Research that posed hypothetical reasons to people for why they may not visit their GP found that those from poorer backgrounds may indeed select more reasons for not going to a GP. But older people and men were actually less likely to back these hypothetical barriers.
So more work is needed to understand what’s going on here.
Dr Georgios Lyratzopoulos, who led the study in yesterday’s news agrees, saying more needs to be done to identify and tackles things that may prevent people from seeing their doctor.
He adds that the challenge is that some patients may not have had symptoms until just before their emergency diagnosis. And there’s a clue in the data that this may be the case for some patients.
The researchers found that those most likely to present as an emergency with no prior GP visits were patients with brain tumours. Sadly, brain tumours can often be diagnosed with little warning, accompanied with a sudden onset of symptoms, such as a seizure, so an emergency diagnosis in these cases is not unexpected.
Lyratzopoulos adds: “Cancer is also a disease with many different types. And sadly many patients, even with common cancers, don’t have symptoms that give much away, until sometimes they become ill and need urgent help.”
It’s also worth bearing in mind that this study was based on patients diagnosed with cancer in 2010, before much of the recent efforts to improve early diagnosis began, and before new NICE guidelines for GPs on cancer symptoms came out in 2015. So the picture may look different today, with the proportion of patients diagnosed as emergencies after GP consultations becoming even smaller.
That’s something the Royal College of GPs (RCGP) has been quick to point out.
“Those who visit their GP, in the majority of cases, will be diagnosed at a timely stage – 75% of patients found to have cancer are referred after only one or two GP consultations,” said Professor Helen Stokes-Lampard, chair of the RCGP, in a statement.
So while this study doesn’t give all the answers, it highlights the complexity of emergency cancer diagnoses, something we’ve written about before. Research like this can help understand the patterns of emergency diagnoses across different types of cancer and different demographics, so we can work out how to diagnose more people earlier.
“We need to continue to increase awareness of cancer signs and symptoms and help break down the barriers preventing people from seeing their GP earlier,” says Dr Julie Sharp, our head of health information.
And GPs need better access to the right tests and ways of referring patients they suspect may have cancer, which might take more than 1 visit.
Emma Shields is a health information officer at Cancer Research UK
Abel, G., Mendonca, et al. (2017). Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data. British Journal of General Practice. DOI: 10.3399/bjgp17X690869