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Cancer detection and primary care…revisited
Editorial
3 years ago, The Lancet Oncology called for general practitioners (GPs) in the UK to undertake more rigorous training and better continued education to identify the key symptoms of complex diseases such as cancer. As gatekeepers of the health-care system, it is crucial that GPs are able to triage patients to secondary care as soon as possible. Results of a survey released in May, 2012, by the UK Teenage Cancer Trust (TCT) show progress is still urgently needed. A third of all young cancer patients reported their GPs took no action despite presentation with common cancer symptoms and a quarter of patients had to visit the GP four or more times before their symptoms were taken seriously. Patients need to be able to trust their family doctor and be confident that they will be treated accurately and with sufficient priority. The TCT survey is disturbing—misdiagnoses were frequent and some patients were labelled as attention seekers. Rationally, Simon Davies, TCT chief executive, believes, “young people need GPs to take a ‘three strikes’ approach. If a young person presents with the same symptoms three times, GPs should automatically refer them for further investigation”. Although the TCT survey was small (collating the opinions of only 300 patients), the findings mirror those of Lyratzopoulos and colleagues published in The Lancet Oncology in April, 2012, that analysed more than 41 000 patients with 24 types of cancer. In that study, researchers found that nearly a quarter of patients needed three or more consultations with their GP before a referral was made and the probability of an increased number of consultations was higher among young patients. Additionally, the number of consultations varied by cancer type, further indicating a lack of recognition of classic cancer symptoms. So what can be done to restore trust? Usefully, Cancer Research UK and the Royal College of General Practitioners have launched an initiative to support GPs by putting together models of best practice, and by reviewing care pathways and thresholds for further investigation to ensure GPs have better access to diagnostics and secondary care. The initiative has also appointed a national GP clinical lead to coordinate efforts. Additionally, the Department of Health has announced a pilot project within GP practices of cancer-risk prediction www.thelancet.com/oncology Vol 13 June 2012
tools (QCancer risk calculators) developed by researchers at the University of Nottingham. These partnerships are good examples of engagement between policy makers and physicians with organisations that have a perceptive understanding of the patient viewpoint and of research realities and possibilities. Whether these initiatives will be successful in transforming the effectiveness of the GP and improving patient care will take time to assess, but it is unlikely that they will prove to be a broad panacea. It is more likely that even greater engagement between traditional and less traditional partners will be needed to develop innovative solutions. It is becoming increasingly clear, for example, that the UK health-care system is not designed to cope with multiple comorbidities—a common situation among patients with cancer—and in the future GPs will need to take a central and proactive role in coordinating patient care throughout their entire journey within the National Health Service. This will require rethinking of the current infrastructure, and might require adjustments to GPs’ case burdens to ensure sufficient time is available for more thorough consultations, especially in socioeconomically deprived areas. While the role of the GP in cancer diagnosis is undeniably important, it is essential not to forget interdependency on improved patient education, screening, secondary care and access to latest treatments, supportive and palliative care, and coordinated long-term follow-up. The GP, therefore, cannot be blamed entirely for cancer survival in the UK lagging behind other high-income countries. Improved understanding of the factors contributing to the differences between the UK’s cancer outcomes and those of other countries will provide important clues and solutions. 800 000 people visit a GP every day in the UK, but questions are increasingly being asked about the competency of those doctors that undermine patient trust. This is unfortunate given the UK Government is about to hand over considerably more responsibility to primary care physicians as part of the controversial healthcare reform bill. However, implementation of this bill could be a fresh start in a process of restoring trust and ensuring GPs have access to the best tools necessary to provide a first-class service and to guarantee all patients receive the best possible care. ■ The Lancet Oncology
SGO/Science Photo Library
Cancer detection and primary care…revisited
This online publication has been corrected. The corrected version first appeared at thelancet.com/oncology on June 29, 2012 For more on The Lancet Oncology’s call for GPs to receive better education see Leading Edge Lancet Oncol 2009; 10: 97 For more on variation in GP referral patterns for patients with cancer see Articles Lancet Oncol 2012; 13: 353–65 For more on the partnership between Cancer Research UK and the Royal College of General Practitioners see News Lancet Oncol 2012: 12: e232 For more on QCancer risk calculators see http://qcancer.org For more on the challenges of supporting patients with multiple morbidities see Articles Lancet 2012; published online May 10. DOI:10.1016/ S0140-6736(12)60240-2
559
3 years ago, The Lancet Oncology called for general practitioners (GPs) in the UK to undertake more rigorous training and better continued education to identify the key symptoms of complex diseases such as cancer. As gatekeepers of the health-care system, it is crucial that GPs are able to triage patients to secondary care as soon as possible. Results of a survey released in May, 2012, by the UK Teenage Cancer Trust (TCT) show progress is still urgently needed. A third of all young cancer patients reported their GPs took no action despite presentation with common cancer symptoms and a quarter of patients had to visit the GP four or more times before their symptoms were taken seriously. Patients need to be able to trust their family doctor and be confident that they will be treated accurately and with sufficient priority. The TCT survey is disturbing—misdiagnoses were frequent and some patients were labelled as attention seekers. Rationally, Simon Davies, TCT chief executive, believes, “young people need GPs to take a ‘three strikes’ approach. If a young person presents with the same symptoms three times, GPs should automatically refer them for further investigation”. Although the TCT survey was small (collating the opinions of only 300 patients), the findings mirror those of Lyratzopoulos and colleagues published in The Lancet Oncology in April, 2012, that analysed more than 41 000 patients with 24 types of cancer. In that study, researchers found that nearly a quarter of patients needed three or more consultations with their GP before a referral was made and the probability of an increased number of consultations was higher among young patients. Additionally, the number of consultations varied by cancer type, further indicating a lack of recognition of classic cancer symptoms. So what can be done to restore trust? Usefully, Cancer Research UK and the Royal College of General Practitioners have launched an initiative to support GPs by putting together models of best practice, and by reviewing care pathways and thresholds for further investigation to ensure GPs have better access to diagnostics and secondary care. The initiative has also appointed a national GP clinical lead to coordinate efforts. Additionally, the Department of Health has announced a pilot project within GP practices of cancer-risk prediction www.thelancet.com/oncology Vol 13 June 2012
tools (QCancer risk calculators) developed by researchers at the University of Nottingham. These partnerships are good examples of engagement between policy makers and physicians with organisations that have a perceptive understanding of the patient viewpoint and of research realities and possibilities. Whether these initiatives will be successful in transforming the effectiveness of the GP and improving patient care will take time to assess, but it is unlikely that they will prove to be a broad panacea. It is more likely that even greater engagement between traditional and less traditional partners will be needed to develop innovative solutions. It is becoming increasingly clear, for example, that the UK health-care system is not designed to cope with multiple comorbidities—a common situation among patients with cancer—and in the future GPs will need to take a central and proactive role in coordinating patient care throughout their entire journey within the National Health Service. This will require rethinking of the current infrastructure, and might require adjustments to GPs’ case burdens to ensure sufficient time is available for more thorough consultations, especially in socioeconomically deprived areas. While the role of the GP in cancer diagnosis is undeniably important, it is essential not to forget interdependency on improved patient education, screening, secondary care and access to latest treatments, supportive and palliative care, and coordinated long-term follow-up. The GP, therefore, cannot be blamed entirely for cancer survival in the UK lagging behind other high-income countries. Improved understanding of the factors contributing to the differences between the UK’s cancer outcomes and those of other countries will provide important clues and solutions. 800 000 people visit a GP every day in the UK, but questions are increasingly being asked about the competency of those doctors that undermine patient trust. This is unfortunate given the UK Government is about to hand over considerably more responsibility to primary care physicians as part of the controversial healthcare reform bill. However, implementation of this bill could be a fresh start in a process of restoring trust and ensuring GPs have access to the best tools necessary to provide a first-class service and to guarantee all patients receive the best possible care. ■ The Lancet Oncology
SGO/Science Photo Library
Cancer detection and primary care…revisited
This online publication has been corrected. The corrected version first appeared at thelancet.com/oncology on June 29, 2012 For more on The Lancet Oncology’s call for GPs to receive better education see Leading Edge Lancet Oncol 2009; 10: 97 For more on variation in GP referral patterns for patients with cancer see Articles Lancet Oncol 2012; 13: 353–65 For more on the partnership between Cancer Research UK and the Royal College of General Practitioners see News Lancet Oncol 2012: 12: e232 For more on QCancer risk calculators see http://qcancer.org For more on the challenges of supporting patients with multiple morbidities see Articles Lancet 2012; published online May 10. DOI:10.1016/ S0140-6736(12)60240-2
559