Rethinking diagnostic delay in cancer: how difficult is the diagnosis?
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7400 (Published 10 December 2014) Cite this as: BMJ 2014;349:g7400
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The use of the number of relevant consultations in primary care prior to a cancer diagnosis is problematic.
Consultations can only be counted retrospectively and this could lead to an incorrect assumption about the index consultation. Following diagnosis of lung cancer an initial consultation, in a smoker, for a winter cough, could be counted as part of this number yet referral at that point would not have been appropriate. Having come back following, if indicated, a failure of antibiotics to resolve the problem, would the patient already have been regarded as having had two consultations?
It is also not clear that the authors differentiated between consultations arranged by the patient and follow-up arranged by the GP. In the patient I described, if I arranged a chest radiograph the next day and arranged a follow-up appointment two days later, I would have seen the patient three times but referred them promptly, if necessary. By contrast as few as two consultations for presentations which are uncommon and suggest cancer as the most likely diagnosis could suggest delay.
The diagnosis of cancer is a joint responsibility between primary and secondary care, and timely investigation in primary care is, in my rural part of the country, good practice. Any discussion of referral to hospital needs to also consider the harms of unnecessary referral both for patients and in financial cost. Surely it is for society to decide at what level of risk investigations of cancer should be funded and for individual patients to decide with their GP whether to accept, for example, the small risk of endoscopy to exclude a small cancer risk. In my view the increased public emphasis the NHS is placing on early diagnosis of cancer, desirable though that is, is ignoring the need for debate.
Competing interests: No competing interests
Lyratzopolous and colleagues succinct assessment of the complexities that often lie behind what is so often over-simplified as 'too late diagnosis' is a valuable challenge to equally simplistic punishment policies. We would like to add to their stratification by tumour type an additional dimension of specific populations who may harbour 'harder to suspect cancers'. We have previously drawn attention to the problems faced by patients, families and GPs to achieve timely diagnosis of cancer in children and young people (Fern LA, Birch R, Whelan J, Cooke M, Sutton S, Neal RD, et al. Why can't we improve the timeliness of cancer diagnosis in children, teenagers, and young adults? BMJ. 2013;347:f6493. Epub 2013/10/31). We would certainly echo their call prioritising research to reach sensible and indeed evidence-based solutions to avoid unnecessary diagnostic delay for cancers occurring in those groups in whom it is least expected.
Competing interests: No competing interests
Complexity in the aetiology of multiple consultations
We have argued that repeated pre-referral consultations have a range of underlying causes, beyond the clinical reasoning skills of individual doctors.(1) We therefore agree with Taylor that for some patients multiple pre-referral consultations will be generated by guideline-concordant expectant management or investigations.(2) Repeat consultations are nonetheless associated with appreciably prolonged intervals to referral, and efforts are needed to minimise their occurrence.(1) Additionally, for patients with low-risk symptoms (not mandating immediate referral) for whom primary care-led investigations are deemed necessary, shortening scheduling and reporting delays can accelerate the diagnostic process.(2) The difficulty of suspecting the diagnosis varies greatly by cancer.(1) We therefore agree with Taylor that particular diagnostic challenges exist for lung cancer, as also additionally documented by detailed clinical audit and patient symptom studies,(3,4,5). Multifaceted approaches needed to tackle the problem of multiple pre-referral consultations include the development of novel tests, clinical audit activity (possibly triggered by multiple consultations in patients subsequently diagnosed with cancer), and the design of swift and integrated diagnostic care services that bring down traditional primary/specialist care barriers. Focusing on shortening primary care intervals should not detract from the need to also shorten prolonged intervals to presentation due to psychosocial patient factors, or efforts to reduce avoidable delays that may occur after referral and within secondary care – system-wide approaches are required.(1) Minimising the proportion of patients subsequently diagnosed with cancer who experience multiple pre-referral consultations is unlikely to be a problem with ‘quick fixes tomorrow’; better appreciation of the complexity of underlying causes is needed in order to make progress.
Dr Georgios Lyratzopoulos, University of Cambridge
Professor Jane Wardle, University College London
Professor Greg Rubin, Durham University
1. Lyratzopoulos G, Wardle J, Rubin G. Rethinking diagnostic delay in cancer: how difficult is the diagnosis? BMJ. 2014;349:g7400. doi: 10.1136/bmj.g7400. http://www.ncbi.nlm.nih.gov/pubmed/25491791
2. Rubin GP, Saunders CL, Abel GA, Mc Phail S, Lyratzopoulos G, Neal RD (2015) Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: analysis of national primary care audit data. Br J Cancer E-pub ahead of print, 20 January 2015, doi:10.1038.bjc.2014.634 http://www.ncbi.nlm.nih.gov/pubmed/25602963
3. Mitchell ED, Rubin G, Macleod U. Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports. Br J Gen Pract. 2013;63(606):e37-46. http://www.ncbi.nlm.nih.gov/pubmed/23336459
4. Neal RD, Robbé IJ, Lewis M, Williamson I, Hanson J. The complexity and difficulty of diagnosing lung cancer: findings from a national primary-care study in Wales. Prim Health Care Res Dev. 2014 Dec 8:1-14. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/25482333
5. Birt L, Hall N, Emery J, Banks J, Mills K, Johnson M, Hamilton W, Walter FM. Responding to symptoms suggestive of lung cancer: a qualitative interview study. BMJ Open Respir Res. 2014 Dec 11;1(1):e000067. doi: 10.1136/bmjresp-2014-000067. http://www.ncbi.nlm.nih.gov/pubmed/25553249
Competing interests: No competing interests