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In the extensive medicolegal practice dealing with allegations of delayed diagnosis of primary malignant and recurrent disease there is a recurring theme which I believe should be addressed both by NICE and all Consultants responsible for patients with cancer, sarcomas and reticulo-endothelial neoplasms.
There is overwhelming evidence that UK cancer survival rates are worse than Australia, Canada and Scandinavia (1) and the international authors of this paper have recently produced a very detailed European survival paper (2) covering over 10 million patients in 29 countries. The UK survival figures for stomach, colo/rectal, lung, breast, ovary, prostate and lymphoma are all significantly below the European mean figures. A specific paper (3) discusses disparities in breast cancer mortality trends in Europe. A Glasgow paper (4) reviews the incidence of late recurrence in breast, ovary and colonic cancers.
Patients whose primary tumours had been managed at hospital level by surgeons and clinical oncologists are being returned to the care of their General Practitioners at a much earlier date than has been the previous custom. This is because the workload in “follow-up” clinics is rising (fortunately because of more survivors) and because of staffing problems for medical teams because of EWTD regulations. Excellent specialist nurses can support Consultants but their training has not covered the necessary breadth of differential diagnosis skills in dealing with these patients.
In General Practice there are major problems with staffing. Less and less patients are seen by senior practitioners who have been involved in their care over a protracted time. Salaried, locum and part-time doctors can be faced with a patient who has had malignant disease in the past with vague symptoms, e.g. pelvic pain, weight loss or back ache. These are common problems and do not ostensibly require rapid investigation of hospital referral. The patient may not even remember the earlier tumour episode, especially with melanoma. Continuity of care and communication issues at General Practice level can often result in (a) the doctor not being aware of the past malignant history or (b) failure to associate the new symptoms with suspicion that recurrent disease is looming. Fifty eight per cent of recurrent breast cancer patients present first with skeletal metastases. Sadly, too often I see the comment “no red flags” in the notes of these patients when they eventually reach an appropriate Consultant.
I believe that every patient with a history of a malignant condition should have this fact marked in bold letters at the top of their computer-generated General Practitioner notes. Furthermore, the name of the primary treating Consultant should be itemized on this note. Cancer is a condition which can be cured predominantly by surgeons. However, too often nowadays surgical Consultants demit primary responsibility to oncologists for chemotherapy and radiotherapy and often leave long term follow-up of these patients to these teams.
Unfortunately medical oncologists are predominantly therapeutic advisors rather than diagnosticians and in the UK there are far too many cases where patients are not re-evaluated and re-staged at the earliest time of symptoms suspicious of recurrence.
Surgical practitioners are realistic people and know that survival rates for patients are proportional for the stage of tumour at initial diagnosis. The obverse side of these figures is that we expect recurrent disease and the patient’s best chance of successful treatment in these circumstances depends on the earliest possible recognition of the problem. Two week wait re-referral to the original treating Consultant is the best option in these circumstances.
In Europe, Australia and Canada greater emphasis is placed on follow-up by the initial treating Consultant. We can cure early recurrence of many tumours and the failure to provide “rapid reaction” to these suspicious symptoms is one of the reasons why UK results are worse than other countries.
Yours sincerely,
Mr. F.D. Skidmore OBE MA MD FRCS
Consultant Surgeon and Surgical Oncologist
References:
1. Coleman MP et al, Lancet, 2011, 377, 127
2. De Angelis R et al, Lancet Oncology, 2014, 15, 23-34.
3. Autier P et al, BMJ, 2010, 341, p335
4. Stearns AT et al, British Journal of Surgery, 2007, 94, 957.
UK Cancer Survival Rates
Dear Sir,
In the extensive medicolegal practice dealing with allegations of delayed diagnosis of primary malignant and recurrent disease there is a recurring theme which I believe should be addressed both by NICE and all Consultants responsible for patients with cancer, sarcomas and reticulo-endothelial neoplasms.
There is overwhelming evidence that UK cancer survival rates are worse than Australia, Canada and Scandinavia (1) and the international authors of this paper have recently produced a very detailed European survival paper (2) covering over 10 million patients in 29 countries. The UK survival figures for stomach, colo/rectal, lung, breast, ovary, prostate and lymphoma are all significantly below the European mean figures. A specific paper (3) discusses disparities in breast cancer mortality trends in Europe. A Glasgow paper (4) reviews the incidence of late recurrence in breast, ovary and colonic cancers.
Patients whose primary tumours had been managed at hospital level by surgeons and clinical oncologists are being returned to the care of their General Practitioners at a much earlier date than has been the previous custom. This is because the workload in “follow-up” clinics is rising (fortunately because of more survivors) and because of staffing problems for medical teams because of EWTD regulations. Excellent specialist nurses can support Consultants but their training has not covered the necessary breadth of differential diagnosis skills in dealing with these patients.
In General Practice there are major problems with staffing. Less and less patients are seen by senior practitioners who have been involved in their care over a protracted time. Salaried, locum and part-time doctors can be faced with a patient who has had malignant disease in the past with vague symptoms, e.g. pelvic pain, weight loss or back ache. These are common problems and do not ostensibly require rapid investigation of hospital referral. The patient may not even remember the earlier tumour episode, especially with melanoma. Continuity of care and communication issues at General Practice level can often result in (a) the doctor not being aware of the past malignant history or (b) failure to associate the new symptoms with suspicion that recurrent disease is looming. Fifty eight per cent of recurrent breast cancer patients present first with skeletal metastases. Sadly, too often I see the comment “no red flags” in the notes of these patients when they eventually reach an appropriate Consultant.
I believe that every patient with a history of a malignant condition should have this fact marked in bold letters at the top of their computer-generated General Practitioner notes. Furthermore, the name of the primary treating Consultant should be itemized on this note. Cancer is a condition which can be cured predominantly by surgeons. However, too often nowadays surgical Consultants demit primary responsibility to oncologists for chemotherapy and radiotherapy and often leave long term follow-up of these patients to these teams.
Unfortunately medical oncologists are predominantly therapeutic advisors rather than diagnosticians and in the UK there are far too many cases where patients are not re-evaluated and re-staged at the earliest time of symptoms suspicious of recurrence.
Surgical practitioners are realistic people and know that survival rates for patients are proportional for the stage of tumour at initial diagnosis. The obverse side of these figures is that we expect recurrent disease and the patient’s best chance of successful treatment in these circumstances depends on the earliest possible recognition of the problem. Two week wait re-referral to the original treating Consultant is the best option in these circumstances.
In Europe, Australia and Canada greater emphasis is placed on follow-up by the initial treating Consultant. We can cure early recurrence of many tumours and the failure to provide “rapid reaction” to these suspicious symptoms is one of the reasons why UK results are worse than other countries.
Yours sincerely,
Mr. F.D. Skidmore OBE MA MD FRCS
Consultant Surgeon and Surgical Oncologist
References:
1. Coleman MP et al, Lancet, 2011, 377, 127
2. De Angelis R et al, Lancet Oncology, 2014, 15, 23-34.
3. Autier P et al, BMJ, 2010, 341, p335
4. Stearns AT et al, British Journal of Surgery, 2007, 94, 957.
Competing interests: No competing interests