Margaret McCartney: Early cancer diagnosis: how low should we go?
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6442 (Published 30 November 2015) Cite this as: BMJ 2015;351:h6442
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Margaret McCartney
GP, Glasgow, and writer of distinction
Dear Margaret
I always look out for your “Comment” in the BMJ. Your latest one, on cancer screening, is another excellent reminder of how the NHS is being destroyed by recommendations that increase the public's demands of it from unsubstantiated propaganda and squanders money at the same time. I was horrified to see a leaflet on the waiting room wall of our GP’s Surgery that showed a man with a cough and a notice that said: “If you have had a cough for three weeks, pop in and see your GP. It could be cancer”. No doubt you are all too familiar with the leaflet.
Please continue your efforts.
Kind regards
Roger
(Roger H Armour
Retired consultant surgeon)
Competing interests: No competing interests
Margaret McCartney again makes all pertinent points regarding lowering the threshold for cancer referral. NICE now favours referring anyone with an estimated 3% chance of cancer diagnosis. Accordingly, NICE referral guidance for Breast cancer states:-
1.4.1 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
- aged 30 and over and have an unexplained breast lump with or without pain or
- aged 50 and over with any of the following symptoms in one nipple only:
. discharge
. retraction
. other changes of concern. [new 2015]
1.4.2 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
. with skin changes that suggest breast cancer or
. aged 30 and over with an unexplained lump in the axilla. [new 2015]
1.4.3 Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain. See also recommendations 1.16.2 and 1.16.3 for information about seeking specialist advice. [new 2015]
Yet Heather Goodare has heard " several anecdotes recently of younger women in Scotland being refused referral with symptoms that were clearly those of cancer ". Perhaps Heather could let NICE know of these "clear symptoms", of which they may be unaware, urgently. And also, perhaps she could offer to counsel the errant GPs ?
Referring everyone at the slightest concern seems the safest bet. Who would want to be a GP ?
Competing interests: No competing interests
It must be difficult for GPs to decide when to refer patients, but the situation could be improved for women at risk of breast cancer. The harms of screening are well known, but it seems that some women under 50 have difficulty in being referred on to specialists: I have heard several anecdotes recently of younger women in Scotland being refused referral with symptoms that were clearly those of cancer. Do GPs need more training? Or should referral guidelines be revised? Otherwise lives may be lost.
Competing interests: No competing interests
Margaret’s concern about how low in the criteria of screening one should go for early diagnosis is important. Not sure how CEO of CRUK takes a cut off 75% take up for cancer screening? There was reason for Margaret’s rise in blood pressure level! If Harpal Kumar had included cancer with all non-communicable diseases it would be more convincing! As per WHO recommendation of likely successful cancer control, it is synchronized with advocacy for non-communicable diseases and other cancer-related problems. In India, the National cancer control programme (NCCP) is now merged with NCDS -- National Programme for prevention and control of cancer, diabetes, cardiovascular diseases & stroke (NPCDCS).
Such recommendations of 75% take up of GP patients of cancer screening would be region dependent. If high income countries can take up higher screen positives – they have other problems of harms related to over-investigating those results into over-diagnosis. Of course some health education of current evidence is needed for GPs especially in the Indian context and maybe other regions too. In such a case, for a high income country, a small or low incidence disease is also concerning and actions for control are needed. The scenarios for low and middle income countries if there are more screen positives with a low strategy, there are no resources and facilities for diagnosis and treatment. The strategies should be evidence based and the level should depend on facilities and resources. Questions have recently arisen such as Is doing research as important as treating your patients (BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6329 (Published 27 November 2015) Cite this as: BMJ 2015;351:h6329). In order to understand the current evidence in clinical research, GPs if they do not undertake research should at least understand research and update themselves for evidence on cancer screening strategies. Leaving the percent of referrals out of the total GP load, there is definite need for knowledge at the GP level to inform patients about the harms and benefits on low and high strategies of screening adoptable for early cancer diagnosis.
Satyanarayana Labani, Scientist G
Smita Asthana Scientist D
Divisiion of Epidemiology & Biostatistics
Institute of Cytology & Preventive Oncology (ICMR)
Dept of Health Research (MOHFW)
Noida, India
Competing interests: No competing interests
Imperative patient informed consent
Charities have direct economic benefits by arbitrarily exaggerating slogans like "early cancer diagnosis", "early detection", "reduced mortality", "lives saved", "healthy prevention", etc. [1]
Someone should inform NICE counsellors that "cancer screening has never been shown to save lives". [2]
References
[1] http://www.bmj.com/content/345/bmj.e5132/rr
[2] BMJ 2016;352:h6080
http://www.bmj.com/content/352/bmj.h6080
Competing interests: No competing interests