Cancer and Primary Care; Shifting the Narrative

Thomas Round.

Samuel Merriel.

In this issue we lead with a cancer theme. For over 10 years some of the BJGP ’s most impactful papers have focused on this area, including developing the evidence base for symptom-based approaches to cancer diagnosis. Many studies have used large primary care electronic record databases to develop positive predictive values (PPV) for cancer from different symptoms and clinical features, such as unexplained anaemia and thrombocytosis. This work of national and international importance has shaped cancer referral guidelines and the future direction of cancer detection via primary care.

While the lifetime risk of cancer for adults is 1 in 2, at a primary care level diagnoses are a relatively uncommon event. We might call this ‘finding the needle in haystack’. A full time GP might expect to see 8–9 new cancer cases a year, but potentially hundreds of consultations with symptoms and signs that could be due to cancer. For rarer cancers we might expect to see a new diagnosis every 5–10 years or longer. This is the key skill of GPs, using clinical acumen (and gut feeling) to decide when to investigate and when to refer.

We have seen year on year increases in the use of urgent suspected cancer (or 2 week wait) referral pathways, to well over 2 million per year.¹ Previously, 10 in 100 urgently referred patients were diagnosed with cancer (a PPV of 10%). This has dropped to around 7 in 100 (a PPV of 7%), but with record numbers of patients diagnosed following a GP referral, with improved outcomes.²

The most recent National Cancer Diagnosis Audit featured in this BJGP issue shows continued improvements in primary care diagnostic processes.³ The narrative is going in a positive direction. GPs and their teams are offering appointments and cancer referrals in record times, shifting the dial on earlier diagnosis. However, we are still a long way off the NHS Long Term Plan ambition for three-in-four cancers to be diagnosed at an early stage by 2028⁴ (currently around 57%).

We need more diagnostic capacity and to use existing capacity better, using evidence-based triage tests, such as the Faecal Immunochemical Test (FIT),⁵ to help direct patients to the most appropriate investigation. Rapid diagnostic centres (RDCs) are being rolled out across the country. The initial data is very promising, with around 7–12% of those referred diagnosed with cancer,⁶ and importantly many others are also diagnosed with serious health conditions.

The early RDC data begs the question: should we move away from urgent suspected referral pathways for a single cancer and more towards urgent disease pathways?

Issue highlights

Some good news is featured among this month’s BJGP research papers. Swann and colleagues compared the findings from 2014 and 2018 National Cancer Diagnosis Audits and show that cancer diagnostic processes in primary care are improving. Sheppard and colleagues developed and validated STRATIFY-AKI; a risk prediction model for acute kidney injury in primary care patients prescribed antihypertensive medication, which could help identify patients at high risk. Elizabeth Dapre’s no holds barred Life & Times article, ‘Are GLP-1 agonists the answer to our obesity epidemic?’, challenges the UK government to ‘step it up’ in tackling obesity rather than ‘sprinkling teaspoons of water onto an increasing blaze.’

Rather than gate keepers, could we be seen as gate openers to help facilitate rapid diagnostic testing in an evidence-based way, and continue to shift the narrative around cancer and primary care?