My plenary talk tomorrow will be about earlier and more expedited cancer diagnosis. It will argue for why we should have that, of course, but it will focus very much on the clinical and political leadership in the way that we try to get faster and more expedited cancer diagnosis.
What do we need to do to achieve this?
We know that the arrow points towards the first line in the healthcare system and that would be the general practice for many countries, at least for Denmark and for the UK. We need first of all citizens that are aware of cancer symptoms that feel that they can access the general practice and that the general practice is responsible and responsive for patients who are contacting for possible cancer symptoms. We also know that a lot of people have symptoms. We know that at least 15% of all adults have had an alarm symptom during the last year and they are not all going to contact the GP for that. So there’s a lot of filtering going on but the first thing we should ensure is that we have an accessible and responsive general practice.
The next thing is the support that we give the general practitioner in diagnosing cancer. In a lot of countries we have seen that general practitioners are gatekeepers, meaning that they should keep people away from the hospital until it’s necessary to refer to or admit to hospital. But that has also meant that in some countries, and that’s in fact especially Denmark and the UK, in some countries we see that the GPs are so good at gatekeeping that patients with relevant cancer symptoms are not adequately investigated for cancer. So what we see now in Denmark is that we introduced a better support for general practice in the investigation of cancer.
The primary way we are doing that is to use a free let strategy. That is acknowledging that cancer symptoms or patients presenting in general practice, they do not present with a sign, “I have a cancer symptom,” or “I have cancer.” They present in especially three different ways: one is that you might present with an alarm symptom, a symptom that is indicative of cancer. That could be rectal bleeding, lump in the breast or coughing blood up and then the GP should refer you for further investigation. We also know that about 3-8% of those with such a single alarm symptom, they will have cancer. So a good GP will refer, for example, ten or twenty for every cancer patient they diagnose but they all have this alarm symptom. We also know that about 50% of cancer patients, they present with other symptoms. They don’t present with an alarm symptom but they present with other symptoms and in this group we see that there’s a long waiting time until appropriate investigation for cancer. So what we have done in Denmark and what we have done in the UK is to introduce urgent referral for suspected cancer. But in Denmark we now try to focus on the last 50% of all the cancer patients presenting with other types of symptoms. That we’re doing with two initiatives; one initiative is the diagnostic centres. This is an outpatient facility where you have a lot of specialists heavily supported by imaging and lab medicine, where you can refer the patient if they have unspecific but serious symptoms. This is the type of patient that the GPs think, ‘I know this patient is sick but I don’t know exactly whether it’s a lung cancer or it’s a haematological cancer or what type of disease could this be?’ but there’s definitely something wrong. That’s about 10-20% of all cancer patients in Denmark and they are referred now to these diagnostic centres and within two days the GP will have a response from that diagnostic centre – is this something serious that we should continue with?
The third leg is what we call the no/yes clinics. This is actually quite simple because this is the old good diagnostic iterative process where the GPs say, “I know you have this trouble with your stomach, I have investigated you and I think the explanation is this and this but I also want to raise one concern. I don’t want to fail to spot if it is a cancer that you have. So to be sure that it is not a cancer I want, for example, an ultrasound of your abdomen; I want an endoscopy; I would like a CT scan of your lungs and so on.” So this is, in fact, a group of investigations where the GP is in charge, where the GP gets the answer and must take action on it. The patients are not admitted to hospital, you don’t have any history taking or patient records and so on, it’s a simple no/yes answer about was this a cancer, if not, well that’s good.
Is the quick turnaround a case of economics and resources?
Culture in Denmark, and that is why I’m focussing so much on clinical and political leadership, the culture in Denmark now is among a lot of the leading clinicians and politicians and administrators is that people shouldn’t wait for their diagnosis or to get the message that it fortunately wasn’t cancer. We have a clinically relevant waiting time. For example, if we have made a biopsy we would have to wait, for example, a week for the pathologist to give us an answer but there are no good reasons why we should wait, for example, three weeks or four weeks or even longer to get a relevant test for cancer. We know that people’s trust in the healthcare system is actually most dependent on the way that we are able to be responsive in the start of their cancer trajectory. If we are able to make a fast decision about whether this was cancer or not cancer and if it’s cancer we can get a quick treatment, then we know the patients and the public are very satisfied with the healthcare system. There are also a lot of indications that if we do it in a standardised and expedited way we don’t have that much waste and duplication of tests. A UK report recently pointed towards that, if every region in I think it was England, every region performed in the same way regarding early diagnosis, you could save I think it was £210 million per year if you had early diagnosis. So it’s actually a cost effective way to do it.
How do we improve the GP’s role in diagnosis?
First of all I question whether general practice is always accessible for people. What we see is that sometimes there’s a mismatch between the need for easy access to general practice and then the pressure we put on general practice to produce a lot of consultations and also the pressure we put on the population and the general practitioners to do early diagnosis. So sometimes there’s a mismatch between accessibility and the effectiveness of general practice. So we really have to support general practice in being accessible for the public and I think that general practice should think very much about how they could improve people’s access.
How might they do this?
One thing you could think about is having a system where when you get an appointment with your general practitioner you sometimes have to go through a secretary or a receptionist to get that appointment and she will ask you what is the problem and you won’t get an appointment if you’re not very clear about what is your problem. Sometimes when you have a cancer symptom you don’t know what the problem is, you’re just concerned and you want medical advice. So the access, just simple access, “I just need medical advice,” should perhaps sometimes be better. Then also the loop back from the GP to the patient. When you sit there in the consultation and you tell about, “Well, I have this and this problem and I’m perhaps a little concerned about that,” then your GP might introduce that, “I’m busy. I take responsibility of real serious symptoms and serious disease, don’t come bothering me with those not serious symptoms or very early symptoms. Go home and come back if it gets worse.” That’s the kind of signal to people that they might not come back. So it’s very complex and there are a lot of issues around accessibility of general practice.
