GPs' Gut Instinct 'Could Help Earlier Cancer Diagnosis'

Anna Sayburn

October 25, 2019

LIVERPOOL - GPs should arrange more chest X-rays, encourage colorectal cancer screening and trust their gut instincts, if they want to catch cancers at an earlier stage, delegates at the Royal College of General Practitioners (RCGP) annual conference in Liverpool heard.

A recent audit comparing 5 year cancer survival rates put the UK bottom of seven comparable high income countries. The study identified lung and colorectal cancers as diseases that were diagnosed at a later stage in the UK than other countries, suggesting room for improvement.

Dispelling Radiation Concerns

RCGP Cancer Lead Dr Richard Roope, a GP in Southampton; Dr Rachel Marchant, an RCGP clinical support fellow for cancer, and Dr Mat Callister, a consultant respiratory physician in Leeds, led the session on early diagnosis. 

Dr Callister spoke about a project in Leeds that looked at the effects of lowering the threshold for referral for chest X-ray. He said high-risk patients with clear symptoms of lung cancer and low-risk patients without symptoms of cancer were usually dealt with appropriately, but challenged GPs to shift their referral criteria for patients with low- or medium-risk and potential symptoms of lung cancer, such as cough. 

He said X-rays are cheap ("There’s not much you can buy on the NHS for £20,") and that fears of exposing people to radiation were overblown. In fact, he said: "The amount of radiation [from a chest X-ray] is less than you get from a 2-week holiday in Cornwall."

Cornwall has naturally high levels of radon, giving it one of the highest areas of background radiation in the UK.

The Leeds project included a public information campaign to encourage people to "get a check" if they had a cough. The main thrust, however, was education for general practices to encourage them to make more chest X-ray referrals.

Three years after the programme began in 2011, he said, Leeds saw an 8% reduction in lung cancer deaths from 2014 to 2017, compared with 2000 to 2010, a reduction of about 42 deaths per year. He stressed that this could not be put down solely to the project, as it was not a controlled trial, but said the timing of the results suggested it had played a part.

Dr Callister also warned that chest X-rays have a 23% false negative rate for lung cancer, so GPs should consider further investigations or referrals for patients with negative results.

Bowel Cancer Screening Improvements

Dr Roope talked about improvements to the colorectal cancer screening programme, in which the faecal occult blood test (FOBT) is being replaced by the more specific faecal immunochemical test (FIT). As with the older test, it will be sent to people by post, but it is simpler, requiring only one sample, is more sensitive and more specific because it detects only human blood, so is less likely to result in a false positive, and is not subject to interference by diet or drugs. FIT also produces a numerical result, rather than a simple yes/no result, allowing thresholds to be set at different sensitivities for screening and diagnosis.

The test has already been adopted in Scotland and is being rolled out in England and Wales. There is no date for it to be adopted in Northern Ireland. 

Dr Roope said figures from Scotland showed FIT had increased the uptake of screening from 55.4% to 63.9%, and had led to more colorectal cancer investigations and more cancers being diagnosed. 

He said "GP endorsement" of the test by letter or text message could increase the numbers of people taking up the test by between 6% to 12%. He suggested GPs should follow up people who had not sent back their tests at least twice, to encourage them to do so. 

Summing up messages from the session, Dr Marchant said GPs should "trust their gut feeling" when faced with non-specific symptoms in a patient that they were worried about; be more ready to arrange X-rays but be aware that X-rays did not always pick up lung cancer; "beware lung cancer in non-smokers" and ensure they were "safety-netting" patients who had negative results or who did not seem to require cancer referral at first consultation. 

Arnold M, Rutherford MJ, Bardot A et al. Progress in cancer survival, mortality, and incidence in seven high-income countries 1995 to 2014: a population based study. The Lancet Oncology published online 11th September 2019.

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