Rapid Diagnosis Centres Catch Cancers With Vague Symptoms

Liam Davenport

January 16, 2020

Patients with vague and/or non-specific symptoms suspicious of cancer who do not qualify for urgent referral can have a decision on whether or not they have cancer in less than a week if they are referred to a rapid diagnosis centre (RDC), the results of a pilot project in Wales show.

A team from Swansea University and colleagues in the NHS followed 189 patients referred by their GP to an RDC that has been running since mid-2017.

They found that the wait for a diagnosis was just under 6 days for patients referred to the RDC versus more than 80 days for control patients treated on standard care pathways.

Crucially, the RDC became cost-effective compared with standard care once it started running at near-capacity.

The research was published by the British Journal of General Practice on January 13th.

'Beneficial for Patients and the NHS'

Lead author Dr Bernadette Sewell, from the Swansea Centre for Health Economics at Swansea University, said in a news release that their results show "that rapid diagnosis centres are beneficial for patients and the NHS.

"They cut waiting times, which means any treatment that people need can start earlier. The longer it takes to diagnose cancer, the worse the outcomes can be for patients and the more expensive it may be for the NHS to treat."

She added: "The key is to ensure that the centres run at least at 80% of capacity."

Dr Heather Wilkes, Rapid Diagnosis Centre project lead at Swansea Bay University Health Board, said that the service "has made a massive difference in trying to speedily investigate and care for some of the most difficult cases in our community".

"It is highly valued by patients and GPs alike and has been established as a permanent service following our evaluation."

Andy Glyde, is public affairs manager for Cancer Research UK in Wales, which funded the study.

He said the research is "exciting because it shows how new ways to diagnose cancer can benefit patients and be cost effective for the NHS…There now needs to be a decision about how this pilot can be integrated into normal practice, including linking up with the Single Cancer Pathway."

He added: "We know that diagnosing cancer at an early stage improves survival, so it is important that the Welsh Government and NHS Wales continue to improve the way we test and diagnose cancers in Wales.

"This needs to include ensuring we have the right number of specialists to run cancer tests."

Vague Symptoms

In 2017, the National Institute for Health and Care Excellence (NICE) revised its recognition and referral guidelines for suspected cancer in England to stipulate that patients with 'red flag' symptoms, conferring a cancer risk of more than 3%, should be referred to the urgent suspected cancer pathway.

However, around half of patients with cancer in general practice do not present with the required red flags, having instead vague and/or non-specific symptoms.

The result, the authors say, is that these patients have to "wait a median of 34 days longer to diagnosis compared with patients presenting with alarm symptoms".

Taking inspiration from a similar project in Denmark, the NHS created diagnostic centres in which patients with vague or non-specific symptoms could have fast access to multidisciplinary teams, all under one roof.

As reported by Medscape Medical News, a pilot scheme of 10 RDCs was announced by NHS England in 2018, in addition to which two centres were piloted in Wales.

The current analysis focuses on the RDC at Neath Port Talbot Hospital, near Swansea, which runs two half-day, five-patient clinics per week, with a team comprising a consultant physician, a radiologist, a clinical nurse specialist and a healthcare support worker.

GPs can refer adults with vague or non-specific symptoms that could be cancer but do not meet the criteria for red flags. The patients are then seen at the RDC within a week and leave with either a diagnosis and management plan, or appointments for further investigations.

Cost-effectiveness

To examine the cost-effectiveness of the RDC in its first year of operation versus standard clinical practice, the researchers used patient-level discrete-event simulation and decision analytic modelling to assess all adults referred to the RDC between June 2017 and May 2018.

In addition, they simulated a cohort of 1000 patients, outcome-matched to those in the RDC cohort, who were referred to the urgent suspected cancer pathway but then downgraded to the non-urgent pathway.

One hundred and eighty nine patients attended the RDC during the study period, of whom 54% were female. The mean age was 70 years. The majority presented with unexplained weight loss, pain, fatigue and shortness of breath.

A cancer diagnosis with referral to a specialist was given to 12% of the patients, while 16% had a non-cancer diagnosis, 36% had no serious pathology and were discharged to their GP and 36% had no diagnosis and continued with investigations.

The team calculated that the mean time to diagnosis was 5.9 days among RDC patients who had a cancer diagnosis, other diagnosis or were discharged. This compares with an average wait of 84.2 days for control patients.

For patients who required further investigations, the mean time to diagnosis was 40.8 days, falling to 33.9 days when the team removed patients needing specialised services with 3-month delays.

During the start-up phase of the RDC, it saw a mean number of 2.78 patients per clinic, and at this capacity was both more effective and more costly than standard care pathways, at an incremental cost-effectiveness ratio of £29,732.

The probability of being cost-effective, at a willingness-to-pay threshold of £20,000, was 48.5% during this phase.

Since July 2018, the RDC has been running at near or full capacity, seeing an average of 4.65 patients per clinic, and has been more effective but less costly than standard care, with a probability of being cost-effective at full capacity of 56.0%.

The team determined that the RDC becomes more cost-effective than standard care pathways when it sees an average of four patients per clinic, which equates to 80% capacity.

If the RDC ran at full capacity, with five patients at each clinic, it was calculated that £148,320 could be saved over standard care pathways, and there would be a gain of 9.2 quality-adjusted life years for every 1000 patients seen.

The researchers write: "Referral to rapid diagnosis services from primary care for patients with vague and/or non-specific symptoms suspicious of cancer addresses an important unmet need and provides value for money when run near or at full capacity.

"Furthermore, it reduces time to diagnosis and has the potential to improve patient outcomes."

Urging the creation of a dataset or registry that includes patient quality of life, they underline that the harmonisation of data and a consensus over controls "will be crucial in any comparisons".

The authors note that using the current study "as a template will enable further investigation as data mature".

The study was funded by Cancer Research UK.

No conflicts of interest declared.

Br J Gen Pract 2020 DOI: 10.3399/bjgp20X708077

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