NCRI 2015

Too many people diagnosed with late-stage cancer at A&E

Prof Kathy Pritchard-Jones - University College London, London, UK

We’ve published a one year follow-up of a cohort of patients whose cancer was first diagnosed after they presented to the Emergency Department in all of the A&E departments across our system. So it’s nearly 1,000 patients, they were diagnosed in the first nine months of 2013 and since that time we’ve been doing some work to follow-up what’s happened to them.

How did you collect this data?

We’re very concerned about late diagnosis of cancer, particularly in Northeast London. We therefore wanted to understand why patients were going to A&E rather than to their doctor when they had symptoms they were concerned about. We also wanted to understand what happened to those patients. We therefore worked with all eleven A&E departments across our system to get the frontline staff to tell us when a cancer patient first presented through the Emergency Department. We then worked with those teams to look at the patient’s story, both inside the hospital but also to write to their GP and get the route to diagnosis. What we found was we had 963 patients diagnosed across a nine month period; about a third of them had lung cancer, the next commonest diagnosis was colorectal cancer and after that cancer affecting the liver, pancreas and biliary tree.

The data we’re presenting now is to see what’s happened to those patients at least one year from diagnosis. The results are really quite shocking although unfortunately not unexpected. Overall a quarter of the patients are dead within two months of first presenting to A&E. If you’re aged over 65 only a quarter of the patients were still alive one year after first diagnosis. For the younger patients, the group under 65, just over half of them were alive one year from diagnosis.

What can we do about this?

This is a terrible problem and we really need to take action. We have previously presented at last year’s NCRI conference the routes to diagnosis that these patients had taken. So the vast majority of them were registered with a GP and many of them had been to see their GP about symptoms related to their cancer. In many cases the GP had actually tried to do the right thing, so they had either sent the patient on an urgent referral to the hospital or they had requested some tests. But because the system is too slow, even for an urgent referral, some of these patients had deteriorated whilst waiting for that appointment or test and had therefore taken themselves to the A&E Department.

So we’ve clearly identified that we need to bring primary care and hospitals closer together to improve access to diagnostics and clinical advice for GPs when they see a patient they’re worried about. Because many of these patients could have been managed and investigated in an outpatient setting if testing had been initiated earlier. However, what we found is that many of the patients coming to A&E had quite advanced disease at diagnosis, to the extent that the treating oncology team felt that they were only suitable for palliative treatment and they were beyond the stage at which curative treatment could be offered. This was the case in 80% of the patients in whom we knew about the treatment intent. So this is very late diagnosis and we’re only going to tackle that by raising public awareness of the signs and symptoms of cancer, encouraging patients to go and seek medical attention earlier and, most crucially, encouraging GPs to do more diagnostic testing earlier and make it a more efficient system for the local health economy.

What would be the ideal urgent referral time?

In the British NHS an urgent referral is counted as one where the patient must be seen within two weeks from first GP referral. However, that doesn’t mean they get their test within two weeks and in fact sometimes, perversely, going through a clinic can actually slow down the process. So what we need to see is when a GP recognises worrying symptoms they’re able to access a test and get the result and a clinical opinion within a much shorter space of time. Indeed, our new National Cancer Strategy nationally for England recommends that we switch towards a maximum of four weeks to get every patient with worrying symptoms tested, seen and with a definitive diagnosis about what’s wrong with them.