Improving cancer diagnosis and earlier detection

Purpose and context

Cancer treatment and prognosis continue to evolve rapidly. The GPST reform programme has a responsibility to train the future GP workforce to be able to continue supporting patients through referral, investigation, diagnosis and treatment as the patient’s trusted physician.

Currently only 54 per cent of cancers are diagnosed in the early stages (stages one and two). This matters because early diagnosis relates to better outcomes for patients. The NHS in England has set an aim to diagnose 75 per cent of cancers in the early stages by 2028. Much of this improvement will come from developments in evidence-based screening, along with timely access to investigations and treatments.

However, there remains a case for improvements in cancer diagnosis to be part of the GPST reform programme in order to increase GP diagnostic ability and improve understanding of the pros and cons of screening, genetic screening and risk assessment.

Restrictions and fears during the early waves of the COVID-19 pandemic delayed patient presentations, reduced screening participation and delayed access to diagnostic investigations and treatment. There is an ongoing backlogdue to this disruption that is being tackled at all levels within the NHS.

We heard...

GP trainees and educators highlighted that delays in diagnosis often occur after investigations are requested or referrals made. The two-week wait referral threshold is set to detect symptoms where there is a minimum three per cent risk of a cancer diagnosis. While no system or clinician is perfect, GPs believe that appropriate referrals are made if symptoms fit those referral requirements.

Clinicians are very aware that early presentations are typically vague and often only clear in hindsight, without comparison to the many symptoms that are not due to cancer. All involved said they were clear that they wish to diagnose cancers early and value support to do so.

There was concern about over-investigation and over-diagnosis based on incidental findings, recognising the potential psychological and physical harms of both. On this basis, colleagues stated they would value help to better direct investigations and referrals. They noted that the average GP diagnoses six people with cancer per year but will be referring many times more than that.

Priorities and action

As part of the new NHS England, we want to work with the cancer and diagnostics teams to ensure that our reforms are aligned to developments and best enhance GP understanding to support the early stages of the cancer pathway.

We propose the following initiatives:

• education opportunities to engage with cancer diagnostic academics, including the GRAIL blood test;
• diagnostic support, including the use of risk assessment tools such as QCancer, GPST training packages such as those of Cancer Research, and technology solutions such as C the Signs;
• training in clinical decision-making to enhance diagnostic and referral skills;
• learning about the challenges and harms of overdiagnosis and overloaded referral pathways, and the impact on patients;
• innovative integrated training post (ITP) placements, such as those offered by C the Signs and Cancer Research.

We recognise that the diagnosis of cancer may be a life-limiting condition. We therefore recognise the ongoing need for all doctors in primary care to remain up to date in the area of palliative medicine.