Should GPs Refer More Patients for Cancer Tests?
Should GPs Refer More Patients for Cancer Tests?
I'm David Kerr, professor of cancer medicine, from the University of Oxford. I want to talk about general practitioners (GPs) and early referral for cancer. I'm fond of GPs. The jewel in the crown of the United Kingdom's National Health Service is our primary care service populated by GPs. Imagine how hard it is for them to sift through the thousands of consultations they have every year to try and get the early diagnosis of cancer right. The average GP will see a handful of cases every year [that may require referral for cancer workup], and yet we see a bottleneck.
Some data suggest that patients in the UK present with more advanced disease than elsewhere in Europe. That is one of the reasons underpinning the fact that our cancer survival figures aren't as good.We have a body called the National Institute for Health and Care Excellence (NICE). Famed throughout the world as a national institute for cost-effectiveness, they provide clinical guidelines, and they have just released their latest set of guidelines for GPs for early referral. These have doubled in size in terms of the length of the guidelines and have taken the positive predictive value of the symptom clusters down to 3%. They used to be set at 5%, but they have taken it down to 3%.
For example, anyone age 40 or older with unexplained abdominal pain should be referred for a cancer workup. The question is, have they reduced the threshold too far? GPs would say, "Well, these guidelines are pretty useful but rather vague and open-ended. What we want is better access to diagnostic devices, ultrasonography, CT scans, and being able to work locally with clinicians for endoscopy, etc." I agree with them. To me it looks like the new guidelines are so wide that you could drive a double-decker bus through them. With a positive predictive value of only 3%, they are hardly worth anything at all. Cough, and you are sent off with a potential diagnosis of lung cancer.
It's difficult. I know that. We have to somehow improve the transition between primary and secondary care. I have no doubt whatsoever that it is logical that the earlier that we detect the cancer, the more we can do for the patient. But one wonders whether there aren't more tests that we could put rationally in the hands of GPs—if there is more responsibility we could give them rather than this very open set of guidelines which I'm not sure will lead to very much improvement.
I would be very interested in your ideas, especially from those of you who work in primary care and are faced with this extraordinarily difficult set of affairs. In the UK, the GPs are seen as gatekeepers. They are seen as filters, and only the relatively sick and the relatively symptomatic are referred to hospital systems, which is why we have been able to keep our healthcare costs down. It's open for debate.
I'm David Kerr, professor of cancer medicine, from the University of Oxford. I want to talk about general practitioners (GPs) and early referral for cancer. I'm fond of GPs. The jewel in the crown of the United Kingdom's National Health Service is our primary care service populated by GPs. Imagine how hard it is for them to sift through the thousands of consultations they have every year to try and get the early diagnosis of cancer right. The average GP will see a handful of cases every year [that may require referral for cancer workup], and yet we see a bottleneck.
Some data suggest that patients in the UK present with more advanced disease than elsewhere in Europe. That is one of the reasons underpinning the fact that our cancer survival figures aren't as good.We have a body called the National Institute for Health and Care Excellence (NICE). Famed throughout the world as a national institute for cost-effectiveness, they provide clinical guidelines, and they have just released their latest set of guidelines for GPs for early referral. These have doubled in size in terms of the length of the guidelines and have taken the positive predictive value of the symptom clusters down to 3%. They used to be set at 5%, but they have taken it down to 3%.
For example, anyone age 40 or older with unexplained abdominal pain should be referred for a cancer workup. The question is, have they reduced the threshold too far? GPs would say, "Well, these guidelines are pretty useful but rather vague and open-ended. What we want is better access to diagnostic devices, ultrasonography, CT scans, and being able to work locally with clinicians for endoscopy, etc." I agree with them. To me it looks like the new guidelines are so wide that you could drive a double-decker bus through them. With a positive predictive value of only 3%, they are hardly worth anything at all. Cough, and you are sent off with a potential diagnosis of lung cancer.
It's difficult. I know that. We have to somehow improve the transition between primary and secondary care. I have no doubt whatsoever that it is logical that the earlier that we detect the cancer, the more we can do for the patient. But one wonders whether there aren't more tests that we could put rationally in the hands of GPs—if there is more responsibility we could give them rather than this very open set of guidelines which I'm not sure will lead to very much improvement.
I would be very interested in your ideas, especially from those of you who work in primary care and are faced with this extraordinarily difficult set of affairs. In the UK, the GPs are seen as gatekeepers. They are seen as filters, and only the relatively sick and the relatively symptomatic are referred to hospital systems, which is why we have been able to keep our healthcare costs down. It's open for debate.
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