National Cancer Diagnosis Audit shows good quality of care

Dr Richard Roope, FRCGP, RCGP and Cancer Research UK Clinical Champion for Cancer

The first results from the National Cancer Diagnosis Audit (NCDA) have recently been published in the BJGP1. In all 409 practices across 139 English CCGs took part, reviewing over 17,000 cancer cases diagnosed in 2014. The analysis showed there to be a very representative cross section of cancer types and demographics.

It has been recognised that UK cancer outcomes lag behind similar health systems, in terms of both 1- and 5-year survival rates.The reasons for this are several – our patients "not wanting to waste the GP's time", a lower "readiness for GPs to refer,3"and less access to diagnostics4. Further to this, the countries we are benchmarked against, have more doctors per 1,000 population5,spend a higher proportion of GDP on health care,and a higher proportion of their health spending on cancer care7.

Despite this, the early NCDA findings show there is much to celebrate. 78% of those, where it was recorded, were referred after 1 or 2 consultations, despite many cancers presenting with vague and non-localising symptoms. However, although the mean time from first presentation to referral was as low as 4 days, in 25% of cases this was over 27 days. 20% of all cases were felt to involve an unnecessary delay, many in relation to investigations.

In addition, there were still delays within the wider health system, reflecting the relative lack of resources, and what, many would now say, are outdated pathways. There are currently pilots, under the oversight of the ACE (accelerate, coordinate and evaluate) programme, trialling pathways that reflect the reality of Primary Care, in that we see patients with symptoms, not defined diagnoses. Too often, Primary Care Clinicians have had to choose between upper GI, lower GI, Urology and Gynaecology pathways, to make the first referral. What is needed in these scenarios is the option to refer to an "Abdominal Pain-ologist", or access to a one stop diagnostic clinic. The Oxford ACE pilot has been trialling a novel pathway to address this, with such patients accessing a CAP (chest, abdomen and pelvis) CT scan.

This NCDA reviewed 2014 cancer cases, which predated the NG12 NICE Guidance. The ensuing revision of 2-week referral pathways (in most CCG areas), and a cancer education programme of RCGP Faculty days, and the Cancer Research UK Facilitator programme are helping cancers to be diagnosed earlier. Data shows that, since 2014, the proportion of cancers diagnosed at an early stage increased from 50.6% in 2014 to 52.5% in the 12 months to 31.3.168. Primary Care has already shown that with heightened awareness, increased access to diagnostics, and support, early cancer diagnosis is increasing, and with further endeavour and resourcing, it could improve even further. The NCDA is due to run again in 2019, those who took part in this audit found it both stimulating and informative – I would personally recommend that you sign up at the earliest opportunity.

1Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit
Ruth Swann, Sean McPhail, Jana Witt, Brian Shand, Gary A Abel, Sara Hiom, Jem Rashbass, Georgios Lyratzopoulos, Greg Rubin, The National Cancer Diagnosis Audit Steering Group. Br J Gen Pract 18 December 2017; bjgp17X694169. DOI: 10.3399/bjgp17X694169
2scienceblog.cancerresearchuk.org/2015/08/05/cancer-survival-in-england-is-improving-but-still-lagging-behind-similar-countries/
3Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? British Journal of Cancer (2013) 108, 292–300. doi:10.1038/bjc.2012.542  
4who.int/gho/health_workforce/physicians_density/en/
5who.int/gho/health_workforce/physicians_density/en/
6oecd.org/els/health-systems/Health-at-a-Glance-Europe-2016-CHARTSET.pdf
7ihe.se/wp-content/uploads/2016/08/IHE-Report_2016_4.pdf
8ncin.org.uk/cancer_type_and_topic_specific_work/topic_specific_work/cancer_outcome_metrics

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