Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Breast cancer experience and wider implications for referrals policies
- S. Michael Crawford (13 August 2007)
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Two week rule too weak
- David A Gorard (14 August 2007)
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For Fools Rush In Where Angels Fear To Tread
- Dr. Herbert H. Nehrlich (14 August 2007)
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Fools who don't rush in when death is very preventable
- benjamin dean (16 August 2007)
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Disappointing leader
- Wilfrid Treasure (17 August 2007)
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inaccurate impression of British GPs
- GORDON FERGUSON (18 August 2007)
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S. Michael Crawford, Consultant Medical Oncologist Airedale General Hospital, Skipton Road, Steeton, Keighley, West Yorkshire. BD20 6TD
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The implications of the study by Potter et al of the fast track referral policy for suspected breast cancer [1] and the accompanying editorial by Jiwa and Saunders [2] raise issues for the National Health Service(NHS) that go beyond this disease. It is not the job of the general practitioner (GP) to diagnose breast cancer; this requires a multidisciplinary approach that involves clinical, imaging and pathological expertise. The GP is expected to allocate patients into one of three groups, those who can be reassured that no investigation is needed, those in whom cancer is suspected, these warrant urgent referral by the fast track, and an intermediate group where investigation is desirable but cancer is thought unlikely; these patients are referred by a standard track route. The existence of two queues itself defies the sensible observation that to manage multiple queues for a particular service is inefficient[3]. Potter et al list the criteria by which GPs are expected to identify patients for urgent attention. Their paper shows that the sensitivity and specificity of this discriminant in real clinical practice are low. We do not know how many patients were inappropriately reassured by their GPs before being found to qualify for referral but experience suggests that there will have been some. All this comes about because the capacity for specialist assessment of women with breast symptoms is inadequate; the real comparison is with those health systems that allow patients direct access to specialists whose workload is therefore unfiltered but which attain timely diagnoses. When resources are diverted to ensuring that fast track patients are seen within the target time at the expense of standard patients, including those with cancer, an illusion of success by the system is created. This is a manifestation of Goodhart’s Law which states that once a measure, such as the time to an urgent consultation, is made a target for the purpose of conducting policy it ceases to be a meaningful measure[4]. The wider relevance to the NHS is that as the trend towards many services being provided by very specialised teams in a small number of locations, access to them will be in the hands of gatekeepers who lack specialist expertise. It is important that the specificity and sensitivity of the discriminants they use are properly assessed. If the sensitivity is such that the number of patients denied access to a service is kept at negligible levels it is likely that the specificity will be low. This will demand that the specialised service has the capacity to accept patients who do not need the intervention offered. The numbers may well be such that rather than a regionally centralised facility, these services will more effectively be provided in dispersed locations. References 1] Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, et al. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007;335:288-90. 2] Jiwa M, Saunders C. Fast track referral for cancer BMJ 2007; 335: 267- 8. 3] NHS Modernisation Agency. 10 High Impact Changes for service improvement and delivery: a guide for NHS leaders London, 2004 4] Goodhart, CAE Monetary Relationships: A View from Threadneedle Street in: Papers in Monetary Economics Volume I, Reserve Bank of Australia, 1975 Competing interests: As a medical oncologist I practise as a tertiary referral specialist in a district general hospital |
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David A Gorard, Consultant Gastroenterologist Wycombe Hospital, High Wycombe, Bucks HP11 2TT
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It has been known for some time that patients with gastrointestinal cancers do not benefit from the 2 week rule [1-3]. This is partly due to the wide-ranging and non-specific clinical features of early gastrointestinal cancers, which overlap greatly with functional disorders. Since it is now evident that earlier diagnosis of breast cancer, a condition with a narrow cluster of clinical features, is also not helped by the 2 week rule [4], is it not time to abandon the rule for all suspected cancers? A further negative aspect of the current referral system is that patients with other serious but non malignant illnesses have to compete for attention in clinics – for example patients with liver cirrhosis may have a life expectancy similar to that of some malignancies yet do not have a mandatory fast-track referral mechanism. Jiwa and Saunders outline factors involved in the primary care consultation that may influence referral decisions [5]. These are qualitative, involve experienced judgement and do not readily fit into the trend to tick-box referrals. We must move away from the current binary system that oversimplifies referred patients as either having or not having suspected cancer. Instead, general practitioners should be allowed to accurately express their concerns about each patient’s clinical problem, without fear that the patient will enter a slow referral stream. . References 1. Flashman K, O'Leary DP, Senapati A, Thompson MR. The Department of Health's "two week standard" for bowel cancer: is it working? Gut. 2004; 53: 387-91. 2. Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ 2001 322: 1555-1556. 3. Spahos T, Hindmarsh A, Cameron E, Tighe MR, Igali L, Pearson D, et al. Endoscopy waiting times and impact of the two week wait scheme on diagnosis and outcome of upper gastrointestinal cancer. Postgrad Med J 2005; 81: 728-30. 4. Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, et al. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007; 335: 288-90. 5. Jiwa M, Saunders C. Fast track referral for cancer BMJ 2007; 335: 267- 8. Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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I would say to this "Hold your horses." Fast tracking cancer patients to a system of treatment known to have dismal chances of success ? I am sorry if I have to point out again that we have really lost the war on cancer. The alternative camp has taken over and people can be seen to abandon conventional treatment in droves. To me, from this admittedly limited viewpoint, it seems that cancer can be treated in two ways. Find the most far-fetched "natural" "cure" or, which is what I would prefer, do nothing. There is no question in my mind that the majority of cancer sufferers would do better doing nothing. Competing interests: None declared |
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benjamin dean, sho oxford
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I wonder how much solid scientific evidence Dr Nehrlich requires to refute his amazing statement 'There is no question in my mind that the majority of cancer sufferers would do better doing nothing'? Modern medicine has resulted in massively improved cancer related mortality and morbidity, to claim otherwise is utter nonsense. His kind of attitude does not merely border on the negligent, it is negligent. I have personally seen several very sad cases where patients, who had very early highly curable cancers, were persuaded to have alternative treatment and not the standard modern medical treatment. There are some very unscrupulous quacks out there who are very happy to profit from the uneducated and kill them in the process, it is hard to describe in words just how immoral this kind of practice is. Competing interests: None declared |
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Wilfrid Treasure, GP principal MMG, EH4 4PL
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I find this leader disappointing. There are what I believe are numerous weaknesses which I shall comment on in the order in which they appear. Paragraph 3 indicates that the complexity of the general practice consultation makes diagnosis of cancer difficult: the reference cited, however, deals not primarily with the consultation but with the process of research and incorporating research into clinical practice. Paragraph 6 is puzzling. “Bayes’s theorem demonstrates that the probability that a patient has cancer is affected by the prevalence”: I would say the probability IS the prevalence. And “the prevalence of cancer in a primary care population depends on the symptoms in question”: I don’t understand this sentence. “Research about the positive predictive value of signs and symptoms of the common cancers in primary care does exist”: that is true, but one difficulty in applying this data is that the values are not high enough to produce high enough posterior probabilities to enable the clinician to decide, say, on whether or not to fast track the patient. Paragraph 7 includes an undated wikipedia reference: the content of this is changeable and of debatable authority. The latest reference cited, apart from the accompanying research paper, is from 2005 which is surprisingly long ago. I look to a leader in a the BMJ to be accurate, analytical, up to date and constructive: this article does not quite achieve any of these adequately. Nicholas Summerton’s “Patient-centred diagnosis” (Radcliffe, 2007) is one example, perhaps amongst many, of, in some ways, more advanced thinking on this important topic. Competing interests: None declared |
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GORDON FERGUSON, GP partner Bewick Crescent Surgery, Newton Aycliffe DL5 5LH
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Dear Sir or Madam: The editorial by Jiwa & Saunders (BMJ 335:267-268) appears opposite the editor’s choice “How not to do things” – how apposite. They suggest – from Australia – that British GPs act on the basis of “personal experience, respected local opinion, and anecdotal evidence”. In my practice at least, we refer on the basis of published guidelines (e.g. BACS CancerCare Factfile information). They suggest that patients with altered bowel habit may not be investigated in GP. This is true in our practice, because we would refer such patients if the symptoms were new & had lasted the 6 weeks specified in the above guidelines, instead of using the extremely blunt instruments of doing an FBC, or doing FOBs which are a screening tool only, inappropriate for use in symptomatic patients. They are on stronger ground when discussing the fast-track referral of breast lumps, however. This is always an emotive topic for women. There is a straightforward symptom which women fully appreciate the potential significance of, and thus negotiation with the patient is likely to result in fast-track referral, almost whatever the age of the patient – and let us remember that those of us who have been in practice for some time can reel off a list of young(ish) patients lost to breast cancer. Perhaps part of the answer is as Jiwa & Saunders suggest is community education. Virtually all women are aware of the potentialIy important discovery of a breast lump. I find some evidence that such messages are filtering through to some patients with regard to the importance of altered bowel habit. This is an area worthy of further effort – for patients also, knowledge is power. As well as this, if the evidence on which we base our referral patterns is imperfect, then we need better evidence on predictive symptoms in primary care. Yours sincerely Gordon Ferguson GP partner Bewick Crescent Surgery Newton Aycliffe Co. Durham Competing interests: None declared |
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