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GP is suspended after retirement for failing to refer woman with symptoms of cancer

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1534 (Published 22 June 2022) Cite this as: BMJ 2022;377:o1534

Rapid Response:

Be aware of the limitations of the cancer fast track referrals in improving outcomes

Dear Editors

While not disputing the determination of the MPTS hearing Dr Jain's case, readers should be made aware of the following facts:

1. The "current cancer referral policy in the UK—whereby patients with a given set of symptoms are seen within two weeks—results in more patients who have cancer being seen on routine waiting lists than on the fast track list. This means diagnosis is delayed even further." and " Introduction of the two week standard clinics has not improved the outcomes for patients in some of the commonest cancers." (ref 1)

2. "among patients who were diagnosed following a GP referral, the use of fast-track referral varies substantially between patients with different cancers and sociodemographic characteristics. In particular, cancers with nonspecific symptoms and low-risk patients are less likely to have a fast-track referral. " (ref 2). This of course does not absolve the significance of Patient A's high risk of cancers having Lynch Syndrome previously diagnosed.

3. "UK public awareness campaigns in 2011, and revision of the NICE GP referral guidelines in 2015, have substantially increased referrals to fast track clinics. These referrals are overwhelming hospital resources without producing the expected increases in survival. The policies did not take into account the high prevalence of bowel symptoms in the absence of underlying cancer, and failed to ensure that only those with persistently higher risk symptoms and signs were fast tracked for urgent investigation in hospital." (ref 3)

4. "Lynch syndrome is the hereditary predisposition to several cancers caused by pathogenic variants in the germline of certain DNA mismatch repair (MMR) genes: MSH2 (and EpCAM), MLH1, MSH6 and PMS2 [1]. The greatest risks are for colorectal cancer and endometrial cancer, but other organs are also at increased risk for cancer at earlier than expected ages [2]. Surveillance colonoscopy every 1–3 years and timely gynecological surgery can significantly decrease cancer mortality in patients with Lynch syndrome. Managing cancer risk in other organs is more controversial, and a variety of management regimens have been suggested over time by different expert panels.".
"Gastric cancer in Lynch syndrome has been a controversial risk problem for a variety of reasons.". "The problem here is that the reported incidence of gastric cancer in Lynch syndrome ranges from 6 to 13% [4], but there may be changes in incidence over the last 100 years, and there are certainly different incidences in geographical locations or ethnic groups that have a higher background incidence of this disease "

It is therefore not certain that early detection of stomach cancer related to Lynch syndrome would result in improved survival in Patient A. Nevertheless Dr Jain is sanctioned for not following a well-publicised guideline.

References:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1941881/
2. https://www.nature.com/articles/bjc2017381
3. https://www.bmj.com/content/371/bmj.m3273
4. https://link.springer.com/content/pdf/10.1007/s10689-021-00235-3.pdf

Competing interests: No competing interests

23 June 2022
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia