Dr Anthony Cunliffe discusses barriers to cancer diagnosis and investigations imposed by the pandemic and how to overcome them
Read this article to learn more about:
- the role of the GP in recognising signs and symptoms suggestive of cancer
- the effect of the pandemic on patient access to consultations, screening services, and diagnostic tests
- effective investigation of concerning symptoms in virtual consultations.
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Primary care has an essential role to play in the earlier diagnosis of cancer—GPs are the first clinicians that most people will present to with concerns about cancer or with symptoms and signs that may represent an underlying cancer diagnosis.1 Although a full-time GP will only see an average of eight or nine new cancer diagnoses a year, they may see multiple patients whose symptoms raise the suspicion of cancer every day.2 This charges GPs with the difficult task of ensuring that they investigate, refer, and offer safety netting advice appropriately, but without causing unnecessary anxiety or ordering unnecessary tests. This is ordinarily a challenge for GPs, but over the last few months, further significant barriers imposed by the COVID-19 pandemic have made this even more difficult to get right.
The impacts of COVID-19 on the cancer pathway
A decrease in presentations and referrals
COVID-19 is one of the biggest crises that many GPs will have seen the health system face. Understandably, significant changes to working practices had to be made to manage the impact of the coronavirus and keep people safe while also trying to maintain services for other serious health conditions. The Government, along with NHS England and Public Health England, ran an effective campaign to keep people at home to minimise the infective risk and support the appropriate use of health services. This meant that primary care saw a significant reduction in people presenting, virtually or otherwise, with concerns regarding symptoms that they may have raised in normal times.3 It is very difficult to quantify the impact of this drop in presentations over the last few months; however, one proxy measure that can be used is the number of urgent suspected cancer referrals made. At its most impactful, there was an overall reduction in the number of urgent suspected cancer referrals of over 60%.4,5 This decline in presentations may lead to a substantial increase in the number of avoidable deaths from cancer.
Reduced access to diagnostic tests
Some of the main tools a GP will use in the initial stages of investigating an individual with symptoms that suggest an underlying diagnosis of cancer are direct-access diagnostics.6 These diagnostic tests include:
- blood tests
- urine and stool tests
- use of more complex imaging modalities.
Unfortunately, during the pandemic, many GPs saw a considerable reduction in access to these tests, and some were not available at all. There were additional barriers that made it more difficult for people to access diagnostic tests, such as a reduction in sites where tests were available. Without easy access to these vital investigations, GPs may have felt ‘disarmed’ in making decisions regarding how concerned they should be, and regarding the best course of action in managing an individual with concerns.
Continuation of treatment versus COVID-19 risk
There were, of course, additional changes necessitated by the pandemic that can be expected to have a further impact on cancer outcomes. For people diagnosed with cancer during or just before the pandemic, and who had existing treatment plans in place or were partway through treatment, the pandemic has resulted in delayed or altered treatment. The decision to postpone or change treatment for some patients was made to ensure that people receiving cancer treatment aren’t put at increased risk of contracting the virus or experiencing fatal consequences as a result of the increased vulnerability that comes with undergoing cancer treatment. Initial reports from China suggested that current or recent chemotherapy was associated with significant excess mortality from COVID-19.7 These data informed early changes in practice; however, updated data from the UK are much more reassuring—an analysis of over 1000 patients with cancer and COVID-19, matched with non-cancer COVID-19 controls, showed that (except in individuals with blood cancers) chemotherapy was not associated with a significantly increased risk of poor outcomes from COVID-19.8
Cancer screening programmes put on hold
National cancer screening programmes are one way in which the health system attempts to identify cancer early in individuals in the hope that they can then access successful treatment. Unfortunately, as a result of the COVID-19 pandemic, screening programmes for many cancer types were paused because of access or capacity issues further along the screening pathway.9 Although cancer screening programmes are now recommencing, there are significant backlogs that need to be addressed. In addition, there is much work to be done to encourage the public to re-engage in screening programmes, some of which already had very poor uptake before the pandemic.
Barriers to communicating with patients during the pandemic
Good-quality consultations are at the heart of primary care and are essential for strong doctor–patient relationships.10 Issues with communication can lead to problems in establishing accurate diagnoses, and so anything that interrupts clear communication between doctor and patient can disrupt the provision of care. The COVID-19 pandemic led to very significant changes in the way consultations are conducted in primary care, with the majority of contacts, at least in the early stages of the pandemic, taking place virtually.11 Obviously, this shift to remote consultations had challenging aspects for both patients and primary care healthcare professionals.
Some practices may have already been utilising telephone triage, but for many GPs and nurses, this was a new skill to develop. Without being able to rely on non-verbal clues, some physicians find it more difficult to feel confident that they are gathering the right information and communicating in a clear way. With a reduction in the number of physical examinations being carried out, GPs were having to make difficult decisions based on much less information than they would normally have. It is also important to recognise that, for some groups of patients, a virtual consultation is not appropriate in any form. These groups include:
- some elderly or frail patients
- people with learning difficulties
- people for whom English is not their first language
- people with sensory difficulties
- people who do not feel digitally confident.
As virtual consultations become more prominent in how primary care healthcare professionals communicate with patients, the systems put in place to support this should include measures to identify those who may find this way of communicating challenging and to provide safe alternatives.12
Safety netting has always been a crucial element when diagnosing cancer or investigating concerning symptoms in primary care.13 During the pandemic, it has become even more important for GPs to use robust processes to ensure that, in the face of reduced face-to-face consultations, changes to referral pathways, and inconsistent availability of diagnostic tests, patients are proactively followed up. Practices should put secure processes in place to achieve this, ideally using information technology systems, and again this relies on clear communication between the primary care team and patients.
Encouraging patients to seek care
Other issues faced during the pandemic have included the reluctance of the public to access the health service and the impact of Government and public health messaging. GP practice doors being ‘locked’ and confusing answerphone messages have led some members of the public to deduce that primary care is ‘closed’. This is obviously not the case—primary care has continued to function throughout the pandemic, albeit in a more virtual way. In addition, campaigns asking people to ‘stay at home, protect the NHS, save lives’ have understandably led to fewer people reaching out to their GP with concerns that they would previously have made an appointment to discuss. Although the demand on primary care is rising again, it is difficult to predict how long it will take for people to return, and what the impact will be on the later diagnosis of serious illness.
A poignant example is persistent cough or respiratory symptoms. In an attempt to diagnose lung cancer earlier, national campaigns (such as the ‘Be Clear On Cancer’ campaign) encourage people to present to their GP if they have been coughing for more than 3 weeks.14 In contrast, since the start of the pandemic, public messaging has asked people not to contact their GP if they have a cough! For medical professionals, understanding the difference between COVID-19 and potential lung cancer is extremely difficult, which makes the task exponentially more challenging for the general public. This raises the question of how we can now work together to ensure that clear messaging is issued on the potential signs and symptoms of lung cancer in an effort to minimise the longer-term impact of the pandemic on missed diagnoses.
Another element of public messaging that has had an impact on people presenting with health concerns is the fear that health settings are high-risk environments for contracting coronavirus.15 This has been a valid concern, and early on in the pandemic, before organisations had been able to set up COVID-secure environments, this was an important message to disseminate to the public. As time has passed, and hospitals and GP practices have developed hot and cold sites and COVID-safe processes, contracting COVID-19 in a healthcare setting has become much less of a risk; however, the information that most sites are now safe has not been communicated effectively. Anecdotally, many people would still rather not attend a healthcare setting because of concerns regarding infection risk, which is a significant problem if a medical professional feels that an examination or diagnostic test is vital. Again, this issue of adequate cascading and reach of communication is fundamental to enabling services to return to functioning effectively.
What does the future hold for cancer services?
Currently, most organisations are trying hard to get back to operating normally. However, there will obviously be some things that will remain different in comparison to the pre-pandemic situation. For example, virtual consultations will continue to be a much bigger part of daily clinical practice; training must be made available to support healthcare professionals to consult safely in this new way, as must the capability to convert to face-to-face consultations whenever necessary. It will also be necessary to ensure that this shift to virtual consultations does not drive inequality, and that those who are not digitally fluent for whatever reason, or for whom a virtual consultation is not appropriate, are effectively identified and given alternative routes of engagement.
In addition, clear messages must be developed and cascaded to the public to make it clear that primary care is very much ‘open’ and always has been. It is necessary to ensure that people understand that, just as before the pandemic, they should contact their GP with any health concerns they may have, and not delay for fear of wasting our time or risking exposure to COVID-19 by visiting a healthcare setting. Yes, the experience may be different from what they are used to, but patients must be reassured that healthcare professionals remain able to safely review and investigate any concerns regarding cancer, and that if an individual is subsequently diagnosed, they will still receive safe and appropriate treatment.
Finally, a word on resilience. The last few months have put an unprecedented strain on the health system and everyone working within it. It would be unrealistic not to acknowledge the toll that this will have taken on many, and that medical professionals need support to deal with the impact of working under immense stress. We all individually have a responsibility to our colleagues—just as the health system, along with support organisations, has a responsibility to employees of the NHS and care homes—to ensure that they receive any help they may need at this challenging time. In recognition of the impact that COVID-19 has had, and will continue to have, on people living with cancer and the workforce supporting them, Macmillan has developed a wealth of support and information to form a Coronavirus Hub.16 The Coronavirus Hub houses supporting information, guidance, tools, and resources to ensure that people living with cancer and their healthcare professionals are able to access up-to-date guidance and support.
Dr Anthony Cunliffe
Joint National Lead Macmillan GP Adviser, Macmillan GP Adviser London; Joint Clinical Chair, South East London Cancer Alliance
- Rubin G, Berendsen A, Crawford M et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16 (12): 31–72.
- Round T, Gildea C, Ashworth M, Møller H. Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study. Br J Gen Pract 2020; 70 (695): e389–e398.
- GP Online. Millions of patients ‘avoiding calls to GP’ during COVID-19 pandemic. gponline.com/millions-patients-avoiding-calls-gp-during-covid-19-pandemic/article/1681384 (accessed 13 October 2020).
- NHS England. Cancer waiting times. england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/ (accessed 13 October 2020).
- Mahase E. Covid-19: Urgent cancer referrals fall by 60%, showing ‘brutal’ impact of pandemic. BMJ 2020; 369: m2386.
- Maringe C, Spicer J, Morris M et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncol 2020; 21: 1023–1034.
- Yang K, Sheng Y, Huang C et al. Clinical characteristics, outcomes, and risk factors for mortality in patients with cancer and COVID-19 in Hubei, China: a multicentre, retrospective, cohort study. Lancet Oncol 2020; 21 (7): 904–913.
- Lee L, Cazier J, Starkey T et al. COVID-19 prevalence and mortality in patients with cancer and the effect of primary tumour subtype and patient demographics: a prospective cohort study. Lancet Oncol 2020; 21 (10): 1309–1316. doi.org/10.1016/S1470-2045(20)30442-3
- Hamilton W. Cancer diagnostic delay in the COVID-19 era: what happens next? Lancet Oncol 2020; 21 (8): 1000–1002. doi.org/10.1016/S1470-2045(20)30391-0
- Howie J, Heaney D, Maxwell M. Quality, core values and the general practice consultation: issues of definition, measurement and delivery. Family Practice 2004; 21 (4): 458–468.
- Greenhalgh T, Koh G, Car J. Covid-19: a remote assessment in primary care. BMJ 2020; 368: m1182.
- Healthwatch. The doctor will zoom you now: getting the most out of the virtual health and care experience. London: Healthwatch, 2020. Available at: www.healthwatch.co.uk/sites/healthwatch.co.uk/files/The_Dr_Will_Zoom_You_Now_-_Insights_Report.pdf
- Nuffield Department of Primary Care Health Sciences. Safety netting to improve early diagnosis in primary care. phc.ox.ac.uk/research/cancer-research-group/primary-care-cancer-diagnostics/safety-netting-to-improve-early-diagnosis-in-primary-care (accessed 13 October 2020).
- Public Health England. Be clear on cancer. campaignresources.phe.gov.uk/resources/campaigns/16-be-clear-on-cancer/overview (accessed 13 October 2020).
- Ng K. ‘Fear’ stopping people from seeking urgent treatment for non-coronavirus-related illnesses, doctors say. independent.co.uk/news/health/coronavirus-nhs-uk-doctors-urgent-treatment-heart-attack-a9460391.html (accessed 13 October 2020).
- Macmillan Cancer Support. Coronavirus. www.macmillan.org.uk/coronavirus (accessed 13 October 2020).