Catching cancer early: what more can we do as GPs?

Summary

The earlier cancer is diagnosed, the better the chances of successful treatment. Early diagnosis leads to:

• fewer side effects
• faster recovery,
• fewer long-term physical and psychological complications.

In this blog, GP, Amelia Randle sets out a number of ways clinicians can develop their daily practice to improve cancer diagnosis at an early stage.

This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024.

Content

Initiatives to improve early diagnosis focus on education, pathway design, and access to tests. However, it's crucial to recognise the role of healthcare professionals in early cancer detection.

The NICE guideline for the recognition and referral of suspected cancer (NG12) outlines a protocol for patients who should be offered a referral to exclude cancer as a potential cause of their symptoms. But diagnosing cancer is challenging. There are hundreds of different types of cancer, and each tumour behaves uniquely. It is impossible to cover all presentations under a set NICE protocol.

In this article, I set out a number of ways clinicians can develop a daily practice to improve cancer diagnosis and achieve our ambition of diagnosing 75% of cancers at an early stage.

Catching cancer early

Opportunities for improving cancer diagnosis occur throughout the cancer timeline and begin before it even develops. For individuals with risk factors such as genetic predisposition and lifestyle choices, the potential for cancer development is heightened. Recognising these high-risk individuals and maintaining a lower threshold for suspecting and screening for cancer is a vital part of our patient care. Developing a non-judgmental approach to patients with poor lifestyle choices is essential to achieving this.[1]

Involving patients in questioning symptoms

As cancer progresses, it begins to manifest symptoms, presenting the first opportunity for clinical diagnosis. Diagnosing the tumour can be more challenging if it does not produce typical symptoms. One way to increase the chances of early cancer detection is to raise awareness among patients and encourage them to be more inquisitive in situations where the symptoms do not fit obvious diagnostic patterns. Fear of generating anxiety and increasing demand for overstretched services can be a barrier to this.

Our approach to the brief 10–15-minute window with patients is also crucial, as it often holds the key to the patient sharing the critical piece of the puzzle. Continuity is achievable, and we should work towards it for those who will benefit. However, we need to develop ways of getting to the bottom of the issue in a 10-15-minute consultation, even when we don't know the patient.

Building trust

Trust is the cornerstone of our profession. When patients trust us, they are more likely to share their symptoms and concerns more openly, which can facilitate early cancer detection. During the COVID-19 pandemic, we rapidly transitioned to remote access and telephone consultations without co-production. Although this was the right direction for primary care, it changed how patients perceive healthcare delivery.

This shift may have affected patient trust and their expectations for future care, including cancer detection. Understanding these changes is crucial for addressing the current challenges in early cancer detection. For patients to develop their full potential as co-producers of health, trusting relationships must be built on a new basis.[2]

Restoring trust is a collective responsibility. As healthcare professionals, we need to engage with our patients and show that we are interested and willing to help, regardless of the reason.

Deep listening is key

Studies have shown that clinicians wait as little as 20 seconds before redirecting patients' initial descriptions of their concerns[3], [4]. Once redirected, the descriptions are rarely completed. Focusing on listening and engaging with patients at the start of a consultation is rarely wasted time. This is more than just hearing; it is striving for deep listening.

Actively listening in a way that fosters connection is a skill that can make a significant difference in patient care. Providing an environment that enables the patient to divulge the crucial part of the diagnostic puzzle whether they realise its significance or not. The details often not divulged, resulting in the patient feeling unheard, need to be nurtured and encouraged in the therapeutic space.

Learning from missed opportunities

Around 1000 cases of cancer are diagnosed every day in the UK, which gives us a wealth of experience to learn from if we can be brave enough to do so. We must be open to learning from missed opportunities, which will inevitably exist in many cancer diagnoses. To make the most of these opportunities, we must develop a learning culture that involves a non-judgmental examination of the events leading up to the diagnosis that allows us to reflect, without a sense of shame or failure, on how we might have done things differently.

A diagnosis of cancer is a distressing event for everyone involved, which can be expressed in terms of criticism. This damages our ability to learn as we shy away from the discomfort. It’s much more challenging to look inwardly for a cause than to blame something outside our control. Having the courage to admit our doubts allows us to be flexible and open to new learning. [5]

Learning from patients and families

The gold standard would be to ask patients and families where they think the missed opportunities were and how they feel about their pathway to diagnosis. This would identify many learning opportunities and have a therapeutic effect, fostering collaboration between the clinician and the patient. Addressing the distress associated with the delayed diagnosis is crucial. Developing a culture of courageous practice that enables us to lean into the distress and encounter the consequences of our decisions, both as a patient and a clinician, would help us to fully engage as diagnosticians. 

Final thoughts

Developing the courage to put ourselves at risk by relating to patients in the hope of achieving meaningful outcomes is a critical factor in achieving an accurate diagnosis. Many systemic factors distract us from this approach, which we can overcome through conscious daily practice.

We all have a role in developing the psychologically safe environment that enables this to grow. Transitioning from partial listening to a genuine, entire encounter with a patient is a complex task. It requires practice and dedication to address our mistakes and continuously improve our listening skills. It requires us to forgive our own mistakes and the mistakes of others. Unless we prioritise practising this skill, we will continue to engage in a superficial and cursory manner with our patients and colleagues. Importantly, we will continue to miss opportunities to diagnose cancer. 

References

1. Quaife SL, Vrinten C, Ruparel M et al. Smokers' interest in a lung cancer screening programme: a national survey in England. BMC Cancer. 2018 May 2;18(1):497.  
2. Hart T. The Political Economy of Healthcare: A clinical perspective. Policy Press. 2010.
3. Marvel K, Epstein R, Flowers K et al. Soliciting the patient's agenda: have we improved? JAMA. 1999 Jan 20;281(3):283-7.
4. Beckman H and Frankel R. The Effect of Physician Behavior on the Collection of Data. Ann Intern Med.1984;101:692-696. 
5. May, R. The courage to create. W. W. Norton. 1975. 

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