NAMED AND SHAMED: GPs who miss cancer diagnoses
If you saw the Mail on Sunday today you would have seen the above headline.
According to Wikiquotes, Daniel Patrick Moynihan, 4-time US senator and academic, once said “You are entitled to your own opinions, but not to your own facts”. Rather than writing an extensive counter-diatribe of rhetoric on the ridiculousness of the article, the irresponsible attitude to health reporting and Jeremy Hunt in general, I have decided to try a new form of discussion. I call it ‘The Facts’.
Here are the National Institute for Clinical Excellence guidelines for referring patients to a specialist with the suspicion of cancer. http://www.nice.org.uk/guidance/CG27*
This is how common bowel cancer is: there are 47.2 new cases per 100,000 people per year (crude). This equals around 40,000 new cases nationally, which means nearly 1 case per UK GP per year.
This is how common breast cancer is: there are 155 new cases per 100,000 people per year (crude)
This is how common lung cancer is: there are 77 new cases per 100,000 people per year (crude)
The national screening programme for bowel cancer, in the over 60 group, finds cancer in 1.62 people per 1000 people screened.
For bowel cancer: The presentation depends on the site of the cancer: (from Patient.co.uk;)
- Right colon cancers: weight loss, anaemia (low blood count), occult bleeding, mass in right iliac fossa, disease more likely to be advanced at presentation.
- Left colon cancers: often colicky pain, rectal bleeding, bowel obstruction, tenesmus, mass in left iliac fossa, early change in bowel habit, less advanced disease at presentation
In a study following 230 patients who presented with abdominal pain, 77% of them were found to have later improved, with no cause for their pain identified. 5 had appendicitis and 1% were found to later have a cancer. 
In a similar study following 307 patients presented to A&E with abdominal pain, 88% of them were found to have later improved, with no cause for their pain identified. No cancer was found.
The rate of serious harm in screening colonoscopy is estimated to be 1-2.8 per 1000 which includes bleeding and perforating the bowel wall.
The average GP sees over 10,000 patients per year –
A colonoscopy costs between £1100-£1650 per procedure.
The bowel cancer screening programme (for ages 60-69) already costs £77 million pounds per year. http://www.cancerscreening.nhs.uk/bowel/bowel-screening-cost.html
In summary, guidelines exist base on the probability of a diagnosis for further investigation, (Fact 1). Cancer is relatively rare, a single GP will see 1 new case each working year (Fact 2) out of 10,000 consultations, (Fact 7). The presentation of bowel cancer is variable (fact 4), and may be more advanced depending on several factors. Other cancers can be equally vague. Non-specific symptoms are rarely serious, (Fact 5) and returning to the GP is a useful diagnostically. Investigations and diagnosis have their own harms, (Fact 6).
Now for some opinions.
If this new idea comes into practice, GPs will refer more patients unnecessarily. This will mean a greater cost, greater harm without any evidence of benefit. Medicine, sadly, is full of ‘what-ifs’. This article is very willing to discuss what if this patient had been referred earlier to a specialist, but not about what if an additional hundred healthy patients were also referred, the additional cost and the potential harm that might cause. Not to mention the clogging of services.
I’m going to be controversial now. I don’t think lay people should be able to make decisions about health policy. Especially politicians. Health, like so many big topics in our modern society, is incredibly complicated. No one person, doctors included, can fully understand it. That is why we arrange to perform studies by hundreds of people, looking at millions of patients, before we can answer the simplest question in medicine. Politicians need to boil that down to a single-one liner that they can sell to the public and to the newspapers. That is, in my opinion, impossible. And, more than ever these days, incredibly costly, dangerous and irresponsible.
Even more controversially, I don’t think lay people should report or publicise health stories. Most doctors, myself included, struggle to understand what new studies really mean in terms of the patient in front of them. The Daily Mail is one of the worst offenders, it is deliberate and sensationalist and completely unaccountable. I wonder how many patients irresponsible health journalism has harmed? **
Having researched this blog properly, I find the idea that doctors that ‘miss’ cancer being penalised utterly ludicrous. Take the example of bowel cancer- the average GP will only see one new case of bowel cancer a year. So even if he or she ‘misses’ every case they see every year for five years, what sounds like a dangerous and scandalous GP- that’s still only 5 patients out of 50,000. When will Jeremy Hunt decide that GP needs to be named and shamed? How many mistakes would the average person consider acceptable before requiring a GP to be tarred and feathered? 0? 1? 10? 20?
Now there’s an opinion I don’t have any facts for.
*I appreciate NICE guidance as ‘facts’ is somewhat contentions. For those of you are interested their is a lot of controversy about the politicising of NICE, the interpretation of evidence and concerns over ‘tick box’ clinical practice. However, for the purposes of the above, these guidelines exist, and here they are.
** If you are interested, here is how I propose we investigate irresponsible health journalism; All health stories in major newspapers (Especially the Daily Mail) from the past ten years regarding health topics are identified, scrutinised for their accuracy against the scientific data available, and then calculated how inaccurate they are qualitatively on a scale of 1 to 5, 1 being minor inaccuracies (e.g. misspelling a name) to 5 being major inaccuracies causing potential harm (e.g. reporting an unsubstantiated conclusion and recommending a change in the behaviour of the individual that could result in disease e.g. Avoiding vaccinations). The impact of the story is then calculated by the potential harm, the readership, and the prevalence of the outcome. An excess death figure is calculated based on this. E.g. reporting vaccinations cause autism, calculating the drop in vaccination as per the readership and then the prevalence of new cases of measles for example and excess death. I appreciate this would be nearly impossible, but this is an exercise in imaginary science. Then, based on this, we could Name and Shame the greatest offenders and the relative risk of reading each paper on the individuals health. By law, this would have to printed on the front of each newspaper under a Health Warning label.