APPENDIX 3
Memorandum submitted by Dr Nicholas Summerton,
University of Hull/Winterton Medical Practice
INTRODUCTION
As a clinical senior lecturer in primary care medicine
at the University of Hull and a general practitioner within the
Winterton Medical Practice, I am associated with two organisations
with interests in cancer research in primary care. Both organisations
have supported me in the production of the book "Diagnosing
Cancer in primary Care"1 and in the development of research
bids/protocols focusing on cancer diagnosis. I believe that enhancing
research into cancer diagnosis within primary care falls within
the remit of the Committee's enquiry, as effective and prompt
diagnosis is an integral component of treatment.
THE CURRENT
CANCER RESEARCH
CULTURE
Contacts have been made with a number of the
key UK cancer research charities and specific pharmaceutical companies.
Unfortunately, cancer diagnostic research and research into primary
care oncology are generally not viewed as key components of an
oncological research strategy amongst these organisations.
THE IMPORTANCE
OF CANCER
DIAGNOSTIC RESEARCH
WITHIN PRIMARY
CARE
According to the Medical Defence Union, failure/delay
in diagnosis accounted for 28 per cent of the notified patient
complaints against GPs in 19982. The most frequent clinical condition
associated with diagnostic failure or delay was missed malignancy.
Roetzheim and colleagues have demonstrated that
the supply of primary care physicians is significantly correlated
with the stage at diagnosis of patients with colorectal cancer:
as the supply of primary care physicians increased, the odds of
late-stage diagnosis decreased.3
THE DISTINCT
NATURE OF
CANCER DIAGNOSIS
IN GENERAL
PRACTICE
As is illustrated by the attached "symptom
pyramid" a much lower proportion of patients with one of
the "ten warning symptoms of cancer" in the community
or in primary care will turn out to have cancer. Due to selective
processes of referral, patients seen by "specialists"
in their clinics are very different from those seen in primary
care, eg only 7 per cent of all patients with rectal bleeding
within the community eventually reach a specialist clinic.1 Furthermore,
patient symptoms and signs evolve and become more defined and
differentiated as time passes and patients move up the pyramid.
General practitioners necessarily need to use
a broader range of information to assess a patient's risk of having
cancer and they need more and better research in order to determine
which "traditional symptoms" described in textbooks
have discriminant value amongst the patients they encounter. General
practitioners will always "miss" some cancers but it
is unacceptable to fail to recognise and refer patients with cancers
as a result of inadequacies in the available evidence.
THE INADEQUACIES
IN THE
CURRENT EVIDENCE
Work undertaken as part of an ongoing systematic
review has highlighted significant inadequacies in the current
evidence-base. This confirms previous findings made as a result
of the literature review leading to the book "Diagnosing
Cancer in Primary Care"1 and the cancer guidelines work undertaken
under the auspices of Professor Mike Richards.4
Specific evidence inadequacies have been identified
by other reviewers for both cough and lung cancer5 and haematuria
and urological malignancy.6, 7
WORK ALREADY
UNDERTAKEN BY
THE AUTHOR
OF THIS
MEMORANDUM IN
SEEKING TO
DEVELOP THE
PRIMARY CARE
DIAGNOSTIC ONCOLOGY
RESEARCH AGENDA
Book and publications in key medical journals.
Written submissions to specific cancer charities,
pharmaceutical companies and the Department of Health.
Oral presentation to Yorkshire Cancer Research.
Establishing links with Members of Parliament
with a key interest in cancer research (Dr Ian Gibson) or primary
care oncology (David Taylor).
Securing a small research grant from the Royal
College of General Practitioners in order to undertake a systematic
review (ie published and unpublished evidence in the UK and elsewhere)
focusing on cancer diagnosis within primary care.
Collaborative work and links with colleagues
with a significant commitment to the development of key aspects
of primary care oncology in Oxford (eg Professor David Mant),
Leeds (eg Professor Peter Selby), London (eg Professor Mike Richards
and Professor Denis Pereira Gray), Canada (eg Professor Ian McWhinney)
and Holland (eg Professor André Knottnerus).
REFERENCES
1. Summerton N. Diagnosing Cancer in
Primary Care. Oxford: Radcliffe Medical Press, 1999.
2. Lee R. How the new complaints procedure
has succeeded. General Practitioner (GP): 2 April 1999 p.
85.
3. Roetzheim RG, Pal N, Gonzalez EC et al.
The effects of physician supply on the early detection of colorectal
cancer. J Fam Pract 1999; 48: 850-8.
4. Department of Health. Cancer waiting
times, achieving the two-week target. [HSC 1999/205]. London:
Dept of Health, 1999.
5. Liedekerken B M J, Hoogendam A, Buntinx
F et al. Prolonged cough and lung cancer: the need for more
general practice research to inform clinical decision making.
Br J Gen Pract 1997; 47:505.
6. Bruntinx F, Wauters H. The diagnostic
value of macroscopic haematuria in diagnosing urological cancers:
a meta analysis. Fam Pract 1997; 14: 63-68.
7. Froom P, Froom J, Ribak J. Asymptomatic
microscopic haematuria—is investigation necessary? J
Clin Epidemiol 1997; 11: 1197-1200.
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