General Practitioners (‘GP’) play an important and essential role in the cancer detection pathway. The majority of patients will first see their GP when first exhibiting symptoms which could relate to cancer.
Although a GP is not able to diagnose cancer, they are the vital first step in initiating cancer pathways for all sub-types of cancer and making sure that the patient is seen by the correct specialist at the earliest opportunity.
Approximately 950 new cancer diagnoses are made daily in England, and General Practices manage over 1 million patient consultations daily, which is more than 90% of NHS interactions per day. And although delays in diagnosis of cancer affect a small proportion of patients that are seen every day, when there has been a delay in diagnosis of cancer, the impact on patients and their families can be devastating.
The importance of the first referral cannot be underestimated to the timely and accurate diagnosis of cancer.
The Delayed Diagnosis of Cancer: A Thematic Review of General Practice Indemnity Claims published by NHS Resolution analyses 105 settled claims which related to a delay in the diagnosis of cancer as a result of negligence by a GP. Of the 105 cancer claims that were analysed, £2,187,821 was paid in compensation to Claimants. The review focuses on the impact that delays have had on the referral time and diagnosis and identifies themes that can be addressed to improve patient safety.
Common themes in cancer claims
Claims that were settled due to delay in diagnosis were affected by the following themes: -
- Many patients had multiple consultations, with delays averaging from 5 to 16 months depending on cancer types. The analysis found that patients attended on three or more occasions before diagnosis.
- Repeated or routine diagnostic tests often did not lead to timely escalation of referral. Urgent imaging that was required for the referral was ordered on a routine basis, and there was no follow-up or escalation in the event of delays.
- Failures included lack of follow-up on abnormal results and delayed investigations. Vague symptoms such as weight loss, loss of appetite, abdominal pain and fatigue often persisted untreated and lead to diagnostic challenges.
- Routine prioritisation of tests prior to the referral could take up to six weeks. On occasion where a routine blood test was ordered prior to referral under a cancer pathway, the appointment was booked for up to six weeks later causing a delay in communication of the results to the patient, as well as a delay in the referral.
- The routine referral system was used at a later point in the patient’s presentation in 60% of cases, and in 40% of the claims analysed the referral system was not used at all with the diagnosis being made through presented at A&E or the diagnosis being made at a routine referral with a specialist.
- From the cases analysed, the average GP delay for breast cancer was 6 months due to other misdiagnoses such as cysts and hormonal changes.
- Colorectal cancers had an average delay of 9 months with symptoms being misattributed to IBS or hemorrhoids.
- Gynecological cancers had an average delay of 1 year with symptoms being thought to be caused by infection and other benign conditions.
- The average GP delay for lung cancer was 7 months which was attributed to a recurrent failure to request chest x-rays when there were symptoms.
- Prostate cancer had an average delay of 1 year and 4 months which was attributed to lapses in the management of the blood test used to monitor prostate related changes in the blood.
The report highlights that analysis of 105 successful claims revealed recurring themes related to the diagnostic process, patient/ GP communication during consultations, and patients’ ability —or inability— to advocate for themselves and properly explain their symptoms.
As a result, there were missed diagnoses or failures to consider differential diagnoses. Additionally repeated patient attendances were not being adequately monitored, there was a lack of timely urgent reviews, and concerns were noted regarding the management of negative findings or lack of response to treatment, among other factors.
Solutions
Some of the solutions identified to address these issues were:
- Systems to identify repeat attendance and the development of systems to track persistent symptoms would assist GPs to identify when there were symptoms that required escalation through the referral process.
- Increase awareness of the non-specific symptom pathway so that the persistent symptoms that present with no clear diagnosis are escalated to seek specialist advice which may help decrease the length of time patients are waiting for a diagnosis.
- Utilising diagnostic imaging referral systems where available, as well as increasing training concerning remote consultations.
- Increasing the options for self-referral pathways, especially for patients with vague symptoms or a previous cancer diagnosis.
MDS welcome changes and recommendations that will improve cancer diagnosis for patients, and to allow GPs to make the decision for onward referral at the earliest opportunity so that treatment can be initiated as soon as possible. We have seen firsthand the impact delays in diagnosis of cancer, and the difficulties that patients face with non-specific symptoms that then turn out to be due to cancer.
Case summary
We have successfully assisted a client with a claim against her GP, where there were concerns arising out of a delay in diagnosis of breast cancer. Although liability was not accepted by the GP, the claim resolved following negotiation.
The claim related to attendances from January to June in the same year for muscular and chest pain that cumulated in intense pain in the left arm after a minor injury. Investigation at A&E revealed that she had a bone lesion which was because of the spread of breast cancer to her bones. Through expert evidence it was identified that had breast cancer been diagnosed earlier, she would have avoided a fractured arm, surgery to her right leg and the increased pain that she experienced as a result of the delay, although it would not have prevented the spread of the cancer.
The claim shows how important it is to be able to identify when there are non-resolving symptoms that have the potential to be related to cancer. In this case our expert evidence concluded that our client should have been referred for further investigation into the cause of her pain after her x-ray was reported as normal. With further investigation the ongoing persistent pain would have been identified as being related to cancer, and earlier treatment would have improved her symptoms. Please click here if you would like to read more about this claim.
Quote from author, Lauren Kerse, Associate Director, and Specialist Medical Negligence Solicitor from MDS, said “As medical negligence solicitors, we see the devastating impact delays in diagnosis of cancer can have. The implementation of any of the recommendations which could result in less suffering for patients and their families is welcomed.
