16 October 2009: The pattern of referral from general practice to hospital for patients with oesophago-gastric (O-G) cancer varies significantly by region in England and Wales, according to a new report released today.
One third of patients diagnosed with stomach or oesophageal cancer were initially sent to hospital by their GP using non urgent referral pathways. This means that the cancer diagnosis may be delayed. Late diagnosis is associated with more advanced disease and a poorer chance of survival.
The proportion of patients who were not referred urgently ranged from 13 per cent to 66 per cent among the 30 regional cancer networks in England and Wales, according to the second annual report from the National Oesophago-Gastric Cancer Audit.
The audit, commissioned by the Healthcare Quality Improvement Partnership, led by the Association of Upper Gastro-Intestinal Surgeons, the British Society of Gastroenterology and the Royal College of Surgeons of England and managed by the NHS Information Centre, looked at the treatment in NHS hospitals of more than 12,000 patients.
In 12 per cent of the patients with oesophageal cancer and in 23 per cent of patients with stomach cancer, the disease was only discovered after an unplanned emergency admission to hospital. These patients had their cancer detected only when their symptoms became so bad that they needed urgent help.
The audit recommends that O-G cancer services should aim to improve awareness of the disease among their population, local GPs and hospital clinicians. National initiatives such as the recent O-G cancer awareness week will make an important contribution. Although this is typically a cancer affecting people aged 60 to 80, one in 10 of the patients with O-G cancer were under 55.
The audit also found that early outcomes from surgery appear to be improving since treatment was centralised to bigger, high volume hospitals. The percentage of patients dying within 30 days of surgery has fallen from 13.7 per cent in 2002 to 3.2 per cent for removal of the oesophagus (oesophagectomy) and from 10.3 per cent to 4.2 per cent for removal of the stomach (gastrectomy).
NHS Information Centre chief executive Tim Straughan said: "This is the second report from the National Oesophago-Gastric Cancer Audit, which is vital in gaining an understanding of the how patients with this disease are treated and the outcome of their treatment. The regional variation in early diagnosis indicates the need for greater awareness, among both clinicians and the public, of the signs of these cancers so patients have the best possible chance of survival. Although the audit indicates a lower mortality rate following surgery, which is encouraging, the fact remains many patients are diagnosed too late for surgery to be a possibility."
Clinical Audit Lead and Consultant Surgeon Richard Hardwick said: "We now have some detailed information on how our oesophago-gastric cancer teams are performing across the country which will help us set standards and raise the quality of care for these patients. The major challenge for all of us remains to make the diagnosis earlier when surgery can cure this cancer. Too often I see patients in my clinic with incurable disease. We must and can do better."
National Director for Cancer Mike Richards said: "I welcome this report which highlights the excellent progress on reducing 30 day mortality. The fall from 13.7 to 3.2 per cent for oesophagectomy and from 10.3 to 4.2 per cent for gastrectomy is truly remarkable. This shows that the work we are doing to improve diagnosis is having a major impact and this will improve further as from 2011-12, we will offer all patients in England access to diagnostic tests within one week.
"Under the new plans where a patient presents with symptoms that require investigation, but the GP does not think that the risk of cancer justifies an urgent referral to see a specialist within two weeks, the GP will be able to refer for the appropriate tests to be undertaken within one week."
Healthcare Quality Improvement Partnership National Clinical Audit Manager Helen Laing said: "We are very pleased with the success of this collaborative, multi-professional national clinical audit which has achieved a high standard of participation across the NHS. The audit has provided reassurances regarding clinical standards whilst also identifying important variations in practice; this has the potential to bring about real service improvement."
Consultant Gastroenterologist and audit representative for the British Society of Gastroenterology, Stuart Riley, said: "Unfortunately the diagnosis of gastric and oesophageal cancer can be difficult as early symptoms may be mild and non-specific. However the variability in urgency of referral that we have seen suggests a need to improve awareness of these common cancers'
RCGP Chairman Professor Steve Field said: "GPs are extremely vigilant about picking up on the early signs of cancer but our efforts can be severely hampered by limited access to diagnostic tests. We also face the dilemma of worrying patients unnecessarily by referring them to hospital when there might be a host of other explanations for their symptoms. Giving GPs easier access to diagnostics and allowing us to refer patients directly for MRI, CT scans and ultrasound without going to a specialist will enable us to make earlier and accurate diagnoses, preventing the development of cancers and saving more lives."
O-G cancer affects approximately 13,500 people in England and Wales annually and is the fifth most common form of cancer in the UK and the fourth most common cause of cancer death. Approximately 93 per cent of oesophageal cancer patients and 87 per cent of gastric cancer patients in England and Wales will not survive beyond five years from diagnosis.
The full audit report can be accessed here.
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