Delayed Cancer Diagnosis…and how to avoid it (possibly)

Barnsley GP Training Scheme, 2013

• To understand the concept of “delayed diagnosis” (with regards Cancer)

• To identify the causes of delayed cancer diagnoses

• To identify tools that can help you as a clinican improve your detection of cancer

294,000 people will be diagnosed with cancer andaround 155,000 will die from cancer every year

http://info.cancerresearchuk.org/cancerstats/incidence/#mortality

Leading cause of mortality in people under age of 75 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/dh_081006

8-9 new cancer cases per 2000 patients (DoH, 2009)

• Examples of a delayed cancer diagnosis:– What is a delayed cancer diagnosis?– At what point in the “patient journey” was the delay?– Why did that occur?– What could be done/changed/instigated to avoid the delay?

Definition of a delayed diagnosis (NPSA, 2010)

Delayed diagnosis in cancer is when someone who has

cancer:

• is not investigated or referred for investigation;or

• having been investigated, is not diagnosed at the time of the investigation;or

• is diagnosed incorrectly;or

• where a positive test result or diagnosis is not communicated effectively to a clinician with

• The ability to act on the information;or

• where a positive test result or diagnosis is not acted upon and treatment commenced as appropriate.

i.e. US – GPs !! “mis-diagnosis and insufficient examination most common themes (Mitchell, 2008)

Hansen’s model

Appraisal: delay in symptom interpretation may account for up to 60 % of total cancer delay in Breast/Gynae cases (Anderson, 1995)

Behavioural: delay in making an appt; Cancer was No 1 Fear ahead of MIs, Alzhemier’s and Terrorism (CRUK, 2007)

Scheduling: delay between making appt and being seen

Pathology 41%

Radiology 12%

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26%

Cancellations 15%

Only 11% of patients referred with suspected Cancer = Cancer

Audit PGP, all Cancer dx May 2010 – May 2011 = 58 cases

14% Routine (5/8 potentially 2WW)

30% 2WW

12% Emergency (only 2/7 potentially 2WW)

Always our fault…

• Types of Patient Safety Incidents:

– Diagnostics

• Pathology 41%

• Radiology 12%

– Communications 26%

– Cancellations 15%

– Clinical Assessments 5%

– Waiting Lists <1%

• Key issues raised by “stakeholder meetings”:

– Communication

– Clinical assessment and management

– Cultural issues (patients assuming a “passive” role)

MDU• More than 50 % claims settled against GPs were

for delayed diagnosis

• Major risk group was Cancers:– Breast 22%– Bowel 14%– Cervical 13% – Skin 8%

• Causes:– Failure to examine patient properly– Inadequate f/u arrangements– Lack of appropriate investigations– Dysfunctional communication

Tools that may help…

• Audit and SEA audits– ENT malignancy audit,10 yrs, 5 malignancies, 39-320 days for

diagnosis (average 130 days)

• Other risk tools

– http://qcancer.org/

Take home messages…

• What are yours?

• Mine:– Communicate effectively (with patients and

with team members ie receptionists/secretaries)– Examine appropriately and thoroughly– Use the appropriate investigations and do not

falsely reassure yourself with “normal” results– SEAs when necessary– Use the guidelines

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HA ENS