Saturday 4th February was World Cancer Day. Most of our patients have cancer on their minds. According to Cancer Research UK, every two minutes someone in the UK is diagnosed with cancer. Together, cases of breast, prostate, lung and bowel cancers account for over half (53%) of all new cancers in the UK.
A missed (or even delayed) diagnosis of cancer is a common, shared fear amongst the public and the medical profession. As no diagnostic test or decision is ever perfect, a missed diagnosis is likely to happen at some time in primary care.
People with cancer present at different stages, as their illness evolves, and the 'red flag' signs and symptoms may be absent or not present at all until the disease has progressed to a late stage. Safety netting is often viewed as a consultation technique (to ensure timely review of a patient's condition), but it is particularly important for conditions such as suspected cancer where patients may present infrequently and symptoms can be common and non-specific, such as pain or fatigue. Safety netting can be an important strategy to help healthcare professionals detect cancers earlier and minimise delayed diagnoses.
Examples of safety netting include reviewing and acting on investigation results quickly after they have been requested. If you ordered the investigation, you should take responsibility for this, or explicitly delegate the task.
It also means actively monitoring symptoms in people at low risk (but not no risk) to see if a patient's risk of cancer changes. This may include using Cancer Decision Support Tools such as QCancer and the Risk Assessment Tools (RAT). You also need to consider review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action at that time. The review may be planned within a time frame agreed with the person, or be patient-initiated if new symptoms develop, if the person continues to be concerned, or their symptoms recur, persist or worsen. Reassuring people who are concerned that they may have cancer that with their current symptoms their risk of having cancer is low, is also important.
When people are being offered safety netting you need to explain which symptoms to look out for and when they should return for review. It may sensible to provide written information, such as one of our PILs, at this time. They can refer to it later, when they may have forgotten key things you mentioned.
More procedural safety netting involves read coding suspected cancer referrals and direct access diagnostics; for example fast tracking suspected (breast) cancer referral or referral for ultrasound investigation and tracking the patient attendance and outcomes for investigations and suspected cancer outpatient appointments, using the relevant software, e.g. ICE software, T-quest list management or other robust electronic systems. This will enable you to actively call patients who do not attend their appointment for investigations or suspected cancer clinic appointment, for review within an agreed time frame.
Many GPs are aware of verbal safety netting; however proactive electronic safety netting refers to optimising IT systems, processes and practice systems to organise patient follow-up. Other examples of this include advising patients about what to look out for, or when to come back for a review of symptoms and signs at a certain time, and booking the follow-up appointment before they leave the consultation.
You should also advise them what to do if 'suspected cancer or two-week wait' appointment is not received by a certain date, or not attended for some reason. You might think about providing a dedicated telephone hotline for elderly or vulnerable patients or asking your admin staff to follow up codes or diary reminders that are searchable on a weekly or fortnightly basis, to track and follow up patient activity and non-attendance.
It is useful to ensure continuity of care by having 'usual doctor' systems, where possible and communicating effectively with colleagues. And, of course, you can always use our patient information leaflets to advise and inform your patients about when to return to their GP for a clinical review. This can also be documented electronically.
The good news is that cancer survival has doubled over the last 40 years in the UK and early diagnosis is a key part of that. Cancer is an enduring clinical priority for the Royal College of General Practitioners (RCGP) and it should be for all of us.