The way in which the NHS manages patients presenting with possible bowel cancer symptoms is in need of urgent review. A new article in The BMJ suggests that the evidence to support fast track referrals to bowel cancer clinics is weak and causes unnecessary concern for patients. The authors recommend that the risk of bowel cancer needs to be more precisely stratified, to allow prompt diagnosis and avoid unnecessary investigations for patients. Healthcare needs to be efficient as well as effective and ideally the system should only fast track people with persistent higher risk symptoms.
Prior to having bowel cancer, we could imagine ourselves arriving at a similar conclusion, namely that increasing bowel cancer referrals does not constitute either an efficient or effective use of resources. Now, as patients with advanced bowel cancer, who have undergone extensive treatments, we find ourselves asking if things need to be looked at differently. Firstly, there needs to be a better understanding of how to manage capacity issues while improving outcomes for bowel cancer patients, and secondly, when stratifying patient risk of bowel cancer, greater consideration needs to be given to symptoms, and the causes of these symptoms, than is current practice
Bowel cancer is notoriously difficult to detect and costly to identify as it can easily be confused with other bowel diseases. We both experienced significant delays in getting referrals and diagnosis for bowel symptoms, repeatedly hearing that our symptoms were probably just down to irritable bowel syndrome, or haemorrhoids. It was clear that in the absence of a clear family history of bowel cancer or other risk factors, our GPs felt that we were too young to have bowel cancer and that the explanation was likely to be a much simpler one. It was only after many months and much more detailed investigations that the true cause of our problems became clear.
For every patient diagnosed with bowel cancer in the emergency department, many others do indeed see their symptoms subside in a few weeks, without any need for investigation or treatment. Clinicians are concerned that the NHS is being overwhelmed by requests for scans and colonoscopies and that this does not represent an efficient or effective use of resources, and also causes undue stress and unnecessary investigations for patients.
Capacity is an emotive issue, but it only becomes an issue when the benefits and costs are not known.
Here is what we do know. We know that the average cost of treating a stage 3 or 4 bowel cancer patient is more than three times the average cost of treating a stage 1 or 2 bowel cancer patient.
We also know that slightly more than one-half of bowel cancers are diagnosed as stage 3 or 4.
The QALY dynamic has changed. People are living longer with late stage cancer and more and more costly interventions such as cyberknife and immunotherapy are being used with increasing success. Strategically expanding capacity of testing to prevent the need for high cost treatment down the line is not wasteful and inefficient, it is a sound investment.
Bowel cancer screening for patients over 60, using the Faecal Immunochemical Test (FIT), has been shown to be cost effective and to help catch bowel cancers before they develop to a late stage. It is our view that the FIT test should also be used for all symptomatic patients as a triage mechanism for referral. In the same way as the screening programme, this could increase the number of cancers caught early while reducing pressure on NHS capacity.
Many bowel conditions put patients at higher risk of developing bowel cancer. It is therefore logical to ensure that when a patient presents with bowel symptoms, the root cause of those symptoms is found, rather than simply treating the symptoms. For example, where a patient presents with persistent haemorrhoids or fissures, it should be considered that while these may explain symptoms such as blood from the rectum they may not be the main source of the problem, they may simply be a symptom themselves.
When the cause of symptoms is found it allows correct treatment, improves patient quality of life, and ensures any monitoring required is correctly undertaken. This may in turn result in patients having their cancer caught at the very earliest stage when patient outcomes are much improved, or prevent them ever developing bowel cancer.
As we can both attest, bowel cancer is a difficult disease to detect early. In our experience GPs aren’t being given the tools and training required to even try to make that early detection, leading them to opt instead for more simple initial diagnoses such as IBS. A more structured, rigorous process for the treatment and testing of patients presenting with persistent bowel symptoms at the primary care stage is an essential first step towards eliminating the more serious causes of symptoms. In our view, investing more time and resources at the outset will increase the chances of patients receiving the correct initial treatment, improving patient outcomes and quality of life, while reducing the burden on the NHS further down the line.
Tom Bartlett, Oxford.
Beth Purvis, Essex.
Competing interests: none declared.