Increasing early presentation of cancer symptoms by welcoming more work for primary care.

One of the few areas where everyone – NHS and politicians, clinicians and public – agrees about the content of the new contract to be created between the NHS and the public in November, is the promise of better survival outcomes for people with cancer over the next 10 years.

Improving cancer treatments will have some impact, as they have over the last decade – spectacularly for breast cancer, and earlier diagnosis of more cancers will have a significant impact – and here the application of Artificial Intelligence will bring down the cost of testing and invite more tests from GPs.

But the biggest impact will come from making sure that people with cancer present to the NHS earlier than they currently do. The NHS now has many more options in treating tumours that are presented to it earlier and the outcomes are much better. So the single biggest change we need to improve survival rates is to encourage more people to go and talk to their primary care team about their worries about a new pain or a new lump they have found.

In August (12/08) Populus published an opinion poll about why the public did not present their worries about cancer to their doctor.

They found that one in four members of the public would not bother having a symptom examined for fear of what the doctor might find. This strikes me as a really difficult issue to tackle. It’s such a human and understandable fear NOT to want bad news and so to put off getting it. The problem is that knowledge of the consequential bad outcomes of NOT presenting your symptoms early isn’t spread equally across the country. A few people know that the problems caused by late presentation are so bad that it’s important to face up to potentially bad news as soon as possible. So they overcome their very human fear of bad news.

But for many people there is no clear understanding of the problems that come with late diagnosis and we need to forcefully present that knowledge in ways that are culturally specific. In the last few years there have been a couple of good campaigns that have had some impact. “Been coughing for three weeks or more? Tell your doctor”, and, when I go to the toilet at a football match, there are posters above the urinal that say “If there is blood in your pee go and see your primary care team”.

Some of the cancer charity rhetoric of recent years “Together we can beat cancer” has been uplifting but the responsibility of the patient in winning that war by going to see their primary care team quickly enough, has not been stressed

We are getting better at making these messages culturally specific, but to have an impact on population health, as the main theme of this blog argues, the NHS needs a lot of help from the rest of civil society. Changing public behaviour, especially about something as personal as fear, will require help from all public institutions.

  • Religious leaders need to preach about the duty of their particular flock to live longer by taking their worries to the doctor.
  • Sporting heroes need to talk about relatives who survived (or didn’t survive) their cancers by going to the doctor early (or not)

But there was a further message from the Populus survey that has direct implications for the NHS .

Half of the UK population, despite discovering a potential symptom of cancer, would not seek medical help with many too afraid that they may be wasting a doctor’s time by raising it.

Whenever I have talked with cancer experts about why the British present their cancers late it is this issue of not wanting to waste the doctor’s time that is specific to our culture.

This must be one of the few down sides to the brilliant relationship between the NHS and the public. Not everybody, but a lot of people feel that the NHS is ‘theirs’. Think how often everyone refers to ‘our NHS’.  And because of that relationship there is a strong positive relationship with the staff who work for ‘us’ in ‘our NHS’. It’s difficult for them to see the staff as simply earning a living – they are doing good for us and perhaps in some way doing us a favour.

Not everybody, but a lot of people feel sympathy for their hard work and don’t want to add to it. That is not how they feel about staff at their bank or energy company. People don’t worry about adding to their burden.

But for the NHS this means that a significant part of the population do not ‘want to bother them and add to their hard work’. Obviously we could do something about that with campaigns about different cancers emphasising that this is the sort of work that we like.

BUT every time there is a headline which says ‘Hard working doctors retiring early because of stresses at work’ some people empathise with those doctors and don’t want to add to their workload. This kind of publicity means that some decide not to go and see their doctor with this persistent cough because the doctor is under such stress.

We are trying to get people to take their cancer symptoms to the very people that everyone says are very stressed.

That’s one of the reasons why yesterday’s post about developing a different model of primary care is so important. If the public felt that primary care was a more serene place that would welcome your bringing your cancer symptoms – more of them would go.

So if we want to improve our cancer survival rates during this 10 year plan we not only have to make it easier for primary care to get cancer diagnostic tests seen to – we also need to make it a lot easier for people who fear they have cancer to ‘bother the primary care team’.

Otherwise we won’t really improve cancer survival rates.