Is the healthcare system failing elderly people with cancer symptoms?

A new report published today – and widely covered in the media – raises difficult questions about how cancers are diagnosed in elderly people in England. The findings are stark – almost 1 in 3 cancers in the over 70s (31 per cent) are diagnosed through an emergency hospital admission, rather than through other routes (such as being referred by their GP).

That’s almost twice the proportion of people under 70 who are diagnosed through an emergency hospital admission (17 per cent).

To put that in perspective, around 58,400 people a year in England are diagnosed with cancer through an emergency hospital admission, sometimes because their symptoms become so severe that they go straight to hospital themselves, or because they’re sent there by their GP. Of these, 38,300 are men and women over the age of 70.

This is worrying – people are much less likely to live beyond 12 months after they’ve been diagnosed through an emergency hospital admission. Clearly something in our healthcare set-up isn’t right if so many people, particularly older men and women, are slipping through the net and being diagnosed in an emergency.

So we urgently need to understand why such a high proportion of the elderly have an emergency diagnosis. After all, our population isn’t getting any younger, and this means more cancers are on the horizon.

This problem won’t go away unless something is changed in the healthcare system. The question is, what?

About the study

The study is published in the British Journal of Cancer and was carried out by members of the National Cancer Intelligence Network (NCIN), including Cancer Research UK.

The NCIN is a UK-wide initiative set up in 2008 to improve cancer care by improving information collected about cancer patients. We’ve written before about the hugely important light the NCIN has shone on cancer healthcare in the UK, and how this ultimately helps to bring cancer survival in the UK in line with better-performing countries in Europe.

It’s a cliché, but one that we’re happy to keep repeating – knowledge is power, and by improving the quality of information we have on the UK cancer patients we can, and will, improve survival.

With this in mind, a couple of years ago Cancer Research UK and the NCIN asked a crucial question: we know what proportion of cases the cancer screening programmes pick up, but what proportion are diagnosed through other routes within the NHS?

More specifically, do patients’ routes to diagnosis depend on their age and the type of cancer they have?

By bringing together many different types of data from across the NHS, today’s study paints a comprehensive national picture of the routes to diagnosis different cancer patients take. It looks at the diagnosis of around three quarters of a million cancer patients, between 2006 and 2008 in England, then tracks back through patient records to see the sequence of events that took them there.

By linking several sources of data, the authors have sorted patients into one of eight different ‘diagnosis route’ groups. Each group represents the first point within the healthcare system that a potential cancer symptom was recognised by a health professional, which led to a patient being diagnosed with the disease. The eight routes are as follows:

• Screen detected: patient’s cancer was detected through the UK breast, cervical or bowel cancer screening programmes.
• Two-Week Wait: a GP spotted potential cancer symptoms in a patient, so referred them urgently to a specialist, under the government’s two-week wait system, meaning they must be seen within two weeks. For each cancer, there are particular criteria that mean a GP should refer a patient under this system.
• Emergency presentation: the patient was seen as an emergency admission in hospital, which led to them being diagnosed with cancer. These patients could have been in hospital for a variety of reasons, which may or may not have had a link to cancer. For example, they may have come into A&E because of an unrelated condition like a broken hip. Or they may have been referred to A&E or to an emergency consultant by their GP.
• GP referral: patient was referred to a specialist for further investigation of an ailment. In this route, the GP would not have suspected cancer.
• Inpatient elective: records show that the patient was admitted for an overnight stay in hospital for a pre-arranged appointment or procedure, and this led to a cancer being diagnosed. But the paperwork trail has gone cold before this point, so records do not show the reason for their visit.
• Other outpatient: patient visited hospital for pre-arranged appointment but did not stay in overnight.
• Death certificate only: no other data about the cancer diagnosis was available other than on the death certificate.
• Unknown: no data available on the patient, other than a record in a cancer registry that they had a cancer diagnosis.

The results

The headline figure, as we said above, is that one in every three older people – nearly twice as many as among under 70 – is diagnosed with a cancer that needs emergency attention. And the older a patient is beyond 70, the more likely their cancer is to be diagnosed through an emergency hospital admission, as the following chart shows:

But the report has a wealth of other valuable information about how cancers are diagnosed within the NHS. Here are some of the other key findings:

• Across all age groups overall, around a quarter (24 per cent) of people are diagnosed through an emergency presentation.
• The proportion of bowel cancers diagnosed through screening increased from 1 per cent in 2006 to 5 per cent in 2008, which reflects the staged introduction of the NHS bowel cancer screening programme across England. This is encouraging, especially alongside recent evidence that patients whose disease is spotted via screening do better than those diagnosed after developing symptoms.
• For all ages, cancers like skin and breast cancer are much more likely to be picked up by GPs. We don’t know for sure why this is, but it’s possible that these cancers are easier to spot.
• On the flipside, a high percentage of brain and central nervous system tumours (62 per cent), pancreatic cancers (50 per cent) and lung cancers (39 per cent) are picked up by emergency hospital admission, suggesting they may be harder to spot in primary care.

The following chart highlights these bleak differences. It underlines that it’s vital to find ways to spot harder-to-treat cancers earlier, at a stage when treatment is more likely to be successful.

Question of accountability

Without a doubt, this report uncovers some sobering statistics about the state of cancer diagnosis in the NHS. The sheer numbers of cancer patients first seen as an emergency are startling.

Who, or what, is to blame?

That’s the million dollar question. We know that, paradoxically, older people are more likely to visit the GP, and are less worried about doing so, than their younger counterparts. So what’s going wrong?

Perhaps older people are slipping through the net because they or their GP are dismissing their symptoms as ‘the usual aches and pains’ of old age. And some elderly patients may well be referred by their GP to a specialist, but don’t get their appointment quickly enough, so end up being diagnosed through an emergency hospital admission.

We will need more research to find out.

This study is the most comprehensive analysis yet of diagnosis routes, and lays the foundation for further work to better understand how we can improve how cancer is diagnosed.

It also helps us to begin to ask questions about which parts of the system need to be improved to help what (on the surface) looks rather like ageism within the NHS.

But accountability doesn’t mean blame. Perhaps GPs are less likely to refer an elderly patient with potential early signs of cancer, but if this is the case we need to know why and remedy the situation. This is likely to involve a mix of strategies that help and encourage elderly people – and their healthcare providers – to spot the potential early signs of cancer and crucially, act on them.

Final diagnosis

Our final diagnosis is stark: elderly cancer patients are faring worse under the current system. But the issues aren’t restricted to older people.

The better news is that now that we have definitive evidence, we can begin to try to understand the reasons behind these differences. Ultimately this will improve the way the NHS diagnoses cancer, irrespective of a person’s age.

Olly

• Read the NCIN press release