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No amount of training, forced or otherwise, can make it easier for GPs to diagnose cancer (News, November 1). By its very nature primary care deals with both uncertainty and very early presentation of disease, which in some cases turns out to be cancer.

For MPs or the public to expect a diagnosis of cancer at first presentation every time is as unrealistic as it is impossible. Of course, when a patient's symptoms and/or signs indicate that cancer is either a certainty or a possibility, an urgent referral is made.

But the layman thinks there is a set of symptoms that invariably and always indicates cancer and that there is a simple test. Nothing could be further from the truth.

The failure to appreciate the enormous difficulty in diagnosing cancer when the clinical picture is not clear or does not fit guidelines is a cause for concern. It is in this area that the All Party Parliamentary Group on Cancer has failed. Additionally it should have addressed the matter of public education on the subject.

I believe that it is possible in primary care to suspect or diagnose cancer in the majority of patients who eventually are shown to have the disease.

However, this does not mean that the cancer is early or even that it is treatable. Diagnosis and treatability are two different things. Bowel cancer, when it first presents, may well be inoperable or advanced and therefore associated with reduced survival.

In the case of stomach, oesophageal, pancreatic and ovarian cancer the condition is far from treatable, apart from palliative treatment, at the time of presentation and diagnosis.

It is important to consider cancer as a possible diagnosis when no other diagnosis fits or routine investigations fail to point to a diagnosis. It is not possible to investigate every symptom as possibly due to cancer without incurring inordinate costs and significantly lengthening waiting lists.

GPs, like all doctors, have to work on the balance of probabilities.

Dr Ken Menon

Ongar,

Essex

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