GPs face influx of patients with heartburn as result of cancer campaign
Exclusive GPs face increasing workloads and the possibility of patients being harmed through over-investigation due to a new Government cancer awareness campaign that encourages patients to see their GPs if they have suffered from heartburn for more than three weeks, Pulse has learned.
The national oesophago-gastric cancer campaign – set to run from 26 January to the end of February – will target men and women aged 50 and over with publicity based on the slogans ‘Having heartburn, most days for three weeks or more, could be a sign of cancer - tell your doctor’ and ‘Food sticking when you swallow could be a sign of cancer - tell your doctor’.
Public Health England (PHE) says provisional findings from a regional pilot conducted in northern England last year found the campaign led to a 46% increase in GP visits for the symptoms described, and a 52% increase in urgent GP referrals for suspected upper gastrointestinal cancer.
GP leaders told Pulse that there is a danger patients will be harmed through over-investigation, while the advice on heartburn is too cautious and conflicts with advice to GPs outlined in NICE guidelines on dyspepsia.
The pilot, run in the Northern England Strategic Cancer Network region, ran from February to April 2014 and involved eight acute trusts, but as yet data regarding its impact on cancer diagnoses have not been fully evaluated.
However, local pilots carried out at seven sites between April and July 2012 found a 20% increase in oesophageal cancer diagnoses following two-week wait referral – but this increase was not statistically significant and there was no change in the conversion rate.
Following the pilot, PHE wrote a letter to CCG and local authority public health leads advising that it was rolling this out on a national level based on the slogans to look out for heartburn and food sticking.
It stated: ‘The decision to run this campaign was based on the results from the regional campaign which ran in the Northern England Strategic Clinical Network region from February to March 2014. The results provided evidence of a significant impact, showing that, within the regional pilot area, there was a 52% increase in urgent GP referrals for suspected upper GI cancers, for February-April 2014, compared to the same months in 2013. This compares to a 17% increase in the control area.
’It is acknowledged that this campaign will impact on endoscopy services. By providing early warning we hope that you can put in place any necessary temporary arrangements to cope with any peak in requirements.’
Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee said the heartburn slogan was over the top.
Dr Green said: ‘I think it a great shame that they did not limit this campaign to the advice about dysphagia, which would be a useful health message to get promoted. Unless there are other worrying features heartburn is such a common symptom in the population that its use as a diagnostic indicator for cancer is limited, and there is a real danger of harm caused by over-investigation.’
Other GP experts said the advice to suspect cancer after heartburn for three weeks goes against current NICE guidance on dyspepsia, which advises GPs to manage uninvestigated ‘reflux-like’ symptoms as uninvestigated dyspepsia and treat with propton-pump inhibitors (PPIs) initially.
Dr John O’Malley, a GPSI in gastroenterology in Stockport, said he had ‘grave concerns’ about the heartburn slogan, which he said was too ‘simplistic’ and would make it difficult for GPs not to refer patients even if this would not be necessary according to the NICE guidelines.
Dr O’Malley said: ‘The likelihood of finding oesophageal cancer in someone with heartburn is very small. It is also contrary to NICE guidance and will force sensible GPs who will want to start a trial of a PPI first, to refer. I am not sure what the point of NICE is when well evidenced guidelines are ignored in this fashion.’
Dr Jamie Dalrymple, gastroenterology GPSI in Suffolk, said he was concerned PHE had not sufficiently piloted the heartburn slogan.
Dr Dalrymple said: ‘I am not clear about the robustness of their findings. My biggest concern is that scant endoscopy resources will be directed towards a condition with a low pick up rate from this large screening population which will result in fewer endoscopies for patients with other conditions such as bowel cancer.’
PHE defended the campaign’s focus on heartburn, which it said was designed to catch patients with cancer at an early enough stage to offer them effective treatments – and stressed that GPs should still use their clinical judgement.
It added: ‘The intention is to give people the permission they may need to see their doctor – in effect, to get across the message that persistent heartburn is a symptom that is serious enough to see their doctor about. GPs are of course being advised to continue to use their clinical judgement as they always would, and not refer all patients on for endoscopies if they consider inappropriate.’
It comes after NICE launched a consultation on a raft of new recommendations about when GPs should refer patients for suspected cancer, reducing the risk threshold for referral from 5% to 3%.
NB This story was updated at 11.00 am to correct Dr O’Malley’s role