Cancer? What cancer?

Have you noticed something about the average age of patients consulting you this past year or two? That it’s reduced somewhat? In the pre-Covid era – when we still had a steady stream coming through our doors – the waiting rooms used to be largely occupied by the 70+. There might have been one or two mums with buggies, but the majority tended to be older. 

Now, when I come to the surgery, I glance through my call list and often see seven or eight working-aged adults – perhaps in their 20s or 30s, commonly with mental health issues, or maybe a new mole or a joint pain. In these cases, I think to myself: ‘Great! They’ll almost certainly have no significant pathology and may be quick to deal with.’ 

You might think this is a good thing – we’re making access easier for a previously under-represented group.  But where have all the over-75s gone? I know they may have been fearful of health services recently, and they’re commonly concerned about making sure that the service doesn’t get overwhelmed: ‘I’m so sorry to bother you, doctor, I know how busy you must be…’. But still, I feel sure that there must be a significant amount of untreated, undiagnosed pathology out there, which we’re still missing.

Late last year, Tim Farron MP relayed to the House of Commons that Macmillan Cancer Services are deeply concerned about the reduced numbers of cancer referrals, describing these as ‘having fallen off a cliff’, also explaining that patients are commonly presenting with later stage cancers. These are much more advanced than in ordinary times.

Are you surprised? I’m not. For when we switched to remote consultations, we immediately made access for the elderly, infirm, or technologically inexperienced more difficult. Same-day access for phone calls has, in most places, got easier, and it seems that our younger patients are making the most of this service. 

If you imagine for a moment a lady in her 70s who calls the surgery with a niggling abdominal pain. It feels a bit like her reflux, or possibly her IBS. Over the phone, you might suggest she take some simple painkillers or increase her dose of omeprazole (you note she’s had a recent endoscopy). But if you were to see her in clinic, you’d observe that she looked gaunt, and her skin was slightly jaundiced. Her mobility has declined, and she doesn’t look well.  These ‘soft signs’ – impossible to fully appreciate by remote means – are often the difference between the first investigations which will lead to a cancer diagnosis, or a false reassurance.  These early tests may, ultimately, give some patients several decades of extra healthy life.

If we make any change which increases accessibility for younger patients (who are statistically far less likely to suffer with significant pathologies), and reduces accessibility (especially face-to-face) for older patients, we should expect that there will be a national decline in early cancer diagnoses. And, therefore, increased cancer mortality. This much is obvious.

And while we’ve had some respite from the challenges of fully booked face-to-face clinics, we’re rapidly finding our phone triage lists are filling up. As younger people get used to being called back (often on the same day) by their GP, they’ll almost certainly start to call more frequently. After all, we can’t be that busy, can we? The face-to-face slots get increasingly squeezed, and as a GP, you’re less likely to book in that 70-year-old old with their niggling tummy pain.

I’d argue that our appointment systems – given the shift to remote consultations – now need to take more account of the fact that serious pathologies are far more likely to be found in certain patient groups. Be it the very young, the old, or non-English speaking – whatever you deem appropriate for your population. We could very easily move to a system where the over-70s are automatically offered face-to-face appointments, and working-aged adults a phone call. Put simply, I think that what’s been happening is likely to be causing a significant increase in avoidable mortality and morbidity.  

Perhaps you worry that you might not be able to cope with the demand if you were to return to this sort of a model. But if the 20-year-old with a funny-looking freckle had to wait four weeks for her call back, would it really be a disaster? It might well wake up the Government to the shortages in our service, that they presently seem quite content turning a blind eye to.

Please imagine for a moment that it’s your parent or spouse who has that pain. They’ve spoken to a GP (perhaps a different one each time), and been prescribed a variety of remedies, but were never actually seen in person. The first you know of their cancer, it’s six months down the line, and has metastasised to multiple organs. Your loved one is given only weeks to live. If the cancer had been picked up at that first appointment, things might have been so different…  Sounds pretty terrible, doesn’t it? Could we – should we – do better?

Dr Katie Musgrave is a newly-qualified GP in Devon and quality improvement fellow for the South West