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As every awareness-raising campaign makes clear, anyone with cancer has a better chance of surviving it, the earlier it is found.
Now, a new rule has been introduced for GPs in England that is aimed at cutting the number of people diagnosed too late to be helped.
It is called Jess’s Rule because it was triggered by a young woman called Jessica Brady, who had 20 GP appointments for symptoms including a persistent cough and abdominal pain. After five months, she sought private treatment and finally learned that she had terminal cancer. She lived only three more weeks.
The new rule says that if someone visits their doctor three times for symptoms that cannot be explained, GPs should rethink and refer the patient for hospital tests or get a second opinion from colleagues.
So, why is Jess’s Rule needed and why is it sometimes so hard for GPs to recognise possible cancer symptoms?
Cancer is one of the diseases that many people fear the most. That is understandable as it is relatively common, with one in four people dying from the condition. It is affecting more of us as we live to older ages.
A missed cancer diagnosis is also something that GPs fear. “We dread missing any significant diagnosis where the delay will affect the prognosis – cancer is going to be the commonest cause of that,” said Dr Keith Hopcroft, a doctor in Essex, who has written a book for GPs called Symptom Sorter.
Health services recognise that cancer diagnosis and treatment should be expedited. Until recently, anyone who had a symptom suggestive of cancer – like a breast lump – was supposed to get further tests at hospital within two weeks.
In 2023, this was changed in England to a 28-day target for the time between GP referral and getting a diagnosis. Scotland, Wales and Northern Ireland have other targets for the time between referral and treatment.
For some kinds of symptoms, it is fairly clear when someone should enter the urgent referral pathway – if a patient has, for instance, a suspicious lump, or unexplained blood in their stool or urine.
A major problem, though, is that about half of cancers cause symptoms that don’t indicate the tumour type, or even any tumour at all. Such “non-specific” symptoms include fatigue, all-over pains, nausea, feelings of dizziness or weight loss when someone isn’t on a diet.
There are a multitude of other reasons that could explain some of these issues. “Fatigue could just be caused by your lifestyle or by a virus, or so many other different things,” said Dr Claire Friedemann Smith, a cancer researcher at Oxford University. “A lot of the time in primary care, those other things are more likely than a cancer.”
Ping pong between hospital and GP
We shouldn’t underestimate the difficulty for GPs in distinguishing the tiny number of people with a tumour from the majority with less serious illnesses. A full-time GP may see about seven of their registered patients develop cancer a year, out of several thousand patient consultations.
And when symptoms are non-specific, it’s not clear which hospital department a patient needs to go to – whether they need to see specialists in the lungs, bowels, and so on. GPs used to have to try several departments in turn, with months wasted as the person went back and forth between their GP and the hospital. “It was like ping-pong,” said Dr Friedemann Smith.
To avoid this, hospitals in England now have a new system for people with non-specific cancer symptoms, where patients have a panel of blood tests as well as a full-body CT scan.
GPs usually have to justify their hospital referrals by stating the patient’s symptoms. But with referrals for non-specific symptoms, GPs can tick a box saying they want the patient seen because of their “gut feeling”. “They have a good skill set for noting subtle changes in their patients,” said Dr Friedemann Smith.
Showing how important that is, gut feeling was the second most common reason for GPs to refer on the non-specific symptom pathway, according to a recent study by Dr Friedemann Smith.
For Jess Brady, this clearly didn’t happen. Her circumstances were fairly unusual because this happened during 2020, and her GP appointments were by phone because of Covid. In fact, her doctors thought she had long Covid.
Nevertheless, the health system failed her and the consequences were devastating. What lessons can be learned and will Jess’s rule help?
Dr Hopcroft said Jess’s case shows the importance of keeping primary care set up so that patients can usually see the same GP each time – who is more likely to notice if they are deteriorating – and that they do see a doctor, rather than a physician associate (soon to be renamed physician assistants) or pharmacist.
Physician associates are less-qualified health care professionals that the NHS is introducing to free up doctors for more difficult tasks. But there is an ongoing row over what jobs physician assistants should be able to do.
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On the three-strike rule, most doctors would already have a rethink if someone is repeatedly presenting with the same symptoms, said Dr Hopcroft. “That is exactly what any self-respecting professional should do.”
And earlier this year, the Royal College of General Practitioners created new training materials that incorporate the “three strikes” guide.
But turning this into a firmer rule could make some GPs think again who previously would not have done. “Jess’s Rule formalises this approach,” said Dr Claire Fuller, medical director at NHS England.
“Hopefully it will make a difference for some of the patients who slip through the net,” said Dr Friedemann Smith.
I’ve also written
The autumn Covid vaccination campaign has started this week, with vulnerable people being urged to have the jab to protect themselves from the virus as winter approaches and the risks of a Covid surge increase.
But the overall impact of Covid is likely to be much less this winter than during the first years of the pandemic, thanks to repeated infections building up people’s immunity. In fact, Covid can easily be mistaken for flu or a cold.
I’ve been watching
The Diplomat is a fast-paced Netflix thriller about a US ambassador sent to London in the aftermath of a mysterious attack on a British aircraft carrier off Iran.
It seems to have about five different plot lines going on at once, and the ambassador’s personal life is about as tangled as Middle East politics. While I need subtitles on to keep track of what’s happening, I’m already hooked.
Hence then, the article about why doctors who miss cancer shouldn t necessarily be blamed was published today ( ) and is available on inews ( Middle East ) The editorial team at PressBee has edited and verified it, and it may have been modified, fully republished, or quoted. You can read and follow the updates of this news or article from its original source.
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