Cancer diagnosis

Surgery plays a fundamental role in the prevention, diagnosis, treatment and palliation of cancer. Over 80% of the 15 million people diagnosed annually with cancer globally require surgery.¹ While surgical resection, along with radiotherapy, is central for the locoregional treatment of solid malignancies, surgeons also play a much broader role in the diagnostic process for both solid and haematological malignancies. It is therefore fitting that this issue of the Annals is dedicated to cancer diagnosis. This issue includes papers reporting results of several innovative approaches developed to manage increasing demand on surgical diagnostic services. Two articles explore the utility of telephone clinics for head and neck and colorectal suspected cancer assessments. Another study assesses patient perceptions of faecal immunochemical testing, and one study demonstrates a faster time to biopsy in head and neck clinics that use local anaesthetic techniques compared with general anaesthesia.

In England, patients reviewed in primary care with a presentation considered concerning for suspected cancer are referred on a cancer pathway for urgent assessment. In general, the number of referrals on these pathways has increased by approximately 10% year on year, resulting in a doubling of referral numbers over the past decade (Figure 1). In contrast, the number of patients diagnosed with cancer through these urgent cancer pathways has increased at approximately 1% year on year, with the rate of cancer diagnosed per urgent referral reducing from 1 in 9 (11%) in 2009–2010 to 1 in 14 (7%) in 2019–2020.

While this cancer diagnostic rate remains above the 3% threshold recommended by the National Institute for Health and Care Excellence as the level at which an urgent referral from primary care should be made,² such sustained yearly increases in referral volumes stress existing diagnostic capacity. Increases in referrals have not led to an increase in the proportions of patients diagnosed with early stage cancer, which has remained consistently at just over half in those patients for whom staging data are available (Table 1). However, positive trends in the route to diagnosis for patients with cancer are observed with a gradual reduction in the proportion of patients diagnosed via an emergency presentation or through routine referral, and a gradual increase in the proportion of patients diagnosed through urgent pathways and population-based screening programmes (Figure 2).

These data suggest that large increases in urgent referrals have had limited impact on downgrading the average stage of cancer at diagnosis. In order to meet the commitment of the National Health Service (NHS) to increasing the proportion diagnosed at an early stage to 75% over the next five years, as stated in the NHS Long Term Plan,³ alternative strategies to simply increasing diagnostic capacity alone are urgently needed. These are likely to include improved risk profiling, widening the age ranges at which people are offered access to population-based screening for common cancers and targetted lung checks with low dose computed tomography for those at most risk.

Technologies such as deep learning analysis of routinely collected health data may generate personalised risk profiles to better inform mechanisms for risk stratified screening and referral, and alternative and effective biomarkers will be of value. These may include multiparameter blood tests that detect circulating tumour DNA, methylation patterns or inflammatory markers that signal cancer and at least one such “liquid biopsy” test is currently being trialled in the NHS.⁴

Improvements in earlier diagnosis will lead to better outcomes from cancer from a combination of increases in capacity, initiatives such as these and other innovations in cancer diagnostic pathways.