Requests from primary care for chest X-ray and CA125 measurements during the COVID-19 emergency: An observational study

Discussion

There are differences in the way tests for patients in whom cancer is recognised as a potential diagnosis, as advised by the National Institute for Health and Care Excellence, are initiated from primary care.³ For example, direct-access endoscopy was suspended early in the peak of the COVID-19 pandemic and as reopening takes place it is recommended that referrals should be subject to vetting before the patient attends.⁴

In contrast, the tests whose usage we have studied are conducted as part of routine primary care practice, usually using the facilities of the local general hospital trust. The sole indication for measuring serum CA125 in primary care is to address the possibility of ovarian cancer. It is an effective triage test.⁵ There are many reasons for requesting CXR; diagnosis of serious conditions such as thoracic malignancy or pulmonary tuberculosis is one important outcome even if these were not under consideration when the request was made and are raised by the reporting clinician. The sharp reduction in these investigations during the first months of the lockdown in response to the COVID-19 pandemic is therefore concerning. The fact that the decline in CA125 requests did not vary with distance from the hospital does not mean that the underlying rates of referral do not differ with these factors, as is well established.^6,7

Reasons for these reductions include patients feeling it inappropriate to turn to any medical facility for minor symptoms during the pandemic. This may be reinforced if a telephone call is answered with a recorded message, as in this local example: ‘If you have a new cough…do not contact your GP, a hospital or a pharmacy.’ The difference between a new cough as a symptom of COVID-19 and a persistent cough as a symptom of lung cancer or tuberculosis may not be appreciated by an anxious patient.

It is reported anecdotally that many patients believed that GP practices were not open. They may also have been reluctant to attend the hospital for a test because of a perception that many patients carrying COVID-19 infection would be present there. Radiology department staff members report that patients state this in conversations about arranging appointments. Seemingly small barriers to accessing the service, such as distance from the radiology service are apparently an influence, as seen in Table 4. GPs are reported to have advised patients to go to the ED rather than the GP practice if they had respiratory symptoms. However, our data (Table 3) show a slight decline in the number of CXRs requested from there. This level of referral has persisted into June.

Primary care professionals may seek to defend the general hospital from work considered not as urgent as that related to the pandemic. Such defensiveness has been approved in a senior hospital physician's personal opinion with regard to access to cancer diagnostic services before the pandemic.⁸ This process may be compounded if the provider requires a telephone call for justification of an investigation before the test could be enacted. This was a temporary requirement at Airedale General Hospital during May 2020. Sometimes this resulted in CT scan being performed rather than CXR, a potentially favourable change. A significant proportion of CXRs from primary care are for follow up. These were not done during the period studied, with the interval being advised to plan such an investigation being increased from 4–6 weeks to 12 weeks.

A further possibility is that, compared with a face-to-face consultation, in a telephone or videoconferencing conversation the GP may not as effectively elicit the symptomatic clues which prompt the investigation or indeed referral. The potential for these changes to be part of normal primary care function will therefore need to be very carefully evaluated.^1,9

The reversion of the CA125 measurements to rates approaching those of the previous year suggests that the issue of potential ovarian cancer is being considered by GPs and that patients are again presenting with relevant symptoms. The requests for chest radiography are not increasing at the same rate, which raises some concerns; the geographical variation would suggest that travel to the hospital is a consideration for patients.

The number of ‘2 week wait’ referrals to Airedale General Hospital for investigation of potential cancer fell by 60% from 554 in April 2019 to 220 in April 2020.¹⁰ This forms part of a general pattern of reduced activity in primary care, which would lead to delayed cancer diagnosis even before the delays in workup of patients that have accessed the specialist services. In discussing the effect of the pandemic on cancer diagnostic processes and the potential effect on outcomes, Hamilton describes services as being in disarray.¹¹

The observations we report pertain to the actions of GPs using the services of one NHS acute hospital. The reduction of activity they represent may differ from the experience in other districts. However, since in the UK referrals from primary care have reduced widely during the first half of 2020 some similar findings are likely around the country.

As the management of the 2020 pandemic is developed, changes in activity will need to be identified and taken into account. It is not possible in a retrospective audit such as this study to identify the contributory factors to the reduction in diagnostic tests but to conduct such research would be valuable. Its findings would instruct planning for future major outbreaks of infectious disease. Continued monitoring of the way such facilities are used will be necessary as usual activity is resumed within the NHS.