How community pharmacists can help in the early detection of bowel cancer
Royal Pharmaceutical Society research manager Erika Kennington describes an RPS national audit that highlights pharmacists’ role in the early detection of bowel cancer
Bowel cancer is the third most common cancer in the UK and, despite the existence of a nationwide screening programme, it is often diagnosed in the very late stages. Many people with bowel cancer are symptomatic at diagnosis, however these symptoms are generally common to several other minor conditions and so patients frequently self-manage their symptoms, often via pharmacy. Pharmacists are therefore in an ideal position to identify symptoms in at-risk individuals who may not otherwise visit their GP.
The aim of this audit was to replicate the approach of the lung cancer symptom audit conducted in 20101 to generate further evidence to support the assertion that cancer can be detected through pharmacy and, specifically, that pharmacy can aid early detection. The audit collected data on the population using pharmacy, what high-risk and lower-risk symptoms they had and what action was taken (eg, over-the-counter sale, GP referral etc).
These data were then used to assess whether cancer symptoms can be detected in pharmacy and whether pharmacists can direct appropriate patients towards GPs for further investigation. A total of 498 community pharmacists were recruited from independents, and small and large multiples, and asked to complete a survey following each conversation/consultation with a patient about bowel cancer symptoms. Data were collected over a two-week period that coincided with the end of the “Be clear on cancer” national bowel cancer campaign organised by the Department of Health in collaboration with other healthcare organisations and relevant charities.
A wide range of patients present at pharmacies with examples of all bowel cancer symptoms
It is noteworthy that men and women were reported in equal numbers; men are hard to reach and pharmacy therefore represents a location through which they can access health services.
Approximately 70 per cent of premises saw at least one eligible patient within the two-week period, and all the specified symptoms were reported in at least one consultation, with a change in bowel habits (either transient or persistent) being the most frequently reported.
This provides further evidence that pharmacists are considered appropriate health service providers by patients with any bowel cancer symptom.
Pharmacists are capable of identifying those patients most appropriate for GP referral
Although the GP referral rate was 40 per cent overall it was significantly higher for patients presenting with any of the five higher-risk symptoms listed, namely: a persistent change in bowel habits; bleeding from the anus without any obvious reason; abdominal pain, especially if severe; a definite palpable right-sided abdominal mass; or unexplained iron-deficiency anaemia.
GP referral rate also strongly correlated with the number of symptoms presented, rising to 80 per cent for patients with three or more symptoms. Equally, OTC sales were predominantly for those patients showing either none or only one of the specified symptoms and were significantly decreased in patients presenting with any of the higher-risk symptoms.
This shows that pharmacists can discern the most appropriate course of action for patients and are not burdening GP resources with over-referrals. In addition, verbal and or written information also accompanied these OTC sales in most cases, showing that the pharmacy environment provides the opportunity for imparting health messages and advice.
Pharmacy has a role to play in the early cancer detection agenda
However, in order to generate robust evidence we need to be able to link pharmacy interventions with patient outcomes. The results of this audit qualitatively suggest that pharmacy is one setting in which early identification of cancer can occur as well as awareness be raised. However, in order to show robustly that cancer can be detected through pharmacy, it needs to be possible to track the patients who are referred (by pharmacy) to their GP, ideally by pharmacists having access to electronic patient records.
The Royal Pharmaceutical Society would welcome further research linking pharmacy interventions to patient outcomes, as this would help quantify the impact of pharmacy in this vital role.
Readers are invited to contact me (email firstname.lastname@example.org) if they would like to discuss this further or if they would like the full results and study details.
A total of 223 pharmacy premises carried out 670 consultations and returned data by the deadline. Of these, 66 (approximately 30 per cent) reported having no patients fit the audit criteria within the data collection period.
Roughly equal numbers of men (51 per cent) and women (49 per cent) were seen. Approximately 15 per cent of consultations were for patients under 40 years, 35 per cent for patients aged between 40 and 60, 25 per cent for those between 60 and 70, and 25 per cent for those over 70.
The most common symptoms reported were a change in bowel habits — transient (35 per cent) or persistent (19 per cent), followed by rectal bleeding with anal symptoms (18 per cent), and abdominal pain without other higher risk symptoms (15 per cent). Twenty-one per cent of patients reported none of the symptoms identified, 55 per cent had only one symptom, and 19 per cent reported two symptoms. Five per cent of patients reported three or more symptoms. Severe abdominal pain was more prevalent in the 50–59 years age group, and bleeding from the anus was more prevalent in males.
Thirty-eight per cent of consultations resulted in an OTC medicine sale. Verbal and written advice was given in 62 per cent and 23 per cent of all consultations, respectively. Forty per cent of consultations resulted in a GP referral. In only 4 per cent of consultations was no action taken. GP referral was significantly increased for patients presenting with any of the five higher-risk symptoms. Conversely there were significantly decreased OTC sales for these patients. GP referral rate also correlated with the number of symptoms presented.
ACKNOWLEDGMENTS The RPS science and research team thanks the pharmacy staff who participated in this audit, and Rebecca Jones and Magdalena Trzcinska for data entry.
1 Kennington EJ, Allen B, Wright H et al. Early detection of lung cancer symptoms — a role for community pharmacy. International Journal of Pharmacy Practice 2012;20(Suppl 1):17
Citation: The Pharmaceutical Journal URI: 11099577
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