Early Cancer Detection and Investigation of Focal Liver Lesions

After reading an article about the GP who ran from Scotland to the Sahara (see 06/02/12), I've been inspired and entered my first marathon in September, the Loch Ness Marathon. It feels like a suitable step up from the Great North Run last September and a good target to aim for. I can already feel the pain though! Thought I'd also share this picture which a friend posted on Facebook recently - a lot of truths there!

I was forwarded an interesting letter this week from the Scottish Medical Officer about a new ambitious 'Detecting Cancer Early' programme which aims to improve survival for patients with cancer. There is of course very strong evidence to show that early detection of cancer results in more effective treatment, however sometimes early presentations are missed. There are several different ways to approach this topic, for example one way of achieving this goal is by educating patients about worrying symptoms ('red-flag' symptoms as doctors would call them) and stressing the importance of seeking help from a GP. Another way to improve early detection is by promoting GPs to refer patients early for investigations where there are symptoms suspicious of cancer. In my role in hospital, I would be expected to have a high index of suspicion for cancer in patients presenting with non-specific symptoms and where there is diagnostic uncertainty. Improved participation of the public in screening programmes is another technique. In Scotland there is going to be a high profile campaign to tackle negative attitudes about cancer, followed by a public campaign to promote awareness of specific types of cancer, starting with breast cancer.

Rational use of imaging in extremely important for many reasons, not least reducing the risk of harm caused by excessive imaging of patients in hospital. In the BMJ this week there is an interesting article about investigating focal liver lesions. I did not know this, but the vast majority of incidental liver lesions found on imaging are benign, not metastatic as I'd previously thought. The differential diagnosis for a focal liver lesion is actually quite extensive and includes simple hepatic cysts, focal nodular hyperplasia, heamangiomas, focal fatty infiltration, primary and secondary malignant tumours. Most benign lesions can be characterised using non-invasive imaging alone without having to resort to liver biopsy. Ultrasound is usually the first line investigation, whislt MRI has a higher sensitivity and specificity than CT. Contrast enhanced ultrasonography is a newer imaging modality becoming more popular and able to perform as effectively as CT or MRI. Liver biopsy is typically only considered when imaging fails to characterise an abnormality with certainty. Approximately 2% of image guided liver biopsies result in complications and therefore they should not be carried out on every patient found to have a focal liver lesion.

Finally, in the news section of the 'Careers' section of the BMJ this week there is an article which warns that the NHS is set to train 60% more consultants than needed by 2020. If this is the case then there is going to be huge competition for consultant posts at the end of specialty training. Strategic changes could involve making training longer, recruiting more consultants who are on-site at all hours to offer more senior expertise out-of-hours, or the introduction of a new tier eg. 'pre-consultant' and 'full consultant'. Controversial I think!