More than three quarters (77%) of cancer patients who first present to their family doctors (GPs) with suspicious symptoms are referred to hospital after only one or two consultations. However, women, young people, non-white patients, and those with some less common cancers appear more likely to see their family doctors three or more times before referral, according to the results of the latest Cancer Patient Experience Survey published Online First in The Lancet Oncology.
The findings also reveal large differences in the promptness of GPs in England to diagnose different cancers, with patients presenting with symptoms of multiple myeloma, lung, and pancreatic cancer requiring much greater numbers of consultations before hospital referral than some common cancers including breast, melanoma, and testicular.
For example, over half (50.6%) of patients with multiple myeloma, a blood cancer that is notoriously difficult to diagnose since it 'mimics' many other conditions, required multiple GP visits compared to just 7.4% of patients with breast cancer.
"These findings highlight limitations in current scientific knowledge", explains Georgios Lyratzopoulos from Cambridge University, Cambridge, UK, lead author of the study. "Medical research in recent decades has prioritised improving cancer treatments, but knowledge about the 'symptom signature' of common cancers and practical solutions on how best to diagnose them is still emerging. We hope our research can help to generate support for further research into the diagnosis of those cancers where the challenge of detection is greatest. This will improve the patient experience of cancer diagnosis and can also lead to earlier and more effective treatment."*
In the UK, most patients are diagnosed with cancer after first presenting with symptoms to their GP. The number of such visits before hospital referral can be a measure of the quality of patient experience and a marker of the timeliness of cancer diagnosis.
Using data provided directly by over 41,000 patients with any of 24 different cancers treated in 158 hospitals across England, the authors examined variation in the number of times patients presented with symptoms of cancer to their family doctor before being referred to hospital according to cancer type, age, sex, ethnic group, and socioeconomic status.
Patients with multiple myeloma, Hodgkin's lymphoma, and cancers of the pancreas, stomach, lung, colon, and ovaries were substantially more likely to see their GP three or more times before being referred to hospital.
The authors suggest that some of the reasons for delayed recognition of these cancers could be the result of differences in the nature and characteristics of symptoms, making them harder to diagnose. Whereas cancers with well known signs and symptoms, such as changes to moles (eg, melanoma) or an obvious lump (eg, breast cancer), were more readily referred to hospital, suggesting they are more easily diagnosed.
Younger patients and those from ethnic minorities were also more likely to have had several GP consultations before hospital referral compared with older or white patients, indicating that GPs are less likely to consider cancer a possibility in young people and possible communication difficulties with patients from different ethnic groups.
The authors conclude by calling for better use of technologies to help GPs calculate a patient's risk of cancer and to improve their ability to spot symptoms earlier: "Research and policy should explore and assess physician-level educational interventions, further development of point-of-care decision aids, risk calculators and diagnostic tests, and redesign of systems to enable more appropriate and timely use of specialist diagnostic tests (eg, imaging or endoscopy)."
In an accompanying Comment, Martin Gulliford from King's College London, London, UK remarks: "These findings raise several questions…that deserve to be tested prospectively in future research…Do modes of cancer presentation vary systematically between different groups of patients? Are GPs more reluctant to refer young or non-white patients for investigation of possible cancer? Are participants in these groups less willing to accept a referral to investigate possible cancer?"
Dr Georgios Lyratzopoulos, University of Cambridge, Cambridge, UK.
T) +44 (0) 780 359 1859 E) gl290@medschl.cam.ac.uk
Dr Martin Gulliford, King's College London, London, UK.
T) +44 (0)754 0672 869 E) martin.gulliford@kcl.ac.uk
Notes to Editors
*Quote direct from author and cannot be found in text of Article.
Journal
The Lancet Oncology