Study examines number of GP visits before cancer patients are referred to specialists

The study, led by researchers at the University of Cambridge, found that patients with breast, melanoma, testicular and endometrial cancers are more likely to be referred to a specialist after just one or two consultations. However, patients with some less common cancers such as multiple myeloma, pancreatic, stomach and ovarian cancer, as well as patients with lung and colon cancers and lymphomas are more likely to require three or more visits to their family doctor before they are referred to a hospital specialist. Patients with multiple myeloma, a blood cancer that is notoriously difficult to diagnose since it mimics many other conditions, are 18 times more likely to require three or more pre-referral consultations compared with patients with breast cancer.

"These findings highlight limitations in current scientific knowledge about these cancers," said lead investigator Dr Georgios Lyratzopoulos, Clinical Senior Research Associate at the University of Cambridge. "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. Hopefully, our study will stimulate investment into research, focusing on patients with cancers and characteristics where the potential to improve the experience of diagnosis of cancer is greatest."

The researchers have also found that the diagnosis of cancer is more challenging among young patients, women, and older ethnic minority patients – all of these three groups are known to have a lower risk of developing cancer compared with older, male and white patients in the United Kingdom.

These findings amplify similar patterns first reported by co-author Dr Richard Neal, Senior Lecturer in General Practice at Bangor University, among cancer patients who took part in a similar survey that was carried out in 2000. Dr Neal said: "The fact that the diagnosis of cancer may be more challenging in some patient groups and for some cancers can help us to tailor diagnostic efforts. The findings will also inform the forthcoming update of the NICE Guidelines for Referral of Suspected Cancer, which will have an important impact on policy and practice."

The researchers proposed some explanations as to why some of the patient groups were less likely to receive a prompt referral:

• As differences in ethnic minorities were only apparent for older patients, they indicate that communication difficulties may be responsible.
• For bladder cancer, women were more than twice as likely as men to have required three or more consultations with their doctor before a decision to refer to hospital was made. In women, there may be difficulties in discriminating symptoms and signs of bladder cancer from those of benign gynaecological conditions or bladder infection.
• As young people have a lower rate of cancer, the researchers believe GPs are less likely to consider cancer as a possibility.

The research used data from more than 41,000 patients with 24 different cancers who took part in the English National Cancer Patient Experience Survey 2010. (The UK government has indicated that patient experience is a critical aspect of measuring care quality.) The researchers examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer.

"Whilst doctors may have concerns about the accuracy of patient-reported data, we have good reasons to believe the validity of our findings", said co-author Greg Rubin, Professor of General Practice and Primary Care at Durham University. "This is because they correlate well with data collected by general practitioners who took part in the independent National Audit of Diagnosis of Cancer in Primary Care. We hope further strides towards diagnosing cancer earlier will be made through the use of both patient experience and clinical audit data."

In order to improve the promptness of referrals, the study makes recommendations for both clinicians and policy makers. For clinicians, they highlight the need to be more aware of some of the patient groups and cancers which tended to be diagnosed less promptly and the need to participate in data collection to benchmark their practice. They also suggest that policy makers 'should explore and evaluate physician-level educational interventions, further development of point-of-care decisions aids, risk calculators and diagnostic tests, and system re-design to enable greater appropriate and timely use of specialist diagnostic tests (such as imaging or endoscopy)'.

Although the researchers are based in the UK, they believe their findings have implications for other countries as well, as they reflect the difficulties of diagnosis cancers with non-specific symptoms and signs more generally. Most patients subsequently diagnosed with cancer first see a doctor in the community regardless of where they live.

More information: The paper 'Variation in the number of general practitioner consultations before hospital referral for cancer: findings from a national patient experience survey' will be published in the 24 February 2012 edition of The Lancet Oncology.

Provided by University of Cambridge