Cancer Diagnosis In Primary Care Research Articles

Primary care practitioners' priorities for improving the timeliness of cancer diagnosis in primary care: a European cluster-based analysis

BackgroundDiagnosing cancer at an early stage increases the likelihood of survival, and more advanced cancers are more difficult to treat successfully.Primary care practitioners (PCPs) play a key role in timely diagnosis of cancer. PCPs’ knowledge of their own patient populations and health systems could help improve the planning of more effective approaches to earlier cancer recognition and referral.How PCPs act when faced with patients who may have cancer is likely to depend on how their health systems are organised, and this may be one explanation for the wide variation on cancer survival rates across Europe.ObjectivesTo identify and characterise clusters of countries whose PCPs perceive the same factors as being important in improving the timeliness of cancer diagnosis.MethodsA cluster analysis of qualitative data from an online survey was carried out. PCPs answered an open-ended survey question on how the speed of diagnosis of cancer in primary care could be improved. Following coding and thematic analysis, we identified the number of times per country that an item in a theme was mentioned. k-means clustering identified clusters of countries whose PCPs perceived the same themes as most important. Post-hoc testing explored differences between these clusters.SettingTwenty-five primary care centres in 20 European countries. Each centre was asked to recruit at least 50 participants.ParticipantsPrimary care practitioners of each country.ResultsIn all, 1,351 PCPs gave free-text answers. We identified eighteen themes organising the content of the responses. Based on the frequency of the themes, k-means clustering identified three groups of countries. There were significant differences between clusters regarding the importance of: access to tests (p = 0.010); access to specialists (p = 0.014), screening (p < 0.001); and finances, quotas & limits (p < 0.001).ConclusionsOur study identified three distinct clusters of European countries within which PCPs had similar views on the factors that would improve the timeliness of cancer diagnosis. Further work is needed to understand what it is about the clusters that have produced these patterns, allowing healthcare systems to share best practice and to reduce disparities.

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models.

Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta. We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis. Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible. Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.

Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer!

UK cancer survival rates are much lower compared with other high-income countries. In primary care, there are opportunities for GPs and other healthcare professionals to act more quickly in response to presented symptoms that might represent cancer. ThinkCancer! is a complex behaviour change intervention aimed at primary care practice teams to improve the timely diagnosis of cancer. To explore the costs of delivering the ThinkCancer! intervention to expedite cancer diagnosis in primary care. Feasibility economic analysis using a micro-costing approach, which was undertaken in 19 general practices in Wales, UK. From an NHS perspective, micro-costing methodology was used to determine whether it was feasible to gather sufficient economic data to cost the ThinkCancer! Owing to the COVID-19 pandemic, ThinkCancer! was mainly delivered remotely online in a digital format. Budget impact analysis (BIA) and sensitivity analysis were conducted to explore the costs of face-to-face delivery of the ThinkCancer! intervention as intended pre-COVID-19. The total costs of delivering the ThinkCancer! intervention across 19 general practices in Wales was £25 030, with an average cost per practice of £1317 (standard deviation [SD]: 578.2). Findings from the BIA indicated a total cost of £34 630 for face-to-face delivery. Data collection methods were successful in gathering sufficient health economics data to cost the ThinkCancer! Results of this feasibility study will be used to inform a future definitive economic evaluation alongside a pragmatic randomised controlled trial (RCT).

Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study.

BackgroundThe most common route to a diagnosis of cancer is through primary care. Delays in diagnosing cancer occur when an opportunity to make a timely diagnosis is missed and is evidenced by patients visiting the general practitioner (GP) on multiple occasions before referral to a specialist. Tools that minimize prolonged diagnostic intervals and reduce missed opportunities to investigate patients for cancer are therefore a priority.ObjectiveThis study aims to explore the usefulness and feasibility of a novel quality improvement (QI) tool in which algorithms flag abnormal test results that may be indicative of undiagnosed cancer. This study allows for the optimization of the cancer recommendations before testing the efficacy in a randomized controlled trial.MethodsGPs, practice nurses, practice managers, and consumers were recruited to participate in individual interviews or focus groups. Participants were purposively sampled as part of a pilot and feasibility study, in which primary care practices were receiving recommendations relating to the follow-up of abnormal test results for prostate-specific antigen, thrombocytosis, and iron-deficiency anemia. The Clinical Performance Feedback Intervention Theory (CP-FIT) was applied to the analysis using a thematic approach.ResultsA total of 17 interviews and 3 focus groups (n=18) were completed. Participant themes were mapped to CP-FIT across the constructs of context, recipient, and feedback variables. The key facilitators to use were alignment with workflow, recognized need, the perceived importance of the clinical topic, and the GPs’ perception that the recommendations were within their control. Barriers to use included competing priorities, usability and complexity of the recommendations, and knowledge of the clinical topic. There was consistency between consumer and practitioner perspectives, reporting language concerns associated with the word cancer, the need for more patient-facing resources, and time constraints of the consultation to address patients’ worries.ConclusionsThere was a recognized need for the QI tool to support the diagnosis of cancer in primary care, but barriers were identified that hindered the usability and actionability of the recommendations in practice. In response, the tool has been refined and is currently being evaluated as part of a randomized controlled trial. Successful and effective implementation of this QI tool could support the detection of patients at risk of undiagnosed cancer in primary care and assist in preventing unnecessary delays.

Cancer diagnosis in primary care after second pandemic year in Catalonia: a time-series analysis of primary care electronic health records covering about 5 million people.

BackgroundDuring the COVID-19 pandemic, the incidence of chronic disease had drastically been reduced due to health care interruptions. The aim of this study is to analyse cancer diagnosis during the last 2 years of the COVID-19 pandemic.MethodsTime-series study of cancer diagnoses recorded in primary care settings, using data from the primary care electronic health records from January 2014 to December 2021. We obtained the expected monthly rate per 100,000 inhabitants using a time regression adjusted by trend and seasonality. We additionally compared rates of cancer diagnoses in 2019 with those of 2020 and 2021 using the t-test. We performed the analysis globally, by sex and by type of cancer.ResultsIn 2020, the rate of cancer diagnoses had reduced by −21% compared to 2019 (P < 0.05). Greater reductions were observed during the lockdown in early 2020 (>40%) and with some types of cancers, especially prostate and skin cancers (−29.6% and −26.9%, respectively, P < 0.05). Lung cancers presented statistically non-significant reductions in both years. Cancer diagnosis returned to expected around March 2021, and the rate in 2021 was similar to that of 2019 (overall difference of 0.21%, P = 0.967). However, an 11% reduction was still found when comparing the pandemic months of 2020–2021 with pre-pandemic months.ConclusionsAlthough primary care cancer diagnoses in 2021 have returned to pre-pandemic levels, missing diagnoses during the last 2 years have not been fully recovered.

Factors determining development of researchers within a research network on cancer diagnosis in primary care (CanTest): an interview study

ObjectivesDeveloping connections with other researchers in a network, learning informally through these connections and using them to reach goals, is expected to increase research capacity and strengthen performance. So far,...

Physician associate/assistant contributions to cancer diagnosis in primary care: a rapid systematic review

BackgroundSymptom recognition and timely referral in primary care are crucial for the early diagnosis of cancer. Physician assistants or associates (PAs) have been introduced in 18 healthcare systems across the world, with numbers increasing in some cases to address primary care physician shortages. Little is known about their impact on suspected cancer recognition and referral.This review sought to summarise findings from observational studies conducted in high income countries on PAs’ competence and performance on processes concerned with the quality of recognition and referral of suspected cancer in primary care.MethodA rapid systematic review of international peer-reviewed literature was performed. Searches were undertaken on OVID, EMBASE, Web of Science, and CINAHL databases (2009–2019). Studies were eligible if they reported on PA skills, processes and outcomes relevant to suspected cancer recognition and referral. Title and abstract screening was followed by full paper review and data extraction. Synthesis of qualitative and quantitative findings was undertaken on three themes: deployment, competence, and performance. Preliminary findings were discussed with an expert advisory group to inform interpretation.ResultsFrom 883 references, 15 eligible papers were identified, of which 13 were from the USA. Seven studies reported on general clinical processes in primary care that would support cancer diagnosis, most commonly ordering of diagnostic tests (n = 6) and referrals to specialists (n = 4). Fewer papers reported on consultation processes, such as examinations or history taking (n = 3) Six papers considered PAs’ competence and performance on cancer screening. PAs performed similarly to primary care physicians on rates of diagnostic tests ordered, referrals and patient outcomes (satisfaction, malpractice, emergency visits). No studies reported on the timeliness of cancer diagnosis.ConclusionThis review of peer-reviewed literature combined with advisory group interpretation suggests the introduction of PAs into primary care may maintain the quality of referrals and diagnostic tests needed to support cancer diagnosis. It also highlights the lack of research on several aspects of PAs’ roles, including outcomes of the diagnostic process.

Cancer diagnosis in primary care: Six steps to reducing the diagnostic interval.

Primary care providers (PCPs) diagnose approximately 1 cancer per month. However, for each malignancy identified, PCPs evaluate many other patients presenting with potential symptoms of cancer.[1][1] Thresholds for investigation must balance resource use and adverse effects from diagnostic and

Improving early cancer diagnosis in primary care

Primary healthcare professionals are in a vital position to help reduce delays to cancer diagnosis, as they can encourage participation in cancer screening programmes and patients often present to their GP practice with symptoms prior to diagnosis. This article discusses some of the measures that can be taken to increase uptake of cancer screening, raise awareness of symptoms of possible cancer, and help identify which patients may benefit from an urgent cancer referral.

The association between unexpected weight loss and cancer diagnosis in primary care: a matched cohort analysis of 65,000 presentations

BackgroundWe aimed to understand the time period of cancer diagnosis and the cancer types detected in primary care patients with unexpected weight loss (UWL) to inform cancer guidelines.MethodsThis retrospective matched cohort study used cancer registry linked electronic health records from the UK’s Clinical Practice Research Datalink from between 2000 and 2014. Univariable and multivariable time-to-event analyses examined the association between UWL, and all cancers combined, cancer site and stage.ResultsIn all, 63,973 patients had UWL recorded, of whom 1375 (2.2%) were diagnosed with cancer within 2 years (days-to-diagnosis: mean 181; median 80). Men with UWL (HR 3.28 (2.88–3.73)) and women (1.87 (1.68–2.08)) were more likely than comparators to be diagnosed with cancer within 3 months. The association was greatest in men aged ≥50 years and women ≥70 years. The commonest cancers were pancreas, cancer of unknown primary, gastro-oesophageal, lymphoma, hepatobiliary, lung, bowel and renal-tract. The majority were late-stage, but there was some evidence of association with stage II and stage III cancers. In the 3–24 months after presenting with UWL, cancer diagnosis was less likely than in comparators.ConclusionUWL recorded in primary care is associated with a broad range of cancer sites of early and late-stage.

Incidentally diagnosed cancer and commonly preceding clinical scenarios: a cross-sectional descriptive analysis of English audit data

ObjectivesCancer can be diagnosed in the absence of tumour-related symptoms, but little is known about the frequency and circumstances preceding such diagnoses which occur outside participation in screening programmes. We...

Patient–physician relationship and use of gut feeling in cancer diagnosis in primary care: a cross-sectional survey of patients and their general practitioners

ObjectivesTo examine whether the quality of the patient–physician relationship, assessed by the general practitioner (GP) and the patient, associates with GPs’ use of gut feeling (GF) in cancer diagnosis.DesignCross-sectional questionnaire...

Predictive value of inflammatory markers for cancer diagnosis in primary care: a prospective cohort study using electronic health records

BackgroundEarly identification of cancer in primary care is important and challenging. This study examined the diagnostic utility of inflammatory markers (C-reactive protein, erythrocyte sedimentation rate and plasma viscosity) for cancer diagnosis in primary care.MethodsCohort study of 160,000 patients with inflammatory marker testing in 2014, plus 40,000 untested matched controls, using Clinical Practice Research Datalink (CPRD), with Cancer Registry linkage. Primary outcome was one-year cancer incidence.ResultsPrimary care patients with a raised inflammatory marker have a one-year cancer incidence of 3.53% (95% CI 3.37–3.70), compared to 1.50% (1.43–1.58) in those with normal inflammatory markers, and 0.97% (0.87–1.07) in untested controls. Cancer risk is greater with higher inflammatory marker levels, with older age and in men; risk rises further when a repeat test is abnormal but falls if it normalises. Men over 50 and women over 60 with raised inflammatory markers have a cancer risk which exceeds the 3% NICE threshold for urgent investigation. Sensitivities for cancer were 46.1% for CRP, 43.6% ESR and 49.7% for PV.ConclusionCancer should be considered in patients with raised inflammatory markers. However, inflammatory markers have a poor sensitivity for cancer and are therefore not useful as ‘rule-out’ test.

National Cancer Diagnosis Audit: initial results on avoidable delays

BackgroundAn earlier diagnosis of cancer can increase cancer survival and quality of life. Characterising avoidable delays to a patient’s diagnosis of cancer can help to direct quality improvement initiatives.AimTo evaluate avoidable delays to cancer diagnoses and the variation by cancer type and patient characteristics using primary care data collected as part of the National Cancer Diagnosis Audit (NCDA).MethodEnglish general practices participating in the NCDA (439) entered primary care data on patients (17,042) diagnosed with cancer in 2014. Using a taxonomy developed from the National Audit of Cancer Diagnosis in Primary Care (2011), GPs reported delays to the diagnosis that in their judgement were avoidable.ResultsIn 22% of NCDA patient records (n = 3380), the GP considered there to be an avoidable delay to the patient receiving their cancer diagnosis. There was variation by cancer type; 7% of breast cancer patients experienced delays compared to 34% of stomach cancer patients. 49% of avoidable delays occurred in primary care and 38% in secondary or tertiary care. Of all delays, 28% were attributed to clinician factors and 34% to health care system factors. Results will be presented by patient characteristics.ConclusionPrimary care data from the NCDA can be used to better understand potentially avoidable delays to diagnosis and identify possible solutions for improving the diagnostic pathway. Avoidable delays during cancer diagnosis occur for many reasons. These insights can inform quality improvement initiatives, which should be directed at both clinical and organisational factors in primary care and hospital settings.

Symptoms in primary care with time to diagnosis of brain tumours.

BackgroundBrain tumours often present with varied, non-specific features with other diagnoses usually being more likely.ObjectiveTo examine how different symptoms and patient demographics predict variations in time to brain tumour diagnosis.MethodsWe conducted a secondary analysis of brain tumour cases from National Audit of Cancer Diagnosis in Primary Care. We grouped neurological symptoms into six domains (headache, behavioural/cognitive change, focal neurology, ‘fits, faints or falls’, non-specific neurological, and other/non-specific) and calculated times for patient presentation, GP referral, specialist consultation and total pathway interval. We calculated odds ratios (ORs) for symptom domains comparing the slowest to other quartiles.ResultsData were available for 226 cases. Median (interquartile range) time for the total pathway interval was 24 days (7–65 days). The most common presentation was focal neurology (33.2%) followed by ‘fits, faints or falls’ and headache (both 20.8%). Headache only (OR = 4.11, 95% CI = 1.10, 15.5) and memory complaints (OR = 4.82, 95% CI = 1.15, 20.1) were associated with slower total pathway compared to ‘fits, faints or falls’. GPs were more likely to consider that there had been avoidable delays in referring patients with headache only (OR = 4.17, 95% CI = 1.14, 15.3).ConclusionPatients presenting to primary care with headache only or with memory complaints remain problematic with potentially avoidable delays in referral leading to a longer patient pathway. This may or may not impact on the efficacy and morbidity of therapies. Additional aids are required to help doctors differentiate when to refer headaches and memory complaints urgently for a specialist opinion.

John Hector Scotson

John Hector Scotson was a much loved general practitioner, known for his kind, gentle, unhurried, and calm approach. His great listening skills stemmed from a genuine interest in patients and...

The completeness of chest X-ray procedure codes in the Danish National Patient Registry.

ObjectiveThe aim of this validation study was to assess the completeness of the registrations of chest X-rays (CXR) in two different versions of the Danish National Patient Registry (DNPR).Material and methodsWe included electronic record data on CXR performed on patients aged 40 to 99 years from nine radiology departments covering 20 Danish hospitals. From each department, we included data from three randomly selected weeks between 2004 and 2011 (reference standard). In two versions of the DNPR from the State Serum Institute (SSI) and Statistics Denmark, respectively, we investigated the proportion of registered CXR compared to the reference standard. Furthermore, we compared the completeness of the recorded data according to the responsible department (main department).ResultsWe identified 11,235 patients and 12,513 CXR in the reference standard. The data from the SSI contained 12,265 (98%) CXR, whereas the data from Statistics Denmark comprised 9,151 (73.1%) CXR. The completeness of the SSI data was fairly constant across years, radiology departments, medical specialties, and age groups. The data from Statistics Denmark was almost complete in 2011 (95.8%). However, for the remaining study period, the data with radiology departments registered as the main department were lacking in the version from Statistics Denmark, and so the overall completeness was 73.1%.ConclusionThe completeness of CXR registrations varied between 98% and 73% depending on the information source, and this should be considered when investigating radiology services in the basis of DNPR.

Tackling cancers of unmet need: the pancreatic cancer pathway

Tackling cancers of unmet need: the pancreatic cancer pathway

Profiling for primary-care presentation, investigation and referral for liver cancers: evidence from a national audit.

The incidence of liver cancer across Europe is increasing. There is a lack of evidence within the current literature on the identification and investigation of liver cancer within primary care. We aimed to profile liver cancer recognition and assessment as well as the timeliness of liver cancer diagnosis from within the primary-care setting in the UK. Data were obtained from the National Audit of Cancer Diagnosis in Primary Care 2009-2010 and analysed. We calculated the patient interval, the primary-care interval and the number of prereferral consultations for liver cancer. We then compared these data with prior data on the respective indicators for other common cancers. The median patient interval was 9 days (interquartile range 0-31 days), and the median primary-care interval for liver cancer was 11 days (interquartile range 0-40 days). Of the 90 patients, 21 (23.3%) had three or more consultations with their general practitioner before specialist referral. For the three metrics (patient interval, primary-care interval and number of prereferral consultations), liver cancer has average or longer intervals when compared with other cancers. The most common symptomatic presentation of liver cancer within the primary-care setting was right upper quadrant pain (11%), followed by decompensated liver failure (9%). Of the patients, 12% were diagnosed with liver cancer on the basis of an incidental finding of an abnormal liver function test. This study provides a detailed and thorough overview of the recognition of liver cancer and the promptness of liver cancer identification in an English context, and should inform strategies for improving the timeliness of diagnosis.

Oral Cancer Diagnosis in Primary Care

The incidence of oral cancer in the UK is rising, with approximately 7,300 new cases diagnosed in 2012. The number of oral cancer cases in the UK has risen by more than a quarter in the last decade. Mouth cancer is within the ten most common cancers encountered among men in the UK. Primary care practitioners, both in a dental and medical setting, have a role in the early diagnosis of oral malignancy, and in providing patients with information regarding risk factors such as smoking, alcohol and betel quid use. The purpose of this paper is to present the epidemiology and risk factors related to oral cancer and particularly review the literature regarding the level of awareness and practice in primary care as recorded in relevant research.