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Yao M, Kaneko M, Watson J, Irving G. Gut feeling for the diagnosis of cancer in general practice: a diagnostic accuracy review. BMJ Open 2023; 13:e068549. [PMID: 37567752 PMCID: PMC10423799 DOI: 10.1136/bmjopen-2022-068549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 05/31/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVES Diagnostic delay in cancer is a challenge in primary care. Although screening tests are effective in diagnosing some cancers such as breast, colorectal and cervical cancers, symptom-based cancer diagnosis is often difficult due to its low incidence in primary care and the influence of patient anxiety, doctor-patient relationship and psychosocial context. A general practitioner's gut feeling for cancer may play a role in the early diagnosis of cancer in primary care where diagnostic resources are limited. The aim of this study is to summarise existing evidence about the test accuracy of gut feeling (index test) in symptomatic adult patients presenting to general practice, compared with multidisciplinary team-confirmed diagnosis of cancer (reference standard). DESIGN Diagnostic accuracy review following Cochrane methods was performed. DATA SOURCES MEDLINE, EMBASE, Cochrane Library, the Database of Abstracts of Reviews of Effects and Medion databases. ELIGIBILITY CRITERIA Cross-sectional, cohort and randomised studies of test accuracy that compared gut feeling (index test) with an appropriate cancer diagnosis (reference standard). No language or publication status restrictions were applied. We included all studies published before 25 March 2022. DATA EXTRACTION AND SYNTHESIS Methodological quality was appraised, using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria. Meta-analysis with hierarchical summary receiver operating characteristic (HSROC) models was used. RESULTS Of 1286 potentially relevant studies identified, six met the inclusion criteria. For two of the six studies, data could not be extracted despite contacting authors. No studies satisfied all QUADAS-2 criteria. After meta-analysis of data from the remaining studies, the summary point of HSROC had a sensitivity of 0.40 (95% CI: 0.28, 0.53) and a specificity of 0.85 (95% CI: 0.75, 0.92). CONCLUSIONS Gut feeling for cancer when used in symptomatic adult patients in general practice has a relatively low sensitivity and high specificity. When the prevalence of cancer in the symptomatic population presenting in general practice exceeds 1.15%, the performance of gut feeling reaches the National Institute for Health and Care Excellence 3% positive predictive value threshold for action, which recommends urgent access to specialist care and further investigations. The findings support the continued and expanded use of gut feeling items in referral pathways.
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Affiliation(s)
- Masahiro Yao
- Department of Family and Community Medicine, Department of Health Data Science, Yokohama Hodogaya Central Hospital, Japan Community Healthcare Organization, Yokohama City University, Yokohama, Japan
| | - Makoto Kaneko
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Jessica Watson
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Greg Irving
- Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
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Stolper CF, van de Wiel MWJ, van Bokhoven MA, Dinant GJ, Van Royen P. Patients’ gut feelings seem useful in primary care professionals’ decision making. BMC PRIMARY CARE 2022; 23:178. [PMID: 35858872 PMCID: PMC9301863 DOI: 10.1186/s12875-022-01794-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 07/12/2022] [Indexed: 11/24/2022]
Abstract
Background Family physicians’ diagnostic gut feelings have proved to be valuable. But what about patients’ gut feelings? Research has shown that patients’ gut feelings may contribute to their physicians’ clinical reasoning. Dutch medical tribunals consider patients’ worry useful for doctors’ diagnostic process. However, how general practitioners and other primary care professionals recognize gut feelings of patients and deal with them in their decision making is yet unclear. We aim to explore how primary care professionals perceive patients’ gut feelings and use this information in their decision-making. Methods We interviewed 30 Dutch and Belgian primary care professionals, exploring how they recognize and value patients’ gut feelings. We coded all interviews using a descriptive content analysis in an iterative process. Data sufficiency was achieved. Results Primary care professionals acknowledged gut feelings in their patients, and most participants found them a useful source of information. Patients’ gut feelings might alert them to possible hidden problems and might provide quicker insight into patients’ perceptions. Primary care professionals listed a whole series of wordings relating to trusting or distrusting the situation or to any changes in normal patterns. A patient’s gut feeling was often a reason for the professionals to explore patients’ worries and to reconsider their own clinical reasoning. Conclusions Primary care professionals regularly considered patients’ gut feelings useful, as they might contribute to their clinical reasoning and to a deeper understanding of the patient’s problem. The next step could be to ask patients themselves about their gut feelings and explore their diagnostic value.
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Prospective Observational Study on the Prevalence and Diagnostic Value of General Practitioners' Gut Feelings for Cancer and Serious Diseases. J Gen Intern Med 2022; 37:3823-3831. [PMID: 35088202 PMCID: PMC8794040 DOI: 10.1007/s11606-021-07352-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND General practitioners (GPs) have recognized the presence of gut feelings in their diagnostic process. However, little is known about the frequency or determinants of gut feelings or the diagnostic value of gut feelings for cancer and other serious diseases. OBJECTIVE To assess the prevalence of gut feelings in general practice, examine their determinants and impact on patient management, and measure their diagnostic value for cancer and other serious diseases. DESIGN This prospective observational study was performed using the Gut Feelings Questionnaire (GFQ). PARTICIPANTS Participants included 155 GPs and 1487 of their patients, from four Spanish provinces. MAIN MEASURES Sociodemographic data from patients and GPs; the reasoning style of GPs; the characteristics of the consultation; the presence and kind of gut feeling; the patient's subsequent contacts with the health system; and new cancer and serious disease diagnoses reported at 2 and 6 months post-consultation. KEY RESULTS GPs experienced a gut feeling during 97% of the consultations: a sense of reassurance in 75% of consultations and a sense of alarm in 22% of consultations. A sense of alarm was felt at higher frequency given an older patient, the presence of at least one cancer-associated symptom, or a non-urban setting. GPs took diagnostic action more frequently after a sense of alarm. After 2 months, the sense of alarm had a sensitivity of 59% for cancer and other serious diseases (95% CI 47-71), a specificity of 79% (95% CI 77-82), a positive predictive value of 12% (95% CI 9-16), and a negative predictive value of 98% (95% CI 86-98). CONCLUSIONS Gut feelings are consistently present in primary care medicine, and they play a substantial role in a GP's clinical reasoning and timely diagnosis of serious disease. The sense of alarm must be taken seriously and used to support diagnostic evaluation in patients with a new reason for encounter.
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Diagnoses after newly-recorded abdominal pain in primary care: observational cohort study. Br J Gen Pract 2022; 72:e564-e570. [PMID: 35760565 PMCID: PMC9242675 DOI: 10.3399/bjgp.2021.0709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Non-acute abdominal pain in primary care is diagnostically challenging. Aim To quantify the 1-year cumulative incidence of 35 non-malignant diagnoses and nine cancers in adults after newly recorded abdominal pain in primary care. Design and setting Observational cohort study of 125 793 Clinical Practice Research Datalink GOLD records. Method Participants, aged ≥40 years, had newly recorded abdominal pain between 1 January 2009 and 31 December 2013. Age- and sex-stratified 1-year cumulative incidence by diagnosis is reported. Results Most (>70%) participants had no pre-specified diagnoses after newly recorded abdominal pain. Non-malignant diagnoses were most common: upper gastrointestinal problems (gastro-oesophageal reflux disease, hiatus hernia, gastritis, oesophagitis, and gastric/duodenal ulcer) in males and urinary tract infection in females. The incidence of upper gastrointestinal problems plateaued at age ≥60 years (aged 40–59 years: males 4.9%, 95% confidence interval [CI] = 4.6 to 5.1, females 4.0%, 95% CI = 3.8 to 4.2; aged 60–69 years: males 5.8%, 95% CI = 5.4 to 6.2, females 5.4%, 95% CI = 5.1 to 5.8). Urinary tract infection incidence increased with age (aged 40–59 years: females 5.1%, 95% CI = 4.8 to 5.3, males 1.1%, 95% CI = 1.0 to 1.2; aged ≥70 years: females 8.0%, 95% CI = 7.6 to 8.4, males 3.3%, 95% CI = 3.0 to 3.6%). Diverticular disease incidence rose with age, plateauing at 4.2% (95% CI = 3.9 to 4.6) in males aged ≥60 years, increasing to 6.1% (95% CI = 5.8 to 6.4) in females aged ≥70 years. Irritable bowel syndrome incidence was higher in females (aged 40–59 years: 2.9%, 95% CI = 2.7 to 3.1) than males (aged 40–59 years: 2.1%, 95% CI = 1.9 to 2.3), decreasing with age to 1.3% (95% CI = 1.2 to 1.5) in females and 0.6% (95% CI = 0.5 to 0.8) in males aged ≥70 years. Conclusion Although abdominal pain commonly remains unexplained, non-malignant diagnosis are more likely than cancer.
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Hardy V, Yue A, Archer S, Merriel SWD, Thompson M, Emery J, Usher-Smith J, Walter FM. Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review. BMJ Open 2022; 12:e053732. [PMID: 35074817 PMCID: PMC8788239 DOI: 10.1136/bmjopen-2021-053732] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/23/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors have been suggested to affect decisions to investigate cancer, but their influence is poorly understood. OBJECTIVE To synthesise evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer. METHODS We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referrals for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice. DATA EXTRACTION AND SYNTHESIS Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We, therefore, performed a narrative synthesis. RESULTS 29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical judgement of symptoms as suspicious or 'alarm' prompted more investigations than non-alarm symptoms. 'Gut feeling' predicted a subsequent cancer diagnosis and was perceived to facilitate decisions to investigate non-specific symptoms as PCP experience increased. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive. CONCLUSIONS PCP interpretation of symptoms as higher risk facilitated testing and referral decisions for possible cancer. However, in the absence of 'alarm' symptoms or 'gut feeling', PCPs may not investigate cancer. PCPs require strategies for identifying patients with non-alarm and non-specific symptoms who need testing or referral. PROSPERO REGISTRATION NUMBER CRD420191560515.
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Affiliation(s)
- Victoria Hardy
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Adelaide Yue
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne VCCC, Parkville, Victoria, Australia
| | - Juliet Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Virgilsen LF, Pedersen AF, Vedsted P, Petersen GS, Jensen H. Alignment between the patient's cancer worry and the GP's cancer suspicion and the association with the interval between first symptom presentation and referral: a cross-sectional study in Denmark. BMC FAMILY PRACTICE 2021; 22:129. [PMID: 34167486 PMCID: PMC8228922 DOI: 10.1186/s12875-021-01480-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/04/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND General practitioners (GPs) have a key role in the diagnosis of cancer. It is crucial to identify factors influencing the decision to refer for suspected cancer. The aim of this study was to investigate the alignment between the patient's cancer worry and the GP's suspicion of cancer in the first clinical encounter and the association with the time interval from the first symptom presentation until the first referral to specialist care, i.e. the primary care interval (PCI). METHOD The study was performed as a cross-sectional study using survey data on patients diagnosed with incident cancer in 2010 or 2016 and their GPs in Denmark. We defined four alignment groups: 1) patient worry and GP suspicion, 2) GP suspicion only, 3) patient worry only, and 4) none of the two. A long PCI was defined as an interval longer than the 75th percentile. RESULTS Among the 3333 included patients, both patient worry and GP suspicion was seen in 39.5%, only GP suspicion was seen in 28.2%, only patient worry was seen in 13.6%, and neither patient worry nor GP suspicion was seen in 18.2%. The highest likelihood of long PCI was observed in group 4 (group 4 vs. group 1: PPR 3.99 (95% CI 3.34-4.75)), mostly pronounced for easy-to-diagnose cancer types. CONCLUSION Misalignment between the patient's worry and the GP's suspicion was common at the first cancer-related encounter. Importance should be given to the patient interview, due to a potential delayed GP referral among patients diagnosed with "easy-to-diagnose" cancer types presenting with unspecific symptoms.
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Affiliation(s)
- Line Flytkjær Virgilsen
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anette Fischer Pedersen
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus C, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus C, Denmark
| | | | - Henry Jensen
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark
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Cavers D, Duff R, Bikker A, Barnett K, Kanguru L, Weller D, Brewster DH, Campbell C. Patient and GP experiences of pathways to diagnosis of a second primary cancer: a qualitative study. BMC Cancer 2021; 21:496. [PMID: 33941114 PMCID: PMC8094599 DOI: 10.1186/s12885-021-08238-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 04/22/2021] [Indexed: 01/25/2023] Open
Abstract
Background More people are surviving a first primary cancer and experiencing a second, different cancer. However, little is known about the diagnostic journeys of patients with second primary cancer (SPC). This study explores the views of patients and general practitioners (GPs) on their experiences of pathways to diagnosis of SPC, including the influence of a previous diagnosis of cancer on symptom appraisal, help-seeking and referral decisions. Methods Qualitative interviews with patients with a SPC diagnosis and case-linked GP interviews in a Scottish primary care setting. In-depth face to face or telephone interviews were conducted, underpinned by a social constructionist approach. Interviews were transcribed and Braun and Clarke’s thematic analysis undertaken. Three analysts from the research team read transcripts and developed the coding framework using QSR NVivo version 10, with input from a fourth researcher. Themes were developed from refined codes and interpreted in the context of existing literature and theory. Results Interviews were conducted with 23 patients (aged 43–84 years) with a SPC diagnosis, and 7 GPs. Five patient themes were identified: Awareness of SPC, symptom appraisal and help-seeking, pathways to diagnosis, navigating the healthcare system, and impact of SPC. GPs interviews identified: experience and knowledge of SPC and referrals and decision-making. Conclusions Insights into the pathway to diagnosis of SPC highlights the need for increased awareness of and vigilance for SPC among patients and healthcare providers (HCPs), and emotional support to manage the psychosocial burden. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08238-0.
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Affiliation(s)
- Debbie Cavers
- Usher Institute of Population Health Sciences, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK.
| | - Rhona Duff
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Annemieke Bikker
- Usher Institute of Population Health Sciences, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Karen Barnett
- Population Health and Genomics, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, DD1 9SY, UK
| | - Lovney Kanguru
- NCJDRSU, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK
| | - David Weller
- Usher Institute of Population Health Sciences, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
| | - David H Brewster
- Usher Institute of Population Health Sciences, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Christine Campbell
- Usher Institute of Population Health Sciences, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
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Vasilakis C, Forte P. Setting up a rapid diagnostic clinic for patients with vague symptoms of cancer: a mixed method process evaluation study. BMC Health Serv Res 2021; 21:357. [PMID: 33865373 PMCID: PMC8052708 DOI: 10.1186/s12913-021-06360-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 04/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background The study sought to evaluate the impact of a Rapid Diagnostic Clinic (RDC) service designed to improve general practitioner (GP) referral processes for patients who do not meet existing referral criteria yet present with vague - but potentially concerning - symptoms of cancer. We sought to investigate how well the RDC has performed in the views of local GPs and patients, and through analysis of its activity and performance in the first two years of operation. Methods The study setting was a single, hospital-based RDC clinic in a University Health Board in South Wales. We used a mixed-method process evaluation study, including routinely collected activity and diagnosis data. All GPs were invited to participate in an online survey (34/165 responded), and a smaller group (n = 8) were interviewed individually. Two focus groups with patients and their carers (n = 7) provided in-depth personal accounts of their experiences. Results The focus groups revealed high rates of patient satisfaction with the RDC. GPs were also overwhelmingly positive about the value of the RDC to their practice. There were 574 clinic attendances between July 2017 and March 2019; the mean age of attendees was 68, 57% were female, and approximately 30% had three or more vague symptoms. Of those attending, we estimated between 42 to 71 (7.3 and 12.3%) received preliminary cancer diagnoses. Median time from GP referral to RDC appointment was 12 days; from GP referral to cancer diagnosis was 34 days. Overall, 73% of RDC patients received either a new diagnosis (suspected cancer 23.2%, non-cancer 35.9%) or an onward referral to secondary care for further investigation with no new diagnosis (13.9%), and 27% were referred to primary care with no new diagnosis. Conclusions The RDC appears to enable a good patient experience in cancer diagnosis. Patients are seen in timely fashion, and the service is highly regarded by them, their carers, and referring GPs. Although too early to draw conclusions about long-term patient outcomes, there are strong indications to suggest that this model of service provision can set higher standards for a strongly patient-centred service. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06360-0.
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Affiliation(s)
- Christos Vasilakis
- Centre for Healthcare Innovation and Improvement (CHI2), School of Management, University of Bath, Bath, UK.
| | - Paul Forte
- Centre for Healthcare Innovation and Improvement (CHI2), School of Management, University of Bath, Bath, UK
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Virgilsen LF, Jensen H, Pedersen AF, Zalounina Falborg A, Vedsted P. Patient's worry about cancer and the general practitioner's suspicion of cancer or serious illness: A population-based study in Denmark. Eur J Cancer Care (Engl) 2021; 30:e13411. [PMID: 33511723 DOI: 10.1111/ecc.13411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/01/2020] [Accepted: 01/06/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE A general practitioner's (GP's) suspicion of cancer is important to ensure early diagnosis of cancer. This study aimed to investigate the association between patients' cancer worry and GP's suspicion of cancer or serious illness. METHODS This population-based study was based on Danish register and questionnaire data from 4,175 incident cancer patients diagnosed in 2010 or 2016 and their GPs. The association between the patient's worry about cancer and their GP's suspicion of cancer or serious illness was estimated by generalised linear models with log link for the Poisson family and presented in prevalence rate ratios (PRR). RESULTS For 6 in 10 of the cases, the first consultation was categorised by absence of both or either patient worry or GP suspicion. When patients worried about cancer, the GPs were more likely to suspect cancer or serious illness in patients (PRR=1.26, (95%CI: 1.20-1.34)). For all levels of patient worry and most pronounced among very worried patients, GPs less often suspected cancer or serious illness in patients who presented with an ´intermediate´ or ´hard´ to diagnose cancer. CONCLUSION GPs were more likely to suspect cancer or serious illness in patients who worried about cancer at the first presentation.
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Affiliation(s)
- Line Flytkjaer Virgilsen
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus C, Denmark
| | - Henry Jensen
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus C, Denmark
| | - Anette Fischer Pedersen
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus C, Denmark
| | - Alina Zalounina Falborg
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus C, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus C, Denmark
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Smith CF, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract 2020; 70:e612-e621. [PMID: 32839162 PMCID: PMC7449376 DOI: 10.3399/bjgp20x712301] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice. AIM To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility. DESIGN AND SETTING Systematic review and meta-analysis of international research on GPs' gut feelings in primary care. METHOD Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings. RESULTS Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval. CONCLUSION GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers.
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Affiliation(s)
| | - Sarah Drew
- London School of Economics and Political Science, London
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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Virgilsen LF, Hvidberg L, Vedsted P. Patient's travel distance to specialised cancer diagnostics and the association with the general practitioner's diagnostic strategy and satisfaction with the access to diagnostic procedures: an observational study in Denmark. BMC FAMILY PRACTICE 2020; 21:97. [PMID: 32475346 PMCID: PMC7262770 DOI: 10.1186/s12875-020-01169-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/17/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Research indicate that when general practitioners (GPs) refer their patients for specialist care, the patient often has long distance. This study had a twofold aim: in accordance to the GP's suspicion of cancer, we investigated the association between: 1) cancer patient's travel distance to the first specialised diagnostic facility and the GP's diagnostic strategy and 2) cancer patient's travel distance to the first specialised diagnostic facility and satisfaction with the waiting time and the availability of diagnostic investigations. METHOD This combined questionnaire- and registry-based study included incident cancer patients diagnosed in the last 6 months of 2016 where the GP had been involved in the diagnostic process of the patients prior to their diagnosis of cancer (n = 3455). The patient's travel distance to the first specialised diagnostic facility was calculated by ArcGIS Network Analyst. The diagnostic strategy, cancer suspicion and the GP's satisfaction with the waiting times and the available investigations were assessed from GP questionnaires. RESULTS When the GP did not suspect cancer or serious illness, an insignificant tendency was seen that longer travel distance to the first specialised diagnostic facility increased the likelihood of the GP using 'wait-and-see' approach and 'medical treatment' as diagnostic strategies. The GPs of patients with travel distance longer than 49 km to the first specialised diagnostic facility were more likely to report dissatisfaction with the waiting time for requested diagnostic investigations (PR: 1.98, 95% CI: 1.20-3.28). CONCLUSION A insignificant tendency to use 'wait-and-see' and 'medical treatment' were seen among GPs of patients with long travel distance to the first diagnostic facility when the GP did not suspect cancer or serious illness. Long distance was associated with higher probability of GP dissatisfaction with the waiting time for diagnostic investigations.
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Affiliation(s)
- Line Flytkjær Virgilsen
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000 Aarhus C, Denmark
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Line Hvidberg
- Department of Quality and Improvement, Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus, Bartholins Allé 2, 8000 Aarhus C, Denmark
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
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Pearson C, Poirier V, Fitzgerald K, Rubin G, Hamilton W. Cross-sectional study using primary care and cancer registration data to investigate patients with cancer presenting with non-specific symptoms. BMJ Open 2020; 10:e033008. [PMID: 31924638 PMCID: PMC6955554 DOI: 10.1136/bmjopen-2019-033008] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Patients presenting to primary care with site-specific alarm symptoms can be referred onto urgent suspected cancer pathways, whereas those with non-specific symptoms currently have no dedicated referral routes leading to delays in cancer diagnosis and poorer outcomes. Pilot Multidisciplinary Diagnostic Centres (MDCs) provide a referral route for such patients in England. OBJECTIVES This work aimed to use linked primary care and cancer registration data to describe diagnostic pathways for patients similar to those being referred into MDCs and compare them to patients presenting with more specific symptoms. METHODS This cross-sectional study linked primary care data from the National Cancer Diagnosis Audit (NCDA) to national cancer registration and Route to Diagnosis records. Patient symptoms recorded in the NCDA were used to allocate patients to one of two groups - those presenting with symptoms mirroring referral criteria of MDCs (non-specific but concerning symptoms (NSCS)) and those with at least one site-specific alarm symptom (non-NSCS). Descriptive analyses compared the two groups and regression analysis by group investigated associations with long primary care intervals (PCIs). RESULTS Patients with NSCS were more likely to be diagnosed at later stage (32% stage 4, compared with 21% in non-NSCS) and via an emergency presentation (34% vs 16%). These patients also had more multiple pre-referral general practitioner consultations (59% vs 43%) and primary care-led diagnostics (blood tests: 57% vs 35%). Patients with NSCS had higher odds of having longer PCIs (adjusted OR: 1.24 (1.11 to 1.36)). Patients with lung and urological cancers also had higher odds of longer PCIs overall and in both groups. CONCLUSIONS Differences in the diagnostic pathway show that patients with symptoms mirroring the MDC referral criteria could benefit from a new referral pathway.
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Affiliation(s)
- Clare Pearson
- Policy and Information, Cancer Research UK, London, UK
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | | | | | - Greg Rubin
- Institute of Health and Society, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Willie Hamilton
- Primary Care, Medical School, University of Exeter, Exeter, UK
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Belciug S. The beginnings. Artif Intell Cancer 2020. [DOI: 10.1016/b978-0-12-820201-2.00002-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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14
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Association between GPs' suspicion of cancer and patients' usual consultation pattern in primary care: a cross-sectional study. Br J Gen Pract 2019; 69:e80-e87. [PMID: 30642908 DOI: 10.3399/bjgp19x700769] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 07/13/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Patients who rarely consult a GP in the 19-36 months before a cancer diagnosis have more advanced cancer at diagnosis and a worse prognosis. To ensure more timely diagnosis of cancer, the GP should suspect cancer as early as possible. AIM To investigate the GP's suspicion of cancer according to the patient with cancer's usual consultation pattern in general practice. DESIGN AND SETTING A cross-sectional study based on survey data from general practice of 3985 Danish patients diagnosed with cancer from May 2010 to August 2010, and linked to national register data. METHOD Using logistic regression analysis with restricted cubic splines, the odds ratio (OR) of the GP to suspect cancer as a function of the patient's number of face-to-face consultations with the GP in the 19-36 months before a cancer diagnosis was estimated. RESULTS GPs' cancer suspicion decreased with higher usual consultation frequency in general practice. A significant decreasing trend in ORs for cancer suspicion was seen across usual consultation categories overall (P<0.001) and for each sex (males: P<0.05; females: P<0.05). GPs' cancer suspicion was lower in patients aged <55 years in both rare and frequent attenders compared with average attenders. CONCLUSION GPs suspect cancer more often in rare attenders ≥55 years. GPs' cancer suspicion was lower in younger patients (<55 years), in both rare and frequent attenders. GPs should be aware of possible missed opportunities for cancer diagnosis in young attenders and use safety netting to reduce the risk of missing a cancer diagnosis.
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15
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Nielsen N, Vedsted P, Jensen H. Risk of cancer and repeated urgent referral after negative investigation for cancer. Fam Pract 2018; 35:582-588. [PMID: 29420706 DOI: 10.1093/fampra/cmx138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Many countries have implemented cancer patient pathways (CPPs) for organ-specific cancers. However, due to high symptom diversity, it can be difficult for the General Practitioner (GP) to decide on the appropriate CPP. OBJECTIVE The aim of this study was to estimate the proportion of patients who were referred to a second CPP, were diagnosed with cancer or died within 6 months after receiving a negative result from clinical investigation through an initial CPP. METHODS We conducted a historical cohort study using routinely collected data with 6 months of follow-up. Data were collected from Danish registries. RESULTS We included 109998 study subjects: 0.6% received a cancer diagnosis, 2.3% died and 6.1% were referred to a second CPP within 6 months. A total of 48.9% of the re-referrals after a first CPP in the gastrointestinal (GI) area were also referred to a second CPP in the GI area. Re-referral to a second CPP corresponded to a positive predictive value (PPV) of 4.4% to be diagnosed with cancer. CONCLUSION A total of 6% of patients who received a negative result after investigation in an organ-specific CPP were re-referred within 6 months to a new organ-specific CPP; many of these were in the same anatomical area as the first CPP. The PPV of 4.4% to be diagnosed with cancer indicates that some cancers may be missed in the diagnostic investigation through the first CPP. This calls for reconsideration of how CPPs may best support the primary cancer diagnosis.
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Affiliation(s)
- Ninna Nielsen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Henry Jensen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark
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16
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Friis Abrahamsen C, Ahrensberg JM, Vedsted P. Utilisation of primary care before a childhood cancer diagnosis: do socioeconomic factors matter?: A Danish nationwide population-based matched cohort study. BMJ Open 2018; 8:e023569. [PMID: 30121615 PMCID: PMC6104784 DOI: 10.1136/bmjopen-2018-023569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Early diagnosis of childhood cancer is critical. Nevertheless, little is known about the potential role of inequality. This study aims to describe the use of primary care 2 years before a childhood cancer diagnosis and to investigate whether socioeconomic factors influence the use of consultations and diagnostic tests in primary care. DESIGN A national population-based matched cohort study. SETTING AND PARTICIPANTS This study uses observational data from four Danish nationwide registers. All children aged 0-15 diagnosed with cancer during 2008-2015 were included (n=1386). Each case was matched based on gender and age with 10 references (n=13 860). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was additional rates for consultations and for invoiced diagnostic tests for children with cancer according to parental socioeconomic factors. Furthermore, we estimated the association between socioeconomic factors and frequent use of consultations, defined as at least four consultations, and the odds of receiving a diagnostic test within 3 months of diagnosis. RESULTS Children with cancer from families with high income had 1.46 (95% CI 1.23 to 1.69) additional consultations 3 months before diagnosis, whereas children from families with low income had 1.85 (95% CI 1.60 to 2.11) additional consultations. The highest odds of frequent use of consultations was observed among children from low-income families (OR: 1.94, 95% CI 1.24 to 3.03). A higher odds of receiving an invoiced diagnostic test was seen for children from families with mid-educational level (OR: 1.46, 95% CI 1.09 to 1.95). CONCLUSION We found a socioeconomic gradient in the use of general practice before a childhood cancer diagnosis. This suggests that social inequalities exist in the pattern of healthcare utilisation in general practice.
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Affiliation(s)
| | - Jette Møller Ahrensberg
- Department of Clinical Medicine, Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
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17
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Jørgensen SF, Ravn P, Thorsen S, Worm SW. Characteristics and outcome in patients with non-specific symptoms and signs of cancer referred to a fast track cancer patient pathway; a retrospective cohort study. BMC Cancer 2017; 17:809. [PMID: 29197366 PMCID: PMC5712161 DOI: 10.1186/s12885-017-3826-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/23/2017] [Indexed: 11/21/2022] Open
Abstract
Background In 2012 a new cancer patient pathway for patients with non-specific symptoms and signs of cancer (NSSC-CPP) was introduced in Denmark. Limited information is available about the patients referred to the NSSC-CPP and the investigational course. The aim was to describe the population and the investigational course, estimate the prevalence of cancer and one-year mortality, and identify factors associated with a subsequent cancer diagnosis in patients referred to the NSSC-CPP. Method This cohort study included patients with at least one visit at the NSSC-CPP at North Zealand Hospital in Denmark (NOH) from October 1st 2013 to September 30th 2014. Data was based on retrospective reviews of the patient files. Logistic regression identified factors associated with a subsequent cancer diagnosis. Multivariate analyses were adjusted by age, gender, smoking status and alcohol consumption. Kaplan-Meier survival plots were made at one-year follow-up. Results Eight hundred twenty-five patients were included with a median age of 67 years, 47.4% were male. Prevalence of cancer within one year was 16.7% (138/825). 70.3% (97/138) were solid cancers and 29.7% (41/138) were haematological cancers. During the investigational course 76.7% went through advanced diagnostic imaging (ultrasound, CT, FDG-PET/CT or MRI). Anaemia (OR1.63 CI1.02–2.60), leucocytosis (OR 2.06 CI 1.34–3.15), thrombocytopenia (OR 4.13 CI 2.02–8.47) and elevated LDH (OR 1.64 CI 1.07–2.52) and CRP (OR 2.56 CI 1.66–3.95) were associated with a cancer diagnosis when adjusting for possible confounders. No single non-specific symptom was significantly associated with a cancer diagnosis. One-year mortality for those diagnosed with cancer was 44.2%. Conclusion The prevalence of cancer matches that of another NSSC-CPP in Denmark. Deviations in basic biochemistry were associated with a higher probability of underlying cancer and could possibly raise the level of suspicion of malignancy among physicians. High one-year mortality was seen amongst patients diagnosed with cancer.
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Affiliation(s)
- Sara Falk Jørgensen
- Department of Pulmonary and Infectious Diseases, University Hospital, North Zealand Hospital, Hillerød, Denmark. .,Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark.
| | - Pernille Ravn
- Department of Pulmonary and Infectious Diseases, University Hospital, North Zealand Hospital, Hillerød, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Søren Thorsen
- Department of Pulmonary and Infectious Diseases, University Hospital, North Zealand Hospital, Hillerød, Denmark
| | - Signe Westring Worm
- Department of Infectious Diseases, University Hospital Rigshospitalet, Copenhagen, Denmark
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Adam R, Garau R, Raja EA, Jones B, Johnston M, Murchie P. Do patients' faces influence General Practitioners' cancer suspicions? A test of automatic processing of sociodemographic information. PLoS One 2017; 12:e0188222. [PMID: 29166652 PMCID: PMC5699847 DOI: 10.1371/journal.pone.0188222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 11/02/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Delayed cancer diagnosis leads to poorer patient outcomes. During short consultations, General Practitioners (GPs) make quick decisions about likelihood of cancer. Patients' facial cues are processed rapidly and may influence diagnosis. AIM To investigate whether patients' facial characteristics influence immediate perception of cancer risk by GPs. DESIGN AND SETTING Web-based binary forced choice experiment with GPs from Northeast Scotland. METHOD GPs were presented with a series of pairs of face prototypes and asked to quickly select the patient more likely to have cancer. Faces were modified with respect to age, gender, and ethnicity. Choices were analysed using Chi-squared goodness-of-fit statistics with Bonferroni corrections. RESULTS Eighty-two GPs participated. GPs were significantly more likely to suspect cancer in older patients. Gender influenced GP cancer suspicion, but this was modified by age: the male face was chosen as more likely to have cancer than the female face for young (72% of GPs;95% CI 61.0-87.0) and middle-aged faces (65.9%; 95% CI 54.7-75.5); but 63.4% (95% CI 52.2-73.3) decided the older female was more likely to have cancer than the older male (p = 0.015). GPs were significantly more likely to suspect cancer in the young Caucasian male (65.9% (95% CI 54.7, 75.5)) compared to the young Asian male (p = 0.004). CONCLUSION GPs' first impressions about cancer risk are influenced by patient age, gender, and ethnicity. Tackling GP cognitive biases could be a promising way of reducing cancer diagnostic delays, particularly for younger patients.
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Affiliation(s)
- Rosalind Adam
- Centre for Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
- * E-mail:
| | - Roberta Garau
- Centre for Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Edwin Amalraj Raja
- Medical Statistics, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Benedict Jones
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom
| | - Marie Johnston
- Aberdeen Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Peter Murchie
- Centre for Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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Cancer suspicion in general practice, urgent referral, and time to diagnosis: a population-based GP survey nested within a feasibility study using information technology to flag-up patients with symptoms of colorectal cancer. BJGP Open 2017; 1:bjgpopen17X101109. [PMID: 30564682 PMCID: PMC6169933 DOI: 10.3399/bjgpopen17x101109] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Patients with symptoms of possible colorectal cancer are not always referred for investigation. Aim To ascertain barriers and facilitators to GP referral of patients meeting the National Institute for Health and Care Excellence (NICE) guidelines for urgent referral for suspected colorectal cancer. Design & setting Qualitative study in the context of a feasibility study using information technology in GP practices to flag-up patients meeting urgent referral criteria for colorectal cancer. Method Semi-structured interview with 18 GPs and 12 practice managers, focusing on early detection of colorectal cancer, issues in the use of information technology to identify patients and GP referral of these patients for further investigation were audiotaped, transcribed verbatim, and analysed according to emergent themes. Results There were two main themes: wide variation in willingness to refer and uncertainty about whether to refer; and barriers to referral. Three key messages emerged: there was a desire to avoid over-referral, lack of knowledge of guidelines, and the use of individually-derived decision rules for further investigation or referral of symptoms. Some GPs were unaware that iron deficiency anaemia or persistent diarrhoea are urgent referral criteria. Alternatives to urgent referral included undertaking no investigations, trials of iron therapy, use of faecal occult blood tests (FOBt) and non-urgent referral. In minority ethnic groups (South Asians) anaemia was often accepted as normal. Concerns about over-referral were linked to financial pressures and perceived criticism by healthcare commissioners, and a reluctance to scare patients by discussing suspected cancer. Conclusion GPs’ lack of awareness of referral guidelines and concerns about over-referral are barriers to early diagnosis of colorectal cancer.
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Næser E, Fredberg U, Møller H, Vedsted P. Clinical characteristics and risk of serious disease in patients referred to a diagnostic centre: A cohort study. Cancer Epidemiol 2017; 50:158-165. [PMID: 28781173 DOI: 10.1016/j.canep.2017.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Little is known about the clinical characteristics of patients referred to a diagnostic centre through the Danish urgent referral pathway for non-specific serious symptoms. We aimed at estimating the distribution of serious disease and the diagnostic value of clinical characteristics for the diagnosis of cancer and serious non-malignant disease in these patients. METHOD A cohort study of 938 patients referred by their GP to the diagnostic centre at Silkeborg Regional Hospital. All patients were followed up for three months in national registries. The likelihood ratio (LR) of cancer or serious non-malignant disease were calculated in relation to clinical characteristics. RESULTS A total of 327 (34.9%) patients were diagnosed with new serious disease within three months: 118 patients (12.6%) with malignant disease and 209 patients (22.3%) with non-malignant disease. Most patients presented general symptoms. The highest LR of cancer was found for abdominal mass, high lactate dehydrogenase or abnormal findings in the diagnostic imaging. The highest LR of non-malignant disease was found for swollen joints or abnormal auscultation of lung or chest. CONCLUSIONS Patients referred by their GP to the diagnostic centre have high risk of serious disease. A multidisciplinary diagnostic approach is needed to embrace the diagnostic spectrum.
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Affiliation(s)
- Esben Næser
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600 Silkeborg, Denmark.
| | - Ulrich Fredberg
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600 Silkeborg, Denmark
| | - Henrik Møller
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Cancer Epidemiology and Population Health, King's College London, Great Maze Pond, London SE1 9RT, United Kingdom
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark; Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1-3, 8600 Silkeborg, Denmark
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21
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Holtedahl K, Vedsted P, Borgquist L, Donker GA, Buntinx F, Weller D, Braaten T, Hjertholm P, Månsson J, Strandberg EL, Campbell C, Ellegaard L, Parajuli R. Abdominal symptoms in general practice: Frequency, cancer suspicions raised, and actions taken by GPs in six European countries. Cohort study with prospective registration of cancer. Heliyon 2017; 3:e00328. [PMID: 28707001 PMCID: PMC5484975 DOI: 10.1016/j.heliyon.2017.e00328] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 04/03/2017] [Accepted: 06/12/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Abdominal symptoms are diagnostically challenging to general practitioners (GPs): although common, they may indicate cancer. In a prospective cohort of patients, we examined abdominal symptom frequency, initial diagnostic suspicion, and actions of GPs in response to abdominal symptoms. METHODS Over a 10-day period, 493 GPs in Norway, Denmark, Sweden, Belgium, the Netherlands, and Scotland, recorded consecutive consultations: sex, date of birth and any specified abdominal symptoms. For patients with abdominal symptoms, additional data on non-specific symptoms, GPs' diagnostic suspicion, and features of the consultation were noted. Data on all cancer diagnoses among all included patients were requested from the GPs eight months later. FINDINGS Consultations with 61802 patients were recorded. Abdominal symptoms were recorded in 6264 (10.1%) patients. A subsequent malignancy was reported in 511 patients (0.8%): 441 (86.3%) had a new cancer, 70 (13.7%) a recurrent cancer. Abdominal symptoms were noted in 129 (25.2%) of cancer patients (P < 0.001), rising to 34.5% for the 89 patients with cancer located in the abdominal region. PPV for any cancer given any abdominal symptom was 2.1%. In symptomatic patients diagnosed with cancer, GPs noted a suspicion of cancer for 85 (65.9%) versus 1895 (30.9%) when there was no subsequent cancer (P < 0.001). No suspicion was noted in 32 (24.8%) cancer patients. The GP's intuitive cancer suspicion was independently associated with a subsequent new cancer diagnosis (OR 2.11, 95% CI 1.15-3.89). Laboratory tests were ordered for 45.4% of symptomatic patients, imaging for 10.4%, referral or hospitalization for 20.0%: all were more frequent in subsequent cancer patients (P < 0.001). INTERPRETATION Abdominal symptoms pointed to abdominal cancers rather than to other cancers. However, the finding of abdominal symptoms in only one third of patients with an abdominal cancer, and the lack of cancer suspicion in a quarter of symptomatic cancer patients, provide challenges for GPs' diagnostic thinking and referral practices.
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Affiliation(s)
- Knut Holtedahl
- Department of Community Medicine, UiT The Arctic University of Norway, Norway
| | - Peter Vedsted
- Aarhus University, Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Denmark
| | - Lars Borgquist
- Linköping University, Department of Medical and Health Sciences, Sweden
| | - Gé A Donker
- NIVEL Primary Care Database, Sentinel Practices, P.O. Box 1568, 3500 BN, Utrecht, Netherlands
| | - Frank Buntinx
- Dept of General Practice, KULeuven, Belgium, and Maastricht University, Netherlands
| | - David Weller
- Usher Institute for Population Health Sciences and Medical Informatics, The University of Edinburgh, Doorway 1, Teviot Place, Edinburgh, EH8 9AG, Scotland, UK
| | - Tonje Braaten
- Department of Community Medicine, UiT The Arctic University of Norway, Norway
| | - Peter Hjertholm
- Aarhus University, Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Denmark
| | - Jörgen Månsson
- Department of Public Health and Community Medicine/Primary Health Care, The Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Eva Lena Strandberg
- Lund University, Department of Clinical Sciences Malmö, Family Medicine/General Practice, Sweden
| | - Christine Campbell
- Usher Institute for Population Health Sciences and Medical Informatics, The University of Edinburgh, Doorway 1, Teviot Place, Edinburgh, EH8 9AG, Scotland, UK
| | - Lisbeth Ellegaard
- Department of Community Medicine, UiT The Arctic University of Norway, Norway
| | - Ranjan Parajuli
- Department of Community Medicine, UiT The Arctic University of Norway, Norway
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Donker GA, Wiersma E, van der Hoek L, Heins M. Determinants of general practitioner's cancer-related gut feelings-a prospective cohort study. BMJ Open 2016; 6:e012511. [PMID: 27625064 PMCID: PMC5030540 DOI: 10.1136/bmjopen-2016-012511] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND General practitioners (GPs) use gut feelings to diagnose cancer in an early stage, but little is known about its impact. METHOD Prospective cohort study of patients in 44 general practices throughout the Netherlands, from January 2010 until December 2013. GPs completed a questionnaire regarding gut feelings, patient and GP characteristics, if they noticed a cancer-related gut feeling during patient consultation. Follow-up questionnaires were sent 3 months later requesting information about the patient's diagnosis. χ(2), univariate and multivariate logistic regression and multilevel analyses were performed. RESULTS A gut feeling (N=366) is most often triggered by weight loss (24%, N=85) and rare GP visits (22%, N=76), but all triggers were not predictive of cancer in a multivariate analysis. Most GPs (95%) acted immediately on the gut feeling, either referring to a specialist or by performing additional medical tests. The average positive predictive value of cancer-related gut feeling was 35%, and it increased with 2% for every year a patient becomes older, and with 3% for every year a GP becomes older. CONCLUSIONS GP's gut feeling for cancer proves to be a useful tool in diagnosing cancer and its relative high predicting value increases if the GP is older or more experienced and when the patient is older. How can younger GPs be trained to increase the predictive value of their gut feeling?
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Affiliation(s)
- Gé A Donker
- NIVEL Primary Care Database, Sentinel Practices, Utrecht, The Netherlands
| | - Eva Wiersma
- VU Medical Center, Amsterdam, The Netherlands
| | - Lucas van der Hoek
- NIVEL Primary Care Database, Sentinel Practices, Utrecht, The Netherlands
| | - Marianne Heins
- NIVEL Primary Care Database, Sentinel Practices, Utrecht, The Netherlands
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Predictive values of GPs' suspicion of serious disease: a population-based follow-up study. Br J Gen Pract 2015; 64:e346-53. [PMID: 24868072 DOI: 10.3399/bjgp14x680125] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Knowledge is sparse on the prevalence of suspicion of cancer and other serious diseases in general practice. Likewise, little is known about the possible implications of this suspicion on future healthcare use and diagnoses. AIM To study the prevalence of GPs' suspicions of cancer or other serious diseases and analyse how this suspicion predicted the patients' healthcare use and diagnoses of serious disease. DESIGN AND SETTING Prospective population-based cohort study of 4518 patients consulting 404 GPs in a mix of urban, semi-urban and rural practices in Central Denmark Region during 2008-2009. METHOD The GPs registered consultations in 1 work day, including information on their suspicion of the presence of cancer or another serious disease. The patients were followed up for use of healthcare services and new diagnoses through the use of national registers. RESULTS Prevalence of suspicion was 5.7%. Suspicion was associated with an increase in referrals (prevalence ratio [PR] = 2.56, 95% confidence interval [CI] = 2.22 to 2.96), especially for diagnostic imaging (PR = 3.95, 95% CI = 2.80 to 5.57), increased risk of a new diagnosis of cancer or another serious disease within 2 months (hazard ratio [HR] = 2.98, 95% CI = 1.93 to 4.62)--especially for cancer (HR = 7.55, 95% CI = 2.66 to 21.39)--and increased use of general practice (relative risk [RR] = 1.14, 95% CI = 1.06 to 1.24) and hospital visits (RR = 1.90, 95% CI = 1.62 to 2.23). The positive predictive value of a GP suspicion was 9.8% (95% CI = 6.4 to 14.1) for cancer or another serious disease within 2 months. CONCLUSION A GP suspicion of serious disease warrants further investigation, and the organisation of the healthcare system should ensure direct access from the primary sector to specialised tests.
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Rasmussen S, Larsen PV, Søndergaard J, Elnegaard S, Svendsen RP, Jarbøl DE. Specific and non-specific symptoms of colorectal cancer and contact to general practice. Fam Pract 2015; 32:387-94. [PMID: 25977134 DOI: 10.1093/fampra/cmv032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To improve survival rates for colorectal cancer, referral guidelines have been implemented. First step in the diagnostic process is for the individual to recognize the symptoms and contact his/her general practitioner (GP) for evaluation. OBJECTIVES To determine (i) the prevalence of specific and non-specific symptom experiences indicative of colorectal cancer, (ii) the proportion of subsequent contacts to GPs, (iii) to explore the possible differences in symptom experience and contact to GPs between age and sex. METHODS A nationwide study of 100000 adults, aged 20 years and older, were randomly selected in the general population and invited to participate in an internet-based survey. Items regarding experience of specific and non-specific alarm symptoms of colorectal cancer within the preceding 4 weeks and contact to GP were included. RESULTS A total of 49706 subjects completed the questionnaire. Abdominal pain was the most common specific alarm symptom (19.7%) and tiredness was the most common non-specific symptom (49.8%). The experiences of symptoms were more common among women and more common in the youngest age groups for both sexes. The symptom leading to the highest proportion of GP contacts was rectal bleeding (33.8%). When experiencing any combination of two specific alarm symptoms, the proportion who contacted a GP was less than 50%. The combination of a non-specific and a specific alarm symptom gave rise to the highest proportion of GP contacts. CONCLUSION Although specific and non-specific alarm symptoms of colorectal cancer are common in the general population, the proportion of GP contacts is low.
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Affiliation(s)
- Sanne Rasmussen
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark.
| | - Pia V Larsen
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Sandra Elnegaard
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Rikke P Svendsen
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
| | - Dorte E Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern, Odense, Denmark
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Jensen H, Tørring ML, Olesen F, Overgaard J, Fenger-Grøn M, Vedsted P. Diagnostic intervals before and after implementation of cancer patient pathways - a GP survey and registry based comparison of three cohorts of cancer patients. BMC Cancer 2015; 15:308. [PMID: 25900050 PMCID: PMC4412104 DOI: 10.1186/s12885-015-1317-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 04/16/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND From 2008, Danish general practitioners could refer patients suspected of having cancer to standardised cancer patient pathways (CPPs). We aimed to compare the length of the diagnostic interval in 2010 with the length of the diagnostic interval before (2004/05) and during (2007/08) the implementation of CPPs in Denmark for all incident cancer patients who attended general practice prior to the cancer diagnosis. METHODS General practitioner questionnaires and register data on 12,558 patients were used to compare adjusted diagnostic interval across time by quantile regression. RESULTS The median diagnostic interval was 14 (95% CI: 11;16) days shorter during and 17 (95% CI: 15;19) days shorter after the implementation of CPPs than before. The diagnostic interval was 15 (95% CI: 12;17) days shorter for patients referred to a CPP in 2010 than during the implementation, whereas patients not referred to a CPP in 2010 had a 4 (95% CI: 1;7) days longer median diagnostic interval; the pattern was similar, but larger at the 75(th) and 90(th) percentiles. CONCLUSION The diagnostic interval was significantly lower after CPP implementation. Yet, patients not referred to a CPP in 2010 tended to have a longer diagnostic interval compared to during the implementation. CPPs may thus only seem to expedite the diagnostic process for some cancer patients.
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Affiliation(s)
- Henry Jensen
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus C, Denmark. .,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.
| | - Marie Louise Tørring
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.
| | - Frede Olesen
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.
| | - Jens Overgaard
- Department of Clinical Medicine - Department of Experimental Clinical Oncology, Aarhus University Hospital, Noerrebrogade 44, DK-8000, Aarhus C, Denmark.
| | - Morten Fenger-Grøn
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.
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Scheel BI, Holtedahl K. Symptoms, signs, and tests: The general practitioner's comprehensive approach towards a cancer diagnosis. Scand J Prim Health Care 2015; 33:170-7. [PMID: 26375323 PMCID: PMC4750720 DOI: 10.3109/02813432.2015.1067512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To study the relative importance of different tools a GP can use during the diagnostic process towards cancer detection. DESIGN Retrospective cohort study with prospective registration of cancer in general practice. SETTING AND SUBJECTS One hundred and fifty-seven Norwegian general practitioners (GPs) reported 261 cancer patients. METHOD During 10 consecutive days, GPs registered all patient consultations and recorded any presence of seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up was done six to 11 months later. For each patient with new or recurrent cancer, the GP completed a questionnaire with medical-record-based information concerning the diagnostic procedure. RESULTS In 78% of cancer cases, symptoms, signs, or tests helped diagnose cancer. In 90 cases, there were 131 consultation-recorded WSC that seemed related to the cancer. Further symptoms were reported for another 74 cases. Different clinical signs were noted in 41 patients, 16 of whom had no previous recording of symptoms. Supplementary tests added information in 59 cases; in 25 of these there were no recordings of symptoms or signs. Sensitivity of any cancer-relevant symptom or clinical finding ranged from 100% for patients with uterine body cancer to 57% for patients with renal cancer. CONCLUSION WSC had a major role as initiator of a cancer diagnostic procedure. Low-risk-but-not-no-risk symptoms also played an important role, and in 7% of patients they were the only symptoms. Clinical findings and/or supplementary procedures were sometimes decisive for rapid referral.
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Affiliation(s)
- Benedicte Iversen Scheel
- Correspondence: Benedicte Iversen Scheel, Department of Community Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway. E-mail:
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Holtedahl K. Predictive values of GPs' suspicion of serious disease are high enough to warrant subsequent investigation. EVIDENCE-BASED MEDICINE 2014; 19:232. [PMID: 25139889 DOI: 10.1136/ebmed-2014-110060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Knut Holtedahl
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Jensen H, Tørring ML, Olesen F, Overgaard J, Vedsted P. Cancer suspicion in general practice, urgent referral and time to diagnosis: a population-based GP survey and registry study. BMC Cancer 2014; 14:636. [PMID: 25175155 PMCID: PMC4164756 DOI: 10.1186/1471-2407-14-636] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/26/2014] [Indexed: 01/17/2023] Open
Abstract
Background Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP’s suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis. Methods We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients’ chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP’s symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression. Results 5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient’s symptoms as ‘alarm’ symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as ‘vague’ had a lower chance of being referred to a CPP than when interpreted as ‘alarm’ symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with ‘vague’ symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with ‘alarm’ symptoms. Conclusions GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP’s choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP’s symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval.
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Affiliation(s)
- Henry Jensen
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark.
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Cook N, Thomson G, Dey P. Managing risk in cancer presentation, detection and referral: a qualitative study of primary care staff views. BMJ Open 2014; 4:e004820. [PMID: 24928585 PMCID: PMC4067858 DOI: 10.1136/bmjopen-2014-004820] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES In the UK, there have been a number of national initiatives to promote earlier detection and prompt referral of patients presenting to primary care with signs and symptoms of cancer. The aim of the study was to explore the experiences of a range of primary care staff in promoting earlier presentation, detection and referral of patients with symptoms suggestive of cancer. SETTING Six primary care practices in northwest England. PARTICIPANTS 39 primary care staff from a variety of disciplines took part in five group and four individual interviews. RESULTS The global theme to emerge from the interviews was 'managing risk', which had three underpinning organising themes: 'complexity', relating to uncertainty of cancer diagnoses, service fragmentation and plethora of guidelines; 'continuity', relating to relationships between practice staff and their patients and between primary and secondary care; 'conflict' relating to policy drivers and staff role boundaries. A key concern of staff was that policymakers and those implementing cancer initiatives did not fully understand how risk was managed within primary care. CONCLUSIONS Primary care staff expressed a range of views and opinions on the benefits of cancer initiatives. National initiatives did not appear to wholly resolve issues in managing risk for all practitioners. Staff were concerned about the number of guidelines and priorities they were expected to implement. These issues need to be considered by policymakers when developing and implementing new initiatives.
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Affiliation(s)
- Neil Cook
- School of Medicine and Dentistry, University of Central Lancashire, Preston, UK
| | - Gillian Thomson
- School of Health, University of Central Lancashire, Preston, UK
| | - Paola Dey
- School of Medicine and Dentistry, University of Central Lancashire, Preston, UK
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