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Primary care and diagnosis of cancer


In The Lancet Oncology Georgios Lyratzopoulos and colleagues1 present a quantitative analysis of medical care before cancer diagnosis from a UK patient experience survey. The results show that, with rectal cancer as the reference, the proportion of patients with three or more primary care visits before cancer diagnosis varies by cancer site, being lower for some cancers, including breast cancer, melanoma, or testicular cancer, but higher for patients with cancer at other sites, including cancer of the stomach, lung, or pancreas. Young patients and those from ethnic minorities were generally more likely to have had several primary care visits before referral than were older patients and white individuals. These results must be viewed in the context of substantially improving cancer survival in recent years.2 Progress in cancer treatment and survival has been uneven, however, being restricted to specic cancer types. In the UK, survival for prostate cancer, colorectal cancer, and breast cancer has increased rapidly, with 5-year survival now substantially greater than 50%. However, survival for other cancers has lagged behind, with fewer than 10% of patients with cancer of the oesophagus, lung, or pancreas surviving for 5 years.2 Survival has also been shown to vary between socioeconomic groups; lower socioeconomic status is often associated with shorter survival, especially for treatable cancers.3 The inferior survival of patients diagnosed and treated in the UK compared with other western European countries has also attracted much attention. Moller and colleagues4 suggested that lower cancer survival in the UK could be partly explained by a less favourable stage distribution.4 These variations between cancer sites, between socioeconomic groups, and between countries have focused attention on pathways to diagnosis of cancer, since it is possible that earlier diagnosis could be associated with less advanced stage at diagnosis and improved cancer outcomes. A national initiative to promote awareness and early detection of cancer has been established in England.5 Recognition of cancer can often be delayed. In a large sample of patients presenting in primary care with socalled red ag symptoms, Jones and colleagues6 noted that in those with haematuria, only 74% of cancer diagnoses were made within 6 months of rst symptom presentation. The equivalent gures were 77% for cancers associated with haemoptysis, 90% for cancers associated with dysphagia, and 76% for cancers associated with rectal bleeding.6 However, evidence that delayed diagnosis might be associated with more advanced disease at diagnosis and shorter survival is inconsistent. A review of 47 studies across a range of cancer sites showed that delays were associated with worse prognosis in nine studies; 29 studies showed no association between delay and survival; and nine showed longer delays associated with better survival.7 Results of a study of bladder cancer suggested that patients with more invasive disease might present after shorter delays but still have worse outcomes than those with less aggressive tumours.8 Methodological issues, including problems of lead-time and length bias, make observational data dicult to interpret. The report by Lyratzopoulos and colleagues1 provides a welcome perspective from patient experience. The investigators analysed survey data for patients with cancer receiving hospital care. The sample size was large, although the overall response rate was 67%. Patients with cancers that are more easily diagnosed because of the presence of a visible lesion or palpable lump (eg, breast cancer or melanoma) seem to be more readily referred to hospital (ie, the referral threshold might be lower) than those with cancers that are less readily detected clinically (eg, pancreatic cancer). Family doctors might also refer patients to hospital more readily when cancer with a good 5-year survival is suspected (eg, breast cancer, melanoma, and testicular cancer) than for cancers with a poor prognosis (eg, lung, pancreas). However, this pattern of association is inconsistent. Lyratzopoulos and colleagues argue that if patients have several primary care consultations before referral for cancer diagnosis this could suggest a potential for improvement of patient experience and timeliness of cancer diagnosis. Lowering the threshold for referral might yield a higher proportion of true positives for some cancers, but for those that present with nonspecic symptoms, a lower referral threshold might be associated with reduced specicity, yielding more falsepositive referrals and lower predictive values. In the study by Jones and colleagues,6 only 75% or fewer patients presenting with red ag symptoms were diagnosed with a related cancer within 3 years. This nding emphasises the diculty facing general practitioners in attempting

Published Online February 24, 2012 DOI:10.1016/S14702045(12)70050-5 See Online/Articles DOI:10.1016/S14702045(12)70041-4

www.thelancet.com/oncology Published online February 24, 2012 DOI:10.1016/S1470-2045(12)70050-5

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to identify those patients who might be diagnosed with cancer, even when the presenting feature is regarded as being highly predictive of cancer. Finally, Lyratzopoulos and colleagues study suggests that individual patient characteristics might be associated with general practitioners readiness to refer for cancer investigation. Young patients and ethnic minorities were more likely to have had three or more consultations before referral than older or white patients. These ndings raise several questions. Do modes of cancer presentation vary systematically between dierent groups of patients? Are general practitioners more reluctant to refer young or non-white patients for investigation of possible cancer? Are participants in these groups less willing to accept a referral to investigate possible cancer? Lyratzopoulos and colleagues study will raise concerns for those involved in diagnosing and treating patients with cancer. This descriptive study suggests several hypotheses concerning pathways to accessing cancer care that deserve to be tested prospectively in future research.

Martin Gulliford
Kings College London, Department of Primary Care and Public Health Sciences, London, UK martin.gulliford@kcl.ac.uk
I declare that I have no conicts of interest. 1 Lyratzopoulos G, Neal RD, Barbiere JM, Rubin GP, Abel GA. Variation in number of general practioner consultations before hospital referral for cancer: ndings from the 2010 National Cancer Patient Experience Survey in England. Lancet Oncol 2012; published online Feb 24. DOI:10.1016/ S1470-2045(12)70041-4. Cancer Research UK. Cancer survival ratestrends. http://info. cancerresearchuk.org/cancerstats/survival/veyear/ (accessed Jan 23, 2012). Coleman MP, Rachet B, Woods LM, et al. Trends and socioeconomic inequalities in cancer survival in England and Wales up to 2001. Br J Cancer 2004; 90: 136773. Moller H, Linklater KM, Robinson D. A visual summary of the EUROCARE-4 results: a UK perspective. Br J Cancer 2010; 101: S11014. Richards MA. The National Awareness and Early Diagnosis Initiative in England: assembling the evidence. Br J Cancer 2010; 101: S14. Jones R, Latinovic R, Charlton J, Gulliford MC. Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ 2007; 334: 1040. Neal RD. Do diagnostic delays in cancer matter? Br J Cancer 2010; 101: S912. Gulliford MC, Petruckevitch A, Burney PG. Survival with bladder cancer, evaluation of delay in treatment, type of surgeon and modality of treatment. BMJ 1991; 303: 43740.

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www.thelancet.com/oncology Published online February 24, 2012 DOI:10.1016/S1470-2045(12)70050-5

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