Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data

Our plain-English summary of Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data, by G.A. Abel, S.C. Mendonca, S. McPhail, et al (The British Journal of General Practice, 2017).

The study

• Authors: G.A. Abel, S.C. Mendonca, S. McPhail, Y. Zhou, L. Elliss-Brookes, G. Lyratzopoulos
• Journal: The British Journal of General Practice
• Published: 2017;67(659):e377-e387
• Cited by: 64 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Emergency diagnosis of cancer is common and aetiologically complex. The proportion of emergency presenters who have consulted previously with relevant symptoms is uncertain.

Aim: To examine how many patients with cancer, who were diagnosed as emergencies, have had previous primary care consultations with relevant symptoms; and among those, to examine how many had multiple consultations.

Design And Setting: Secondary analysis of patient survey data from the 2010 English Cancer Patient Experience Survey (CPES), previously linked to population-based data on diagnostic route.

Method: For emergency presenters with 18 different cancers, associations were examined for two outcomes (prior GP consultation status; and 'three or more consultations' among prior consultees) using logistic regression.

Results: Among 4647 emergency presenters, 1349 (29%) reported no prior consultations, being more common in males (32% versus 25% in females, P<0.001), older (44% in ≥85 versus 30% in 65-74-year-olds, P<0.001), and the most deprived (35% versus 25% least deprived, P = 0.001) patients; and highest/lowest for patients with brain cancer (46%) and mesothelioma (13%), respectively (P<0.001 for overall variation by cancer site). Among 3298 emergency presenters with prior consultations, 1356 (41%) had three or more consultations, which were more likely in females (P<0.001), younger (P<0.001), and non-white patients (P = 0.017) and those with multiple myeloma, and least likely for patients with leukaemia (P<0.001).

Conclusion: Contrary to suggestions that emergency presentations represent missed diagnoses, about one-third of emergency presenters (particularly those in older and more deprived groups) have no prior GP consultations. Furthermore, only about one-third report multiple (three or more) consultations, which are more likely in 'harder-to-suspect' groups.

© British Journal of General Practice 2017.

In plain English

This study re-analysed the 2010 English Cancer Patient Experience Survey, linked to records of each patient's diagnostic route. It included 4647 responders whose cancer, one of 18 types including mesothelioma, was diagnosed as an emergency. It used their answers about how often they had seen a GP about the health problem caused by their cancer before being told to go to hospital. Asbestos exposure was not studied. Overall, 1349 of 4647 (29%) reported no prior GP consultation. This was more common in men, people aged 85 and over, and the most deprived group. Brain cancer patients were most likely to report none. Among mesothelioma patients, 8 of 61 (13.1%) reported none. That was the lowest adjusted odds of any cancer studied (odds ratio 0.30, 95% CI 0.14 to 0.64, versus colon cancer). Of 3298 who had seen a GP, 1356 (41%) had three or more consultations; for mesothelioma, 14 of 53 (26.4%). The authors concluded that about one-third of emergency presenters had no prior GP consultation, contrary to suggestions that emergency presentations represent missed diagnoses. They noted that patients might overestimate consultations and that the ordering of cancers should not be over-interpreted.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Secondary analysis of national patient survey data linked to population-based records of diagnostic route (cross-sectional analysis using logistic regression)
• Who was studied: Survey responders aged 16 or over with cancer, seen as inpatients or day cases in English NHS hospitals in January to March 2010. The analysis was restricted to 4647 emergency presenters with one of 18 common cancers and complete information, out of 67,713 responders.
• Exposure: No asbestos or other occupational exposure was studied. The factors examined were age group, sex, deprivation group, self-reported ethnic group (white or non-white) and cancer site (18 cancers, one of which was mesothelioma). The outcomes came from one survey question. It asked how many times patients had seen their GP about the health problem caused by cancer before being told they needed to go to hospital about cancer.
• Main results:
  • Among all 4647 emergency presenters, 1349 (29%) reported no prior GP consultation. With post-stratification weights the figure was 34%.
  • No prior consultation was reported more often by males (32% versus 25% of females), by those aged 85 and over (44% versus 30% of 65 to 74-year-olds), and by the most deprived (35% versus 25% of the least deprived).
  • Emergency presenters with brain, renal, endometrial or breast cancer were most likely to report no prior consultation, with adjusted odds ratios of 2.08, 1.71, 1.54 and 1.42 compared with colon cancer.
  • Among mesothelioma emergency presenters, 8 of 61 (13.1%) reported no prior GP consultation. The adjusted odds ratio was 0.30 (95% CI 0.14 to 0.64) compared with colon cancer, the lowest among the cancers studied.
  • Among the 3298 emergency presenters with at least one prior consultation, 1356 (41%) had three or more consultations. With post-stratification weights the figure was 35%.
  • Among prior consultees, three or more consultations were more common in females (45% versus 38% in males). They were also more common in younger patients (48% of 16 to 24-year-olds versus 39% of 65 to 74-year-olds) and in ethnic minority patients (52% versus 41% for white patients).
  • Among prior consultees, three or more consultations were most likely in multiple myeloma (adjusted OR 1.81) and least likely in leukaemia (adjusted OR 0.41).
  • Among mesothelioma emergency presenters who had seen a GP, 14 of 53 (26.4%) had three or more consultations. The adjusted odds ratio was 0.58 (95% CI 0.31 to 1.11) compared with colon cancer.
  • In the weighted sensitivity analysis, some cancer-site odds ratios changed considerably. For no prior consultation among mesothelioma patients, the weighted odds ratio was 0.43 (95% CI 0.12 to 1.49). The authors said the exact ordering of cancers should be taken only as a broad indication.
• The authors' conclusion: The authors concluded that, against suggestions that emergency presentations represent missed diagnoses, about one-third of emergency presenters had no prior GP consultation and only about one-third had multiple consultations.
• Limitations the authors state:
  • Consultation history was self-reported, and patients might overestimate consultations compared with medical records.
  • The sample was of recently treated patients, not all incident emergency presenters. The weighting assumed that patients who died early or did not respond were missing at random, which may not be true.
  • Because of limited statistical power, the study could not examine whether the effects of sociodemographic factors differed by cancer site.
  • The data could not establish what proportion of emergency presentations came from direct emergency GP referrals.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Myeloma.

Related studies

• Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England — G. Lyratzopoulos, R.D. Neal, et al. (2012)
• Malignant Mesothelioma Biomarkers: From Discovery to Use in Clinical Practice for Diagnosis, Monitoring, Screening, and Treatment — J. Creaney, B.W.S. Robinson (2017)
• Guideline for referral of patients with suspected lung cancer by family physicians and other primary care providers — M.E. Del Giudice, S.M. Young, et al. (2014)
• Factors affecting the mesothelioma detection rate within national and international epidemiological studies: insights from Scottish linked cancer registry-mortality data — D.R. Camidge, D.L. Stockton, et al. (2006)
• Emergency IVF for embryo freezing to preserve female fertility: a French multicentre cohort study — B. Courbiere, C. Decanter, et al. (2013)
• Current practice in cytoreductive surgery and HIPEC for metastatic peritoneal disease: Spanish multicentric survey — R. Morales-Soriano, N. Esteve-Pérez, et al. (2018)

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