Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England

Our plain-English summary of Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England, by G. Lyratzopoulos, R.D. Neal, J.M. Barbiere, et al (The Lancet. Oncology, 2012).

The study

• Authors: G. Lyratzopoulos, R.D. Neal, J.M. Barbiere, G.P. Rubin, G.A. Abel
• Journal: The Lancet. Oncology
• Published: 2012;13(4):353-65
• Cited by: 355 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Information from patient surveys can help to identify patient groups and cancers with the greatest potential for improvement in the experience and timeliness of cancer diagnosis. We aimed to examine variation in the number of pre-referral consultations with a general practitioner between patients with different cancers and sociodemographic characteristics.

Methods: We analysed data from 41,299 patients with 24 different cancers who took part in the 2010 National Cancer Patient Experience Survey in England. We examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer. Logistic regression was used to identify independent predictors of three or more pre-referral consultations, adjusting for cancer type, age, sex, deprivation quintile, and ethnic group.

Findings: We identified wide variation between cancer types in the proportion of patients who had visited their general practitioner three or more times before hospital referral (7·4% [625 of 8408] for breast cancer and 10·1% [113 of 1124] for melanoma; 41·3% [193 of 467] for pancreatic cancer and 50·6% [939 of 1854] for multiple myeloma). In multivariable analysis, with patients with rectal cancer as the reference group, those with subsequent diagnosis of multiple myeloma (odds ratio [OR] 3·42, 95% CI 3·01-3·90), pancreatic cancer (2·35, 1·91-2·88), stomach cancer (1·96, 1·65-2·34), and lung cancer (1·68, 1·48-1·90) were more likely to have had three or more pre-referral consultations; conversely patients with subsequent diagnosis of breast cancer (0·19; 0·17-0·22), melanoma (0·34, 0·27-0·43), testicular cancer (0·47, 0·33-0·67), and endometrial cancer (0·59, 0·49-0·71) were more likely to have been referred to hospital after only one or two consultations. The probability of three or more pre-referral consultations was greater in young patients (OR for patients aged 16-24 years vs 65-74 years 2·12, 95% CI 1·63-2·75; p<0·0001), those from ethnic minorities (OR for Asian vs white 1·73, 1·45-2·08; p<0·0001; OR for black vs white 1·83, 1·51-2·23; p<0·0001), and women (OR for women vs men 1·28, 1·21-1·36; p<0·0001). We identified strong evidence of interactions between cancer type and age group and sex (p<0·0001 for both), and between age and ethnicity (p=0·0013). The model including these interactions showed a particularly strong sex effect for bladder cancer (OR for women vs men 2·31, 95% CI 1·98-2·69) and no apparent ethnic group differences in young patients aged 16-24 years, whilst the only cancers without an apparent age gradient were testicular cancer and mesothelioma.

Interpretation: Our findings could help to prioritise and stratify early diagnosis initiatives and research, focusing on patients with cancers and sociodemographic characteristics with the largest potential for improvement.

Funding: None.

Copyright © 2012 Elsevier Ltd. All rights reserved.

In plain English

This study analysed 2010 survey answers from 41,299 patients in England with 24 cancer types, including mesothelioma, who had seen their general practitioner (GP) about symptoms before hospital referral. It did not study asbestos or other causes of cancer. Overall, 9671 patients (23%) reported three or more GP visits. This was 7.4% for breast cancer and 50.6% for multiple myeloma. For mesothelioma, 77 of 275 patients (28.0%) had three or more visits. Compared with rectal cancer patients and adjusting for age, sex, deprivation and ethnic group, the odds ratio for mesothelioma was 1.43 (95% CI 1.08 to 1.90). After adjustment, younger patients, women, and Asian and black patients were on average more likely to have three or more visits. Unadjusted, women were less likely than men (21.9% versus 25.0%). Ethnic differences were not apparent among patients aged 16 to 24. Mesothelioma and testicular cancer were the only cancers without an apparent age pattern. Among stated limitations, the survey covered only survivors and could not account for differences between GP practices. They concluded the findings could help prioritise early-diagnosis efforts.

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: Descriptive, observational secondary analysis of a national cross-sectional patient survey, using logistic regression
• Who was studied: 41,299 patients aged 16 or older with 24 cancer types (including 275 with mesothelioma), treated in English NHS hospitals in the first quarter of 2010, who had seen their GP at least once about cancer symptoms before referral and had complete ethnic group and deprivation information
• Exposure: No asbestos or other occupational exposure was studied. The factors examined were cancer type and patient age, sex, ethnic group and deprivation. The outcome was the self-reported number of GP visits before hospital referral, with three or more visits analysed as the main outcome.
• Main results:
  • Of all 41,299 patients analysed, 9671 (23%) reported three or more GP visits with cancer symptoms before hospital referral
  • Breast cancer had the lowest proportion with three or more visits: 625 of 8408 patients (7.4%)
  • Multiple myeloma had the highest proportion with three or more visits: 939 of 1854 patients (50.6%). Its adjusted odds ratio versus rectal cancer was 3.42 (95% CI 3.01 to 3.90).
  • Mesothelioma patients: 77 of 275 (28.0%) had three or more visits
  • Mesothelioma patients compared with rectal cancer patients, adjusted for patient characteristics: odds ratio 1.43 (95% CI 1.08 to 1.90). The unadjusted odds ratio was 1.30 (95% CI 0.98 to 1.72).
  • Patients aged 16 to 24 compared with those aged 65 to 74: adjusted odds ratio 2.12 (95% CI 1.63 to 2.75) for three or more visits
  • Asian compared with white patients: adjusted odds ratio 1.73 (95% CI 1.45 to 2.08). For black compared with white patients it was 1.83 (95% CI 1.51 to 2.23).
  • Without adjustment, a smaller share of women than men reported three or more visits: 4614 of 21,066 women (21.9%) versus 5057 of 20,233 men (25.0%)
  • After adjustment, women compared with men had an odds ratio of 1.28 (95% CI 1.21 to 1.36). The authors attributed the reversal mostly to confounding by cancer type, particularly breast cancer.
  • In the model with interactions, the sex effect was particularly strong for bladder cancer (women vs men odds ratio 2.31, 95% CI 1.98 to 2.69)
  • Ethnic differences grew with age among ethnic minority patients, and no appreciable ethnic differences were seen among patients aged 16 to 24
  • Younger patients were more likely to have three or more visits for every cancer except testicular cancer and mesothelioma
  • Differences between deprivation groups were small and not consistent in direction
  • The pattern across cancer types agreed with a separate national audit based on GP practice records (Spearman rank correlation r = 0.899, p less than 0.0001)
• The authors' conclusion: The authors concluded that their findings could help prioritise and target early-diagnosis initiatives and research toward the cancers and patient groups with the most room for improvement
• Limitations the authors state:
  • For patients with more than one visit, the time period over which the visits happened was not known
  • The number of visits is not a perfect marker of diagnostic quality for an individual patient, because repeat visits for appropriate follow-up could not be told apart from visits where cancer was not suspected
  • Variation between general practices could not be taken into account
  • The survey included only survivors, so patients with short survival were left out
  • Patients with cancers needing frequent hospital contact, such as blood cancers, were over-represented

Topics

Medical terms in this study, explained in our Lexicon: Myeloma, Odds Ratio, Stomach Cancer, Lung Cancer, Mesothelioma.

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