Pre-referral GP consultations in patients subsequently diagnosed with rarer cancers: a study of patient-reported data

Abstract

Background: Some patients with cancer experience multiple pre-diagnostic consultations in primary care, leading to longer time intervals to specialist investigations and diagnosis. Patients with rarer cancers are thought to be at higher risk of such events, but concrete evidence of this is lacking.

Aim: To examine the frequency and predictors of repeat consultations with GPs in patients with rarer cancers.

Design and setting: Patient-reported data on pre-referral consultations from three English national surveys of patients with cancer (2010, 2013, and 2014), pooled to maximise the sample size of rarer cancers.

Method: The authors examined the frequency and crude and adjusted odds ratios for ≥3 (versus 1-2) pre-referral consultations by age, sex, ethnicity, level of deprivation, and cancer diagnosis (38 diagnosis groups, including 12 rarer cancers without prior relevant evidence).

Results: Among 7838 patients with 12 rarer cancers, crude proportions of patients with ≥3 pre-referral consultations ranged from >30.0% to 60.0% for patients with small intestine, bone sarcoma, liver, gallbladder, cancer of unknown primary, soft-tissue sarcoma, and ureteric cancer. The range was 15.0-30.0% for patients with oropharyngeal, anal, parotid, penile, and oral cancer. The overall proportion of responders with any cancer who had ≥3 consultations was 23.4%. Multivariable logistic regression indicated concordant patterns, with strong evidence for variation between rarer cancers (P <0.001).

Conclusion: Patients with rarer cancers experience pre-referral consultations at frequencies suggestive of middle-to-high diagnostic difficulty. The findings can guide the development of new diagnostic interventions and 'safety-netting' approaches for symptomatic presentations encountered in patients with rarer cancers.

Keywords: consultation; diagnosis; investigation; neoplasm; primary care; referral.

Figure 1.

Analysis sample derivation flowchart.

Figure 2.

Odds ratios for ≥3 GP consultations before hospital referral, by cancer type. Central estimates for 12 rarer cancers without prior relevant published evidence shown in red.

Figure 3.

Odds ratios for ≥3 GP consultations before hospital referral, by patient characteristic. Ref = reference

Figure 4.

Distribution of crude proportions of all categories of number of pre-referral consultation, by cancer diagnosis. The blue bars represent rarer cancers without prior relevant evidence.