Prereferral consultations highest for women, minorities, uncommon cancers

Lyratzopoulos G. Lancet Oncol. 2012;doi:10.1016/S1470-2045(12)70041-4.

A physician’s ability to diagnose cancer may be hindered by the patient’s age, gender or ethnicity, according to findings published online by The Lancet Oncology.

Seventy-seven percent of patients who present to their family doctor with suspicious symptoms are referred to a hospital after one or two consultations, a study conducted by researchers in England showed. However, young people, women and older minority patients are more likely to have three or more consultations with their family doctors before referral.

Patients who presented with symptoms of less common cancers also had more consultations before referral than patients who exhibited symptoms of more common cancers.

“These findings highlight limitations in current scientific knowledge about these cancers,” study researcher Georgios Lyratzopoulos, MD, FFPH, FRCP, MPH, a clinical senior research associate at University of Cambridge in England, said in a press release. “Medical research in recent decades has prioritized improving cancer treatments, but knowledge about the ‘symptom signature’ of common cancers and practical solutions on how to best diagnose them is still emerging.”

Lyratzopoulos and colleagues reviewed data from surveys completed by 41,299 patients who participated in the English National Cancer Patient Experience Survey in 2010. The study encompassed patients with one of 24 types of cancer who were treated at 158 hospitals in England.

Researchers examined the variation in the number of times patients with cancer symptoms consulted with their family physicians before referral to a hospital. Researchers specifically looked at variations based on cancer type, age, gender, ethnicity and socioeconomic status.

Patients aged 16 to 24 years were more than twice as likely to require three or more prereferral consultations than patients aged 65 to 74 years (OR=2.12; 95% CI, 1.63-2.75). Women were more likely to require three or more prereferral consultations compared with men (OR=1.28; 95% CI, 1.21-1.36). The likelihood also was higher among Asian and black patients than white patients (P<.0001).

Researchers offered possible explanations for some of their findings. Because the variation among minorities was most apparent among older patients, they said communication difficulties could be responsible for the disparity. Also, family physicians may be less likely to consider that a young patient has cancer, thereby making them less likely to make a prompt referral.

The number of prereferral consultations also varied greatly by cancer type.

More than half (939 of 1,854, or 50.6%) of patients with multiple myeloma — a blood cancer that mimics the symptoms of several other conditions — required multiple consultations with general practitioners, as did 193 of 467 (41.3%) of patients with pancreatic cancer.

Conversely, 113 of 1,124 patients (10.1%) with melanoma and 625 of 8,408 patients (7.4%) of patients with breast cancer required multiple consultations.

“Acknowledging differences in cancer incidence between different patient groups, we strongly encourage research to understand better cancer signs and symptoms in women, young and ethnic minority patients,” the researchers wrote. “Our findings can also help to prioritize policy initiatives and further research focused on patients with cancers associated with a non-specific symptom signature and greater number of prereferral consultations.”

In an accompanying editorial, Martin C. Gulliford, MD, a professor of public health at King’s College in London, said the findings will raise concerns for clinicians who diagnose and treat patients with cancer.

“Do modes of cancer presentation vary systematically between different 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?” Gulliford wrote. “This descriptive study suggests several hypotheses concerning pathways to accessing cancer care that deserve to be tested prospectively in future research.”

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