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www.thelancet.com/oncology Published online February 24, 2012 DOI:10.1016/S1470-2045(12)70050-5 1

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 experi-

ence 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 havehad 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 specific 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 cancerof 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 so-

called red flag symptoms, Jones and colleagues6 noted

that in those with haematuria, only 74% of cancer

diagnoses were made within 6 months of first symptom

presentation. The equivalent figures 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 mightpresent 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 diffi cult 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 non-

specific symptoms, a lower referral threshold might be

associated with reduced specificity, yielding more false-

positive referrals and lower predictive values. In the study

by Jones and colleagues,6 only 75% or fewer patients

presenting with red flag symptoms were diagnosed with

a related cancer within 3 years. This finding emphasises

the diffi culty facing general practitioners in attempting

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DOI:10.1016/S1470-

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DOI:10.1016/S1470-

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

to identify those patients who might be diagnosed with

cancer, even when the presenting feature is regarded asbeing 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 findings

raise several questions. 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? 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 PublicHealth Sciences, London, UK

martin.gulliford@kcl.ac.uk

I declare that I have no conflicts of interest.

1 Lyratzopoulos G, Neal RD, Barbiere JM, Rubin GP, Abel GA. Variation innumber of general practioner consultations before hospital referral forcancer: findings from the 2010 National Cancer Patient Experience Surveyin England. Lancet Oncol 2012; published online Feb 24. DOI:10.1016/S1470-2045(12)70041-4.

2 Cancer Research UK. Cancer survival ratestrends. http://info.cancerresearchuk.org/cancerstats/survival/fiveyear/ (accessed Jan 23,2012).

3 Coleman MP, Rachet B, Woods LM, et al. Trends and socioeconomicinequalities in cancer survival in England and Wales up to 2001. Br J Cancer2004; 90: 136773.

4 Moller H, Linklater KM, Robinson D. A visual summary of the EUROCARE-4

results: a UK perspective. Br J Cancer2010; 101: S11014.5 Richards MA. The National Awareness and Early Diagnosis Initiative in

England: assembling the evidence. Br J Cancer2010; 101: S14.

6 Jones R, Latinovic R, Charlton J, Gulliford MC. Alarm symptoms in earlydiagnosis of cancer in primary care: cohort study using General PracticeResearch Database. BMJ 2007; 334: 1040.

7 Neal RD. Do diagnostic delays in cancer matter? Br J Cancer2010;101: S912.

8 Gulliford MC, Petruckevitch A, Burney PG. Survival with bladder cancer,evaluation of delay in treatment, type of surgeon and modality oftreatment. BMJ 1991; 303: 43740.