Morbidities Associated With Delays in Cancer Referral and Diagnosis

Bianca Nogrady

December 15, 2021

People with multiple preexisting chronic conditions experience a longer wait to receive a diagnosis of cancer and are more likely to be referred to an emergency department for their cancer, according to new research.

These findings are based on a retrospective study of data from 11,716 cancer patients from the United Kingdom's National Cancer Diagnosis Audit – an initiative that aimed to better understand the journey of cancer patients from primary care to diagnosis. Three-quarters of the study participants had at least one morbidity in their primary care record, according to the authors of the new research, which was published in Family Practice (2021 Nov 30. doi: 10.1093/fampra/cmab139).

In their analysis of all of the patient data, Minjoung M. Koo and colleagues found that the median time between first presenting to a primary care physician with cancer symptoms and being referred to a specialist was 5 days. For all patients studied, the median time to receiving a cancer diagnosis was 42 days, the investigators wrote.

Patients with multiple morbidities were 26% more likely to have their cancer diagnosed at least 60 days after the initial primary care consultation than were those without morbidities (95% confidence interval, 1.10-1.45). This was true after adjustment for confounders, including morbidity, sex, age, and cancer. Similarly, those with a Charlson score of 3 or above – signifying more severe comorbidities – had a 19% greater odds of being diagnosed more than 60 days after presenting to primary care (95% CI, 1.01-1.40)

Older Adults "Less Likely to Be Screen-Detected"

Fran Boyle, professor of medical oncology at the University of Sydney, Australia, said it wasn't clear from the study whether people with multiple comorbidities may have symptoms that cloud the diagnostic process, or whether short primary care consultations may not allow for enough time to manage multiple issues.

"Older adults typically have more comorbidities, and they are less likely to be screen-detected; for example, breast cancer screening and bowel cancer screening typically stop after 75," said Boyle, director of Patricia Ritchie Centre for Cancer Care and Research at Sydney's Mater Hospital.

Boyle pointed to a recent systematic review in Australian rural oncology that suggested that patients with more comorbidities tend to be offered less intense treatment, and have higher operative mortality and morbidity, which can contribute to less effective therapy.

Referral Delays Seen in Multiple Patient Groups

Ms. Koo, from the University College London and the National Disease Registration Service in the United Kingdom, and coauthors noted a nonsignificant trend toward increased intervals between primary care consultation and referral or diagnosis even in patients with one or more comorbidities.

A higher burden of comorbidities also meant patients were more likely to have more than one primary care consultation before being referred to a specialist. Those with three or more comorbidities were 21% more likely to have at least three consultations before referral, compared with patients with no comorbidities (95% CI, 1.05-1.40, P = .010).

Overall, 60% of the participants in the study experienced at least one investigation into whether they had cancer by a primary care clinician before being referred to a specialist.

Morbidities Linked With Emergency Referral

The study also saw an association between morbidities and the likelihood of receiving an emergency referral. Those with three or more morbidities were 60% more likely to have an emergency referral than were those with no comorbidities. Those with a Charlson score of three or above were 61% more likely to be referred to an emergency department.

"The greater likelihood of clinical complexity or acute deterior­ation among individuals with multiple or severe chronic conditions means that an emergency referral may be clinically appropriate," the authors wrote.

Commenting on the findings, Diane M. Harper, professor of family medicine at the University of Michigan, Ann Arbor, said primary care patients often have multiple chronic illnesses, and the relationship between the physician and patients determines how quickly symptoms of cancer are explored.

"What this work cannot explore is the quality of discussions between the physician and the patient, nor can it explore how the decision to go to the ED was made," said Harper, president of the North American Primary Care Research Group. "Exploring these data would provide important information to the physician-patient dyad."

Diagnostic Difficulty Might Have Been at Play, According to Authors

The investigators didn't find any evidence of an interaction between cancer site, number of morbidities, and referral or diagnostic time, except in cases of colorectal cancer, where patients with multiple morbidities were more likely to experience a longer wait between primary care consultation and diagnosis.

The authors observed that diagnostic difficulty of the cancer might have been at play here, given that colorectal cancer can have a broad symptom signature.

"This was less often observed among patients diagnosed with a cancer that had a narrow symptom signature ("easy" diagnostic difficulty, e.g. breast cancer) or a broad symptom signature of mostly low PPVs ("hard" diagnostic difficulty, e.g. brain cancer)," they wrote.

The authors concluded that "it is reasonable to sug­gest that both improvement efforts and future research in this field should target patients with multiple or severe morbidity, and explore the reasons for prolonged diagnostic intervals in specialist care."

The study was supported by Cancer Research UK. The authors and experts interviewed for this piece did not declare having any conflicts of interest.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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