Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumour, patient and health-care factors, often in combination. Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. In this Review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this under-researched aspect of cancer diagnosis.

Background:In England, ‘fast-track’ (also known as ‘two-week wait’) general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups.Methods:We examined data from 669 220 patients with 35 cancers diagnosed in 2006–2010 following either fast-track or ‘routine’ primary-to-secondary care referrals using ‘Routes to Diagnosis’ data. We estimated the proportion of fast-track referrals by sociodemographic characteristic and cancer site and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer.Results:There were large variations in the odds of fast-track referral by cancer (P<0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35, respectively, using rectal cancer as reference); whereas patients with brain cancer and leukaemias least likely (adjusted odds ratios 0.05 and 0.09, respectively, for brain cancer and acute myeloid leukaemia). There were sex, age and deprivation differences in the odds of fast-track referral (P<0.013) that varied in their size and direction for patients with different cancers (P<0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer.Conclusions:Fast-track referrals are less likely for cancers characterised by nonspecific presenting symptoms and patients belonging to low cancer incidence demographic groups. Interventions beyond clinical guidelines for ‘alarm’ symptoms are needed to improve diagnostic timeliness.

BackgroundEmergency diagnosis of cancer is common and aetiologically complex. The proportion of emergency presenters who have consulted previously with relevant symptoms is uncertain.AimTo examine how many patients with cancer, who were diagnosed as emergencies, have had previous primary care consultations with relevant symptoms; and among those, to examine how many had multiple consultations.Design and settingSecondary analysis of patient survey data from the 2010 English Cancer Patient Experience Survey (CPES), previously linked to population-based data on diagnostic route.MethodFor emergency presenters with 18 different cancers, associations were examined for two outcomes (prior GP consultation status; and ‘three or more consultations’ among prior consultees) using logistic regression.ResultsAmong 4647 emergency presenters, 1349 (29%) reported no prior consultations, being more common in males (32% versus 25% in females, P<0.001), older (44% in ≥85 versus 30% in 65–74-year-olds, P<0.001), and the most deprived (35% versus 25% least deprived, P = 0.001) patients; and highest/lowest for patients with brain cancer (46%) and mesothelioma (13%), respectively (P<0.001 for overall variation by cancer site). Among 3298 emergency presenters with prior consultations, 1356 (41%) had three or more consultations, which were more likely in females (P<0.001), younger (P<0.001), and non-white patients (P = 0.017) and those with multiple myeloma, and least likely for patients with leukaemia (P<0.001).ConclusionContrary to suggestions that emergency presentations represent missed diagnoses, about one-third of emergency presenters (particularly those in older and more deprived groups) have no prior GP consultations. Furthermore, only about one-third report multiple (three or more) consultations, which are more likely in ‘harder-to-suspect’ groups.

BackgroundMost cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist, suggesting missed opportunities during doctor-patient conversations.ObjectiveTo understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis.Research designQualitative thematic analysis based on video recordings of doctor-patient consultations in primary care and follow-up interviews with patients and doctors. 80 video observations, 20 patient interviews and 7 doctor interviews across 7 general practices in England.ResultsWe found that timeliness of diagnosis may be adversely affected if doctors and patients do not come to an agreement about the presenting problem’s significance. ‘Disagreements’ may involve misaligned cognitive factors such as differences in medical knowledge between doctor and patient or misaligned emotional factors such as patients’ unexpressed fear of diagnostic procedures. Interviews suggested that conversations where the difference in views is either not recognised or stays unresolved may lead to unhelpful patient behaviour after the consultation (eg, non-attendance at specialist appointments), creating potential for diagnostic delay and patient harm.ConclusionsOur findings highlight how doctor-patient consultations can impact timely diagnosis when patients present with persistent or new problems. Misalignments were common and could go unnoticed, leaving gaps for potential to cause patient harm. These findings have implications for timely diagnosis of cancer and other serious disease because they highlight the complexity and fluidity of the consultation and the subsequent impact on the diagnostic process.

IntroductionIt is believed that some patients are more likely to use out-of-hours primary care services because of difficulties in accessing in-hours care, but substantial evidence about any such association is missing.MethodsWe analysed data from 567 049 respondents to the 2011/2012 English General Practice Patient Survey who reported at least one in-hours primary care consultation in the preceding 6 months. Of those respondents, 7% also reported using out-of-hours primary care. We used logistic regression to explore associations between use of out-of-hours primary care and five measures of in-hours access (ease of getting through on the telephone, ability to see a preferred general practitioner, ability to get an urgent or routine appointment and convenience of opening hours). We illustrated the potential for reduction in use of out-of-hours primary care in a model where access to in-hours care was made optimal.ResultsWorse in-hours access was associated with greater use of out-of-hours primary care for each access factor. In multivariable analysis adjusting for access and patient characteristic variables, worse access was independently associated with increased out-of-hours use for all measures except ease of telephone access. Assuming these associations were causal, we estimated that an 11% relative reduction in use of out-of-hours primary care services in England could be achievable if access to in-hours care were optimal.ConclusionsThis secondary quantitative analysis provides evidence for an association between difficulty in accessing in-hours care and use of out-of-hours primary care services. The findings can motivate the development of interventions to improve in-hour access.

Background: Contacting a doctor for advice when experiencing a potential cancer symptom

Background: Understanding pre-diagnostic test use could reveal diagnostic windows where more timely evaluation for cancer may be indicated. Aim: To examine pre-diagnostic patterns of results of abnormal blood tests in bladder and renal cancer patients. Design and setting: Retrospective cohort study using primary care and cancer registry data on bladder and renal cancer patients diagnosed between 2012-2015 in England. Method: We examined the rates of patients with a first abnormal result in the year before diagnosis, for “generic” (full blood count components, inflammatory markers, calcium) and “organ-specific” blood tests (creatinine, liver function test components) which may lead to subsequent detection of incidental cancers. We used Poisson regression, to detect the month during which the cohort’s rate of each abnormal test started to increase from baseline, and examined the proportion of patients with a test found in the first half of the window, as these ‘early’ tests might represent opportunities where further evaluation could be initiated. Results: Data from 4,533 bladder and renal cancer patients were analysed. The monthly rate of patients with a first abnormal test increased towards the time of cancer diagnosis. Abnormalities of both generic and organ-specific tests started to increase from 6-8 months pre-diagnosis, with 25-40% of these patients having an abnormal test in the “early half” of the diagnostic window. Conclusion: Population-level signals of bladder and renal cancer can be observed in abnormalities in commonly performed primary care blood tests up to 8 months before diagnosis, indicating the potential for earlier diagnosis in some patients.

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