title: Uncertainty and anxiety in the cancer of unknown primary patient journey: a multiperspective qualitative study.
abstract: BACKGROUND
  Patients with cancer of unknown primary (CUP) have metastatic malignant disease without an identifiable primary site; it is the fourth most common cause of cancer death.
  
  
  OBJECTIVE
  To explore patients' informal and professional carers' experiences of CUP to inform development of evidence-based, patient-centred care.
  
  
  METHODS
  Qualitative study involving development of multiple exploratory case studies, each comprising a patient and nominated informal and professional carers, with contextual data extracted from medical records.
  
  
  RESULTS
  17 CUP patients, 14 informal and 13 professional carers participated in the study. Two inter-related themes distinct to CUP emerged: uncertainty and continuity of care. In the absence of a primary diagnosis, patients and informal carers experienced uncertainty regarding prognosis, possible recurrence and the primary's hereditary potential. Professional carers experienced difficulty communicating uncertainty to patients, ambiguity in deciding optimal treatment plans in the absence of trial data and a test or treat dilemma: when to discontinue seeking the primary and start treatment. Common problems with care continuity were amplified for CUP patients relating to coordination, accountability and timeliness of care. The remit of multidisciplinary teams (MDTs) often excluded CUP, leading to "MDT tennis" where patients were "bounced" between MDTs.
  
  
  CONCLUSIONS
  The experience of those with CUP is distinctive and it can serve to amplify some of the issues encountered by people with cancer. The clinical uncertainties related to CUP compound existing shortcomings in continuity of care, increasing the likelihood of a disrupted patient journey. However, while little can be done to overcome uncertainty, more could be done to address issues regarding continuity of care.
authors.affiliation: Faculty of Health Science, Cancer Nursing and End of Life Care, University of Southampton & University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK.
authors.forename: A
authors.initials: A
authors.lastname: Richardson
authors.affiliation: Faculty of Health Sciences, University of Southampton, Southampton, UK.
authors.forename: R
authors.initials: R
authors.lastname: Wagland
authors.affiliation: Faculty of Health Sciences, University of Southampton, Southampton, UK.
authors.forename: R
authors.initials: R
authors.lastname: Foster
authors.affiliation: Cancer of Unknown Primary Foundation, The Follies, Brightwalton, Newbury, UK.
authors.forename: J
authors.initials: J
authors.lastname: Symons
authors.affiliation: University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK.
authors.forename: C
authors.initials: C
authors.lastname: Davis
authors.affiliation: Palliative Medicine, Oakhaven Hospice Trust, Lymington, Hampshire, UK.
authors.forename: L
authors.initials: L
authors.lastname: Boyland
authors.affiliation: Faculty of Health Sciences, University of Southampton, Southampton, UK.
authors.forename: C
authors.initials: C
authors.lastname: Foster
authors.affiliation: Faculty of Health Sciences, University of Southampton, Southampton, UK.
authors.forename: J
authors.initials: J
authors.lastname: Addington-Hall
mesh_terms: D000328:Adult; D000368:Aged; D001007:Anxiety; D017028:Caregivers / Q000523:psychology; D003266:Continuity of Patient Care; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009382:Neoplasms, Unknown Primary / Q000523:psychology*; D010166:Palliative Care; D010817:Physician-Patient Relations; D036301:Qualitative Research; D035501:Uncertainty