title: Pre-referral GP consultations in patients subsequently diagnosed with rarer cancers: a study of patient-reported data.
abstract: BACKGROUND
  Some patients with cancer experience multiple pre-diagnostic consultations in primary care, leading to longer time intervals to specialist investigations and diagnosis. Patients with rarer cancers are thought to be at higher risk of such events, but concrete evidence of this is lacking.
  
  
  OBJECTIVE
  To examine the frequency and predictors of repeat consultations with GPs in patients with rarer cancers.
  
  
  METHODS
  Patient-reported data on pre-referral consultations from three English national surveys of patients with cancer (2010, 2013, and 2014), pooled to maximise the sample size of rarer cancers.
  
  
  METHODS
  The authors examined the frequency and crude and adjusted odds ratios for ≥3 (versus 1-2) pre-referral consultations by age, sex, ethnicity, level of deprivation, and cancer diagnosis (38 diagnosis groups, including 12 rarer cancers without prior relevant evidence).
  
  
  RESULTS
  Among 7838 patients with 12 rarer cancers, crude proportions of patients with ≥3 pre-referral consultations ranged from >30.0% to 60.0% for patients with small intestine, bone sarcoma, liver, gallbladder, cancer of unknown primary, soft-tissue sarcoma, and ureteric cancer. The range was 15.0-30.0% for patients with oropharyngeal, anal, parotid, penile, and oral cancer. The overall proportion of responders with any cancer who had ≥3 consultations was 23.4%. Multivariable logistic regression indicated concordant patterns, with strong evidence for variation between rarer cancers (P <0.001).
  
  
  CONCLUSIONS
  Patients with rarer cancers experience pre-referral consultations at frequencies suggestive of middle-to-high diagnostic difficulty. The findings can guide the development of new diagnostic interventions and 'safety-netting' approaches for symptomatic presentations encountered in patients with rarer cancers.
authors.affiliation: Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge.
authors.forename: Silvia C
authors.initials: SC
authors.lastname: Mendonca
authors.affiliation: Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge.
authors.forename: Gary A
authors.initials: GA
authors.lastname: Abel
authors.affiliation: Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London.
authors.forename: Georgios
authors.initials: G
authors.lastname: Lyratzopoulos
mesh_terms: D000367:Age Factors; D057210:Delayed Diagnosis; D055088:Early Detection of Cancer; D058005:General Practitioners; D006301:Health Services Needs and Demand; D006801:Humans; D008485:Medical Audit; D009369:Neoplasms / Q000175:diagnosis*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data; D011379:Prognosis; D035583:Rare Diseases / Q000175:diagnosis*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012196:Review Literature as Topic; D013997:Time Factors; D006113:United Kingdom / Q000453:epidemiology
keywords: consultation; diagnosis; investigation; neoplasm; primary care; referral