Not visiting the GP and the risk of cancer: what are the possible implications for research, policy and practice?
Menée au Danemark auprès de 123 943 patients atteints d'un cancer diagnostiqué entre 2009 et 2013 et âgés de 50 à 89 ans, cette étude de cohorte évalue l'association entre la fréquence des consultations chez le médecin généraliste de 19 à 36 mois avant le diagnostic et le pronostic de la maladie
England and Denmark have been justifiably concerned to address delays in cancer diagnosis, given the comparatively poor survival in our respective countries.[1] This has also led to wider international comparisons of the healthcare system and the role of primary care to accelerate or delay cancer diagnosis.[2] Scope for reducing diagnostic delays has been identified by understanding what influences patients to visit the GP when they have cancer symptoms,[3] what the GP does when patients present[4] or how the wider healthcare system responds when patients are referred with symptoms.[2]
This article by Jensen et al (2017) suggests a need to focus earlier, i.e. on patients' use of primary care before most of them experience symptoms. The authors examined the risk of cancer mortality by GP use 19–36 months before diagnosis in over 120,000 patients in Denmark from 2009 until 2013. They found that a ‘non-trivial’ minority of men and women who do not normally visit their GP are at greater risk of death from cancer than patients who usually consult their GP 3–5 times a year.
By linking data on healthcare use, mortality and cancer with information on patient's socioeconomic circumstances, Jensen et al could investigate some reasons why those that do not consult their GP might be at risk. Contrary to what we might expect from other literature,[3] this group of ‘never consulters’ were not of lower employment or educational status, nor was marital status a predictor of healthcare use. The study also adds to our understanding by examining whether delays in diagnosis were responsible for the greater risk in ‘never consulters’. Whilst stage of diagnosis is later amongst those ‘never consulters’ than ‘frequent consulters’, it does not fully explain the differences in mortality. The authors only look at GP use 19–36 months before diagnosis so it is not possible to confirm whether those non-attenders do indeed delay their healthcare seeking in the period where most of them might be expected to have symptoms.
A natural response to findings of an increased risk of mortality amongst those individuals who do not visit primary care is to consider strategies to increase attendance in primary care. This may be appropriate but also raises some questions for national and international policy and practice and the potential impacts on earlier diagnosis and the healthcare system.
Firstly, what might encourage this group to visit the doctor? Patients' concerns about ‘wasting the doctor's time’ are paramount and compounded by the health care system in the UK at least.[5] Communication to such patients encouraging them to consult may be interpreted in the context of public discourses about GPs’ time being in short supply. Individuals that never consult may be particularly sensitive to concerns about the legitimacy of seeing the doctor especially with minor symptoms. Changes to the healthcare system, as much as encouragement to patients, therefore, may also be required.
Secondly, what should be discussed in consultations with those that rarely attend? If – as Jensen et al found - delays in diagnosis are not the full story behind why ‘never consulters’ are at greater risk of mortality, encouraging earlier discussion of symptoms with the GP will not be sufficient to reduce their risk. What are the other mechanisms by which this group could be at greater risk? For example, those that do not consult their GPs may have more unhealthy lifestyles than regular attenders, though this may vary by country, behavior and gender.[6, 7] As risk behaviours may both influence readiness to consult the GP and risk of mortality from cancer, this might lead to a renewed focus on GP health promotion advice. However, a cautionary note comes from the experience in England of the policy of providing health checks to 40–74 year olds every 5 years to reduce risk factors. The policy has proved controversial, with indications that it may not reduce those risks much.[8]
Finally, what might be the impact on the health care system of increasing attendance at the GP? Alongside any initiatives to encourage consultations amongst ‘never consulters’, it would make sense to estimate potential impacts using prospective modelling studies and measure intended and unintended impacts within and beyond the cancer diagnosis pathway with evaluation. However, the prospect of introducing more patients into the cancer diagnosis pathway at an earlier stage makes it even more important to continue efforts to improve the healthcare system where scope to reduce delays has already been identified.
JS is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health NHS Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health
International Journal of Cancer , éditorial en libre accès, 2016