Understanding the role of GP factors and patient language on more timely investigation of pancreatic cancer

Background Pancreatic cancer is a relatively uncommon but lethal malignancy that is disproportionately diagnosed at an advanced stage. Early diagnosis is challenging due low disease prevalence, non-specific symptomatic presentation and the absence of non-invasive diagnostic tests. National guidelines supporting the recognition and referral of cancer are inadequate for facilitating timely testing decisions that lead to an early-stage pancreatic cancer diagnosis. GP factors and differences in how patients communicate symptoms may influence GPs decision making. Evidence regarding the impact of GP factors and patient language on decisions to investigate pancreatic cancer is lacking but may aid development of strategies that facilitate earlier investigation. Aims To examine the impact of GP factors and patient language on variations in the timeliness of pancreatic cancer investigation and the tests and referrals GPs request leading to a possible pancreatic cancer diagnosis. Methods I conducted a systematic review and narrative synthesis summarising evidence regarding the influence of GP factors on decisions to investigate cancer. Using video recordings of English primary care consultations with linked medical record data from the ‘One in a Million’ archive, I then undertook a qualitative study exploring differences in patient communication styles and the alignment of GP documented symptoms. This was followed by development of a multimedia vignette survey evaluating the effect of identified GP factors and patient communication styles on decisions to investigate pancreatic cancer which I pilot tested in a ‘think aloud’ study before administering in an experimental study. Vignettes presented patients with symptoms of possible pancreatic cancer at ≤1%, ≤2% and 3% risk in four communication styles to which GPs indicated their management plan. I used logistic regression to examine the association of GP factors and patient communication style with decisions to investigate pancreatic cancer where initiation of investigations at <3% risk reflected more timely investigation. Results Patients communicated symptoms using ‘vague’ or ‘medicalised’ descriptors as ‘discomfort’ or ‘pain’. GPs documentation of symptoms aligned with patient-reported symptoms when communication included ‘medicalised’ terms and ‘pain’. ‘Medicalised pain’ as a communication style closely approximated clinical language with other language composites reflecting vaguer (lay) communication. Vaguer communication (‘medicalised or vague discomfort’) led to poorer symptom documentation but more timely pancreatic cancer investigation. GP ‘gut feeling’ was strongly associated with more timely investigation. It also facilitated investigation of higher risk symptoms (3%) communicated in less clear language (‘vague pain’) that were least likely to be investigated. GPs working full time were less likely to investigate higher risk symptoms. There was no clear evidence of an effect of other GP factors. GPs did not always select the most optimal pathway to investigate lower risk symptoms of pancreatic cancer. Conclusion. How patients communicate influences the completeness of GP documentation and the timeliness of pancreatic cancer investigation. Vague communication styles and GP ‘gut feeling’ will prompt more timely investigation of pancreatic cancer in face-to-face consultations providing GPs gather sufficient information relating to symptoms/features. Patients with symptoms qualifying for an urgent suspected cancer referral may not be referred unless symptoms are communicated in clinical language or prompt ‘gut feeling’. Patient-centred interventions that bridge the patient-GP language gap are needed to promote appropriate referral decisions across risk thresholds.

Name dc:type.qualificationname

Doctor of Philosophy (PhD)

Level dc:type.qualificationlevel

Doctoral

Grantor dc:publisher.institution

University of Cambridge

Year dc:date.issued

2025

Author dc:creator

• Hardy, Victoria

Advisors dc:contributor.advisor

• Walter, Fiona
• Usher-Smith, Juliet

• early detection
• early pancreatic cancer diagnosis

Licence

• https://www.repository.cam.ac.uk/bitstreams/415f1778-d42c-4568-9d3c-5f6a9bf00d87/download
• http://purl.org/NET/rdflicense/allrightsreserved

Language dc:language

eng

Author Identifier

0000-0002-8620-4404

OAI identifier oai:identifier

oai:www.repository.cam.ac.uk:1810/396514