Exploring the themes of frailty and cancer diagnosis (the basis for Dr Dan Jones’ academic clinical lectureship at the University of Leeds), has this week lead to CanTest core faculty members including lead author Dr Jones publishing a new paper focusing on the primary care part of the cancer pathway, entitled, ‘Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review’.
Having already carried out a review looking into what happens to older adults within the consultation phase (from general practice to referral) and how age and frailty affected that, Dr Jones and team took further steps to look at how frailty and old age affected appraisal and help-seeking.
Symptom appraisal is defined as the time from noticing a change in your body, to perceiving a need to seek help for that change. Help-seeking is the interval from when you recognise the change is worrying, to getting to the GP’s door. Both of these stages combined are the patient-lead part of the diagnostic process, however, as Dr Jones mentions in his latest BJGP interview it is important to recognise there are things doctors can do to promote symptom appraisal and help-seeking:
This research was a systematic review (a review of reviews), which essentially searched for all evidence of the impact of old age (over 65 as per WHO guidelines) on symptom appraisal and help-seeking in relation to cancer-specific diagnoses.
The main results combined quantitative and qualitative findings from over 80 studies and 300,000 participants worldwide, covering a range of cancers. The team found a link that the symptom appraisal period is longer in older adults, whereas the help-seeking period is shorter. The research determined lots of potential barriers to older adults seeking help including carers/family and friends intervening, other priorities e.g., caring for spouses, fear and embarrassment of cancer/treatment, sense of fatalism (i.e., whatever happens is meant to be), comorbidities (other illnesses), and not wanting to waste doctors’ time. There were also accounts of patients’ own self-management of symptoms (utilising over the counter remedies) before seeking GPs help.
There are two major things that affect symptom appraisal – symptom awareness (not seeing symptoms as a red flag for cancer) and interpreting those symptoms i.e., some put changes down to old age, or on their other morbidities which can present or mask similarly to cancer symptoms. Work can be done to help people recognise red flag symptoms e.g., targeted advertising campaigns etc., but it is more difficult to address the interpretation of symptoms as at this stage people haven’t yet got as far as contacting the GP. The existence of comorbidities, however, means that patients are often already in regular contact with GPs and this presents a potential opportunity (if not for GPs, then practice nurses) to ask questions at times such as the patients’ annual review. Change in primary care settings does require time and proactive behaviour, but Dr Jones advises that any opportunity to educate patients in consultations should be taken where possible.
Waiting room posters, information leaflets and ‘be clear on cancer’ messages all help. Once they have got to their local surgery, patients have navigated the tricky part i.e., recognising symptoms and making the decision to seek help, so GPs need to take what they say seriously and recognise it may not have been an easy decision to contact them in the first place.
Dementia and frailty syndromes, cognitive impairment and comorbidities have been relatively unexplored in terms of how they interact with each other and with cancer symptom appraisal and help-seeking. Their effect on cancer diagnosis is a topic for further research which Dr Jones will be looking to focus on going forward.
— The British Journal of General Practice (@BJGPjournal) September 27, 2022