Factors influencing the patient/practitioner decision to investigate or refer older adults with symptoms potentially indicating cancer: a systematic review

Start Date Apr 2020

Code L7-Aff

Status Ongoing

Project Lead
Senior Lead
Dr Erica Di Martino, Dr Steven Bradley, Dr Judy Wright (all University of Leeds), Dr Cristina Renzi (University College London),  Prof Niek de Wit (University Medical Center Utrecht), Prof Claire Surr (Leeds Beckett University), Prof Andy Clegg (Bradford Institute for Health Research)  


Cancer is a disease of older people with half of all new cancer diagnoses occurring in people aged over 70 and incidence rates for all cancers increasing most rapidly in the over 75 age group. Cancer screening in older people is not recommended (in the UK all cancer screening stops at age 75), and this in part is likely to contribute to the longer time to diagnosis for older people. Evidence suggests that older people are more likely to be diagnosed with cancer following presentation to emergency care services with life threatening manifestations of an underlying cancer. The decision on whether and when, to investigate or to refer older adults is complex and should take into account the patient’s preferences. Earlier guidelines and editorials highlight the lack of age specific evidence on the investigation and referral of cancer symptoms for older people. As a result the importance of shared decision making is frequently highlighted. There is a lack of age specific evidence on the investigation and referral of cancer symptoms for older people. The scarcity of evidence regarding the optimal diagnostic strategies for older people represents a significant challenge for family physicians.

This review will consider the global literature on the effect of old age on the diagnostic process for cancer and the factors specific to old age which affect diagnosis both for healthcare professionals and patients. The review will consider all the factors that could influence the patient and practitioners decision to investigate or refer. These factors may include age, frailty, comorbidities, life expectancy, social circumstances, quality of life and changing life perspective.

Aims & objectives

  1. To identify the factors which influence the decision to investigate symptoms that potentially indicate cancer in older adults in primary care both from a patient and healthcare professional perspective
  2. To understand how the factors identified impact on cancer awareness, help seeking, decision making, processes and outcomes
  3. To explore the effect of increasing age on the primary care interval in the diagnosis of cancer


This study is a systematic review of the available evidence on the factors which influence the decision to investigate and refer older adults with cancer symptoms. Studies will be included in this review if they investigate any factor which could influence the decision to investigate or refer patients aged 65 or over with any cancer symptoms in primary care.  The search strategy and methods was designed by an information specialist at the University of Leeds.

The first two objectives of this review will likely require a synthesis of qualitative research. This will be undertaken using the method of thematic synthesis described by Thomas & Harden (2008) which was developed from the earlier meta ethnography approach described by Noblit and Hare.

Outputs & impact

There is a significant gap in the available evidence on the cancer diagnostic process for older adults. Our preliminary work has highlighted a growing literature considering cancer treatment decisions in older adults but a dearth of evidence on the investigation of possible cancer in primary care.  It is possible that older patients are being over investigated and potentially over-diagnosed with cancers which would not affect life expectancy, causing physical and psychological harm. However, it is also possible that older adults are being denied access to early diagnosis on the basis of age alone. This review will substantially add to the limited available evidence, highlighting an important area for improvement in clinical practice. There is a growing appreciation that the population of older and frail adults is increasing, and for multiple reasons, they may need a different diagnostic approach to cancer symptoms.

Next steps

This review will provide the background information for multiple other studies planned to fully investigate the assessment, management and experience of older adults who experience cancer symptoms.


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