Start Date Oct 2018
Code C5-C, PhD
Early upper gastrointestinal (GI) symptoms of pancreatic cancer are often vague and non-specific, making it difficult for GPs to determine the most effective use of triaging tests and referral pathways. By exploring how GPs interpret and act on non-specific upper GI symptoms, along with GP factors contributing to testing and referral decisions, this project aims to optimise diagnostic strategies for upper abdominal symptoms to improve the pathway to the early detection of pancreatic cancer.
Pancreatic cancer is the 11th most common cancer in the UK, with approximately 9,900 new cases annually. Patients are often diagnosed when the disease is advanced and curative treatment is not possible. Prognosis tends to be poor with only 9% of patients surviving one year after diagnosis. Early detection of pancreatic cancer in primary care is challenging because common early symptoms are non-specific and more frequently indicate other non-cancer conditions. There are currently no triage tests with sufficient discriminatory power for raising suspicion of pancreatic cancer in patients without the ‘alarm symptom’ of jaundice. For patients presenting when the disease is likely to be most treatable it is difficult for GPs to determine the correct diagnostic testing and referral pathway. Consequently, patients may have multiple testing pathways, potentially contributing to advanced disease at diagnosis.
Additionally, we understand very little about how GPs interpret patient communication of upper gastrointestinal and vague bodily changes, and the extent to which this may influence GPs’ diagnostic suspicion and testing/referral decisions for patients with ‘low-risk-but-not-no-risk’ symptoms suspicious of possible pancreatic cancer- this may also contribute to an extended diagnostic interval.
Aims & objectives
This PhD aims to identify strategies for improving GP use of diagnostic tests and referral pathways for patients with upper gastrointestinal and systemic symptoms, to facilitate more timely suspicion and diagnosis of pancreatic cancer.
We will do this in several ways, by:
1. Identifying the role of GP factors in the diagnosis of possible cancer in symptomatic patients in primary care;
2. Exploring how patients describe and doctors interpret upper GI and/or systemic symptoms possibly suspicious of upper GI cancer in primary care consultations;
3. Investigating how GP interpretation of upper gastrointestinal symptoms indicating possible upper GI cancer influences their diagnostic testing and referral strategies;
4. Identifying which existing (combinations of) diagnostic testing and referral strategies lead to earlier suspicion and diagnosis of pancreatic cancer.
The PhD will be underpinned by the Institute of Medicine’s conceptual framework describing the diagnostic process and its outcomes. The mixed methods approaches will include:
- a systematic review;
- a qualitative analysis of archived routine consultation data;
- a vignette-based survey;
- an analysis of linked patient data from the Clinical Practice Research Datalink (CPRD), Hospital Episodic Statistics (HES), Diagnostic Imaging Dataset (DID) and the Cancer Registry.
Outputs & impact
This PhD aims to identify the most effective and safe testing pathway to a pancreatic cancer diagnosis, thereby improving the early detection of a cancer representing one of the biggest diagnostic challenges in UK primary care. There is significant scope for follow-up work leveraging findings from this project to develop GP decision-support interventions.
The systematic review is underway (objective 1), and the qualitative study has received ethics approval (objective 2). The team are preparing for transfer of the archived routine consultation data from the University of Bristol to start this analysis.
- Hardy V, Yue A, Archer S, Merriel SWD, Thompson M, Emery J, Usher-Smith J, Walter FM. Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review. BMJ Open 2022;12:e053732. doi: 10.1136/bmjopen-2021-053732