Pancreatic cancer is the ninth most common cancer in the UK, with about 8000 cases diagnosed every year. Only 22% men and 20% women currently survive pancreatic cancer for 1 year or more, and it has the poorest 5-year survival rates of all cancers at less than 4%. This poor prognosis is mainly due to patients being diagnosed at a stage when curative treatment is not possible. Survival could be improved if patients could be diagnosed earlier.
The non-specific nature of most symptoms of pancreatic cancer creates challenges for early recognition of a potentially serious condition, by both patients and their GP. Our 2016 blog describes some of the challenges of diagnosing pancreatic cancer. In a large English database study, over 40% of patients diagnosed with pancreatic cancer had visited their GP at least three times before referral to specialist care.
There is limited evidence about the evolution of symptoms of pancreatic cancer over time, and how patients appraise their symptoms and decide to seek medical advice. Furthermore, many symptoms of pancreatic cancer are also symptoms of other benign conditions and intra-abdominal cancers (such as colon and ovary), which may be equally difficult to diagnose early.
This qualitative study, now published in BMJ Open, therefore aimed to gain understanding of barriers and facilitators to symptom appraisal and help-seeking decisions among patients with symptoms suggestive of pancreatic cancer early in their diagnostic pathway, to contribute to the development of interventions to promote earlier or more timely cancer diagnosis.
The researchers, led by Drs Fiona Walter and Katie Mills of the Cancer Group at the Primary Care Unit, interviewed twenty six patients who were newly referred to hospital with symptoms suggestive of pancreatic cancer. Due to their subtle and intermittent pattern, many people initially just monitored their symptoms. Symptoms were interpreted based on previous experiences with common conditions such as gastroenteritis, or impact of dietary change or existing gastrointestinal conditions. Many made changes to their eating patterns including type of food, and frequency and quantity of meals, or managed their symptoms with over-the-counter medication. Consequently, they tended not to go to their GP at that point.
Changes to symptom frequency, duration or severity, their impact on daily life, or the appearance of additional symptoms, particularly pain, led many people to further appraise their symptoms and visit their GP. Family and friends often made important contributions to encouraging help-seeking by reflecting on changes in symptoms, although at times social contacts could reinforce self-management strategies. These patterns of symptom appraisal and help-seeking were seen regardless of the cancer or benign diagnosis.
I was also suffering uncomfortable, you know, let’s say stomach irritation, indigestion, wasn’t happy eating, so I literally went along to say ‘look, this isn’t right, I don’t mind losing weight but not like this’’
– male interviewee, 60–69 years, cancer patient
The National Institute for Health and Care Excellence (NICE) guidance on Suspected Cancer: Recognition and Referral, which was revised in 2015, supports a lower threshold for investigating and referring people with single and multiple symptoms suggestive of pancreatic cancer, particularly those in higher-risk groups such as patients with newly diagnosed diabetes. The findings from this study could inform public health activities to prompt timelier help-seeking by patients. Findings should also inform GP education approaches to promote timely investigation and referral for people with these non-specific and intermittent symptoms.
This research was funded by a National Institute for Health Research Programme Grants for Applied Research programme and Pancreatic Cancer Action.
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Cancer Group at the Primary Care Unit
Dr Katie Mills, Primary Care Unit, University of Cambridge
Dr Fiona Walter, Primary Care Unit, University of Cambridge