Improving the diagnostic process for patients with possible bladder and kidney cancer: a mixed-methods study to identify potential missed diagnostic opportunities

Yin Zhou; Hardeep Singh; Willie Hamilton; Stephanie Archer; Sapphire Tan; James Brimicombe; Georgios Lyratzopoulos; Fiona M Walter

doi:10.3399/BJGP.2022.0602

Improving the diagnostic process for patients with possible bladder and kidney cancer: a mixed-methods study to identify potential missed diagnostic opportunities

Br J Gen Pract. 2023 Jul 27;73(733):e575-e585. doi: 10.3399/BJGP.2022.0602. Print 2023 Aug.

Authors

Yin Zhou¹, Hardeep Singh², Willie Hamilton³, Stephanie Archer⁴, Sapphire Tan¹, James Brimicombe¹, Georgios Lyratzopoulos⁵, Fiona M Walter⁶

Affiliations

¹ Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
² Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, US.
³ University of Exeter Medical School, Exeter, UK.
⁴ Department of Public Health and Primary Care, University of Cambridge, Cambridge and Department of Psychology, University of Cambridge, Cambridge, UK.
⁵ Epidemiology of Cancer Healthcare and Outcomes (ECHO), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC), University College London, London, UK.
⁶ Department of Public Health and Primary Care, University of Cambridge, Cambridge and Wolfson Institute of Population Health, Queen Mary University of London, London, UK.

Abstract

Background: Patients with bladder and kidney cancer may experience diagnostic delays.

Aim: To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs).

Design and setting: Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 and October 2019.

Method: Patients with possible bladder and kidney cancer were identified using eligibility criteria based on National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer. Primary care records were reviewed at recruitment and at 1 year for data on symptoms, tests, referrals, and diagnosis. Referral predictors were examined using logistic regression. Semi-structured interviews were undertaken with 15 patients to explore their experiences of the diagnostic process, and these were analysed thematically.

Results: Participants (n = 940) were mostly female (n = 657, 69.9%), with a median age of 71 years (interquartile range 64-77 years). In total, 268 (28.5%) received a referral and 465 (48.5%) had a final diagnosis of urinary tract infection (UTI). There were 33 (3.5%) patients who were diagnosed with cancer, including prostate (n = 17), bladder (n = 7), and upper urothelial tract (n = 1) cancers. Among referred patients, those who had a final diagnosis of UTI had the longest time to referral (median 81.5 days). Only one-third of patients with recurrent UTIs were referred despite meeting NICE referral guidelines. Qualitative findings revealed barriers during the diagnostic process, including inadequate clinical examination, female patients given repeated antibiotics without clinical reviews, and suboptimal communication of test results to patients.

Conclusion: Older females with UTIs might be at increased risk of MDOs for cancer. Targeting barriers during the initial diagnostic assessment and follow-up might improve quality of diagnosis.

Keywords: bladder cancer; early diagnosis of cancer; kidney cancer; missed opportunities; primary health care.

MeSH terms

Aged
England
Female
Humans
Kidney Neoplasms* / diagnosis
Male
Middle Aged
Prospective Studies
Urinary Bladder
Urinary Tract Infections* / diagnosis

Grants and funding

18180/CRUK_/Cancer Research UK/United Kingdom