The patient experience of pathways to lung cancer diagnosis in primary care: A mixed methods investigation of factors influencing timeliness of diagnosis.

Abstract

Patients with lung cancer can experience protracted diagnoses. Reasons are often multifaceted and not well elucidated through quantitative studies. This study aimed to investigate the patient experience of the diagnostic pathway prior to a confirmed lung cancer diagnosis, and understand the interplay of determinants across patient factors, the perceived provider-patient relationship, system and disease factors. A mixed methods design was adopted, comprising clinical audit of General Practitioner (GP) and hospital medical records and qualitative semi-structured interviews with eligible patients enrolled in the Embedding Research (and Evidence) in Cancer Healthcare (EnRICH) program, a prospective clinical cohort of patients diagnosed with primary lung cancer presenting to six major specialist cancer centres in metropolitan and regional New South Wales (NSW), Australia since June 2017. Pre-diagnostic timepoints were defined using Walter et al. (2012) 'Model of Pathways to Treatment', operationalised into the Aarhus Statement, to ensure standardised and deductive measurement. Thirty GP surveys and 29 patient interviews were completed. The median diagnostic interval from first clinical presentation was 19 days (range 0-184 days). Three overarching themes impacting the diagnostic interval were identified: (i) Patient Factors - Agency and health literacy, Quality and frequency of GP relationship, Lifestyle factors (ii) Healthcare Provider and System Factors - Low index of suspicion, Appointment availability and care coordination, Access to diagnostic procedures, testing and results; (iii) Disease Factors - Asymptomatic and inconclusive investigations, Atypical tumour presentation and comorbidities. Healthcare Provider and System Factors as detailed through interviews, had the greatest impact on timely investigation leading to a lung cancer diagnosis. Interventions addressing this area of the pathway are likely to yield the greatest benefit in streamlining and accelerating the process, and supporting clinical decision-making, while patient and provider education represent additional avenues to improve the diagnostic experience beyond timeliness.