Factors affecting the decision to investigate or refer older adults with cancer symptoms: a systematic review

Problem

Diagnosing cancer at an early stage is important and associated with improved survival. In older adults, these survival benefits are reduced, largely due to reduced life expectancy. Older and frail patients have an increased risk of morbidity and mortality from cancer surgery and intolerance of chemo and radiotherapy. The imperative to diagnose cancer early in older adults must be balanced against the preferences of older patients. Older adults have demonstrated a preference for quality rather than length of life, and would accept a higher risk of cancer being undiagnosed. As a result, when older patients present to primary care with cancer symptoms a complex decision is required regarding possible investigation and referral.

The aim of this systematic review of the world literature was to determine the effect of older age on diagnostic processes for cancer and determine the specific factors which affect diagnosis.

Approach

Electronic databases were searched for studies of patients over 65, preventing with symptoms suggestive of cancer to primary care. A search strategy was developed around the concepts of Cancer, Older adults, Primary care and Shared decision making. Titles and abstracts were screened, full texts reviewed and data extracted independently by two reviewer. Studies were synthesised using thematic synthesis and according to the synthesis without meta-analysis (SWIM) guidelines.

Findings

Of the 5336 articles generated through our searches, 57 studies met our inclusion criteria. Analysis of the 33 papers that provided quantitative data found mixed results of the effect of age on the time to investigation or referral, with the majority of studies reporting that age did not affect the length of the primary care interval. Analysis of the 24 qualitative studies highlighted significant variation in the impact of frailty, co-morbidities and cognitive impairment on GPs which resulted in uncertainty in decisions to investigate or refer older adults with cancer symptoms. Patients showed a clear wish to be involved in these complex decisions.

Consequences

The review has highlighted significant uncertainty and variation in the management of older adults with cancer symptoms by GPs which is largely as a result of a lack of evidence on which to base the decisions. The review has highlighted both patients’ and their family’s wishes to be involved in these decisions. Older adults may need a different diagnostic approach to cancer symptoms. Given the uncertainty regarding optimum management of this group of patients a shared decision-making approach is likely to be helpful. However, it is not clear how best to implement this, and several barriers were highlighted, most notably the possible presence of cognitive impairment and the need for addition time within a consultation.