GPs’ involvement in diagnosing, treating, and referring patients with suspected or confirmed primary cutaneous melanoma: a qualitative study

Dear editor,

We read the article by Smith and colleagues with interest as it analysed a wide-range of Australian general practitioners’ involvement in melanoma patients’ journey through prevention, diagnosis, and management.(1) Early diagnosis and treatment is key to reducing mortality and morbidity of cutaneous malignant melanoma.

The well-known theoretical Model of Total Patient Delay, after Safer(2) and Andersen(3), describes the generic pathway cancer patients could journey through from the initial step of inferring illness from their symptoms through to receiving treatments for their cancer. When Walter and colleagues analysed United Kingdom melanoma patients’ journey up to the stage of pre-treatment through the lens of the Safer-Anderson Model of Total Patient Delay,(4) they found the model of Total Patient Delay insufficient in explaining the ‘complex and dynamic nature’ of patients’ journey and proposed the alternative Model of Pathways to Treatment which is grounded by existing psychological theories.(5) The Model of Pathways to Treatment has since been applied to analysing melanoma(6) and lymphoma patients’ journeys.

The time intervals in the Model of Pathways to Treatment begins with the appraisal interval (detection of a change to a skin lesion by patients), followed by the help-seeking interval (patients inferring illness and perceive the need to seek medical advice), the diagnostic interval (assessment, investigations, and referral by clinicians) and ending with the pre-treatment interval (planning and scheduling of treatment).(5,6)

These theoretical models have important practical applications as they provide a framework for studying potential delays in patient pathways. For example, the combined appraisal and help-seeking time intervals are highly variable for different cancers, with one study from Brazil reported 36.4% of 211 melanoma patients waited more than 6 months before their first visit to a clinician.(7) Public health campaigns enabled earlier detection of melanoma(8,9) and this is most likely to be achieved through reducing the patient appraisal and help-seeking time intervals.

Smith and colleagues discussed the impact of clinician education on melanoma patients’ journey, especially concerning the decision to refer to secondary care and the undertaking of wide local excision by general practitioners.(1) Disappointingly, a systematic review in this area had not identified studies showing educational interventions for primary care clinicians had a statistically significant quantifiable impact on patient-centred outcomes, although education increased clinician knowledge, competence and confidence in managing melanoma.(10) Perhaps future studies evaluating clinician education initiatives should examine their impact on various time intervals within the Model of Pathways to Treatment as we found this is an under investigated area.

In the 2018 United Kingdom national audit of cancer diagnosis,(11) 151 of 798 (18.9%) melanoma cases could be classified as having avoidable delays in patients being informed of their cancer diagnosis. Before April 2020, patients in England are expected to be informed of their cancer diagnosis within 31 days and received first treatment within 62 days of a general practitioner referral. The newly implemented Faster Diagnosis Standard(12) set the new target of 28 days for patients to be informed of their cancer diagnosis. A critical review of local care pathways and the introduction of suitable interventions is needed to address patient waiting times.(13) We further hope that the Model of Pathways to Treatment could be extended to include a treatment interval as modern day cancer treatment often involve complex neoadjuvant or adjuvant therapy, and the treatment pathway patients embark on (which could change direction at any time) is a product of the cancer therapy itself modified by the patients’ social experience of the cancer therapy, the teams delivering the care and the support structure around the patient.

References
1. Smith AL, Watts CG, Robinson S, Schmid H, Chang CH, Thompson JF, Rapport F, Cust AE; Australian Melanoma Centre of Research Excellence Study Group. GPs' involvement in diagnosing, treating, and referring patients with suspected or confirmed primary cutaneous melanoma: a qualitative study. BJGP Open. 2020. pii: bjgpopen20X101028. doi: 10.3399/bjgpopen20X101028.
2. Safer MA, Tharps QJ, Jackson TC, Leventhal H: Determinants of three stages of delay in seeking care at a medical clinic. Med Care. 1979, 17: 11-29. doi:10.1097/00005650-197901000-00002.
3. Andersen BL, Cacioppo JT: Delay in seeking a cancer diagnosis: delay stages and psychophysiological comparison processes. Br J Soc Psychol. 1995, 34 (Pt 1): 33-52.
4.Walter FM, Humphrys E, Tso S, Johnson M, Cohn S. Patient understand of moles and skin cancer, and factors influencing presentation in primary care: a qualitative study. BMC Fam Pract. 2010;11:62. doi: 10.1186/1471-2296-11-62.
5. Scott SE, Walter FM, Webster A, Sutton S, Emery J. The model of pathways to treatment: conceptualization and integration with existing theory. Br J Health Psychol. 2013 Feb;18(1):45-65. doi: 10.1111/j.2044-8287.2012.02077.x
6. Walter FM, Birt L, Cavers D, Scott S, Emery J, Burrows N, Cavanagh G, MacKie R, Weller D, Campbell C. 'This isn't what mine looked like': a qualitative study of symptom appraisal and help seeking in people recently diagnosed with melanoma. BMJ Open. 2014; 4(7):e005566. doi: 10.1136/bmjopen-2014-005566.
7. Xavier MH, Drummond-Lage AP, Baeta C, Rocha L, Almeida AM, Wainstein AJ. Delay in cutaneous melanoma diagnosis: Sequence analyses from suspicion to diagnosis in 211 patients. Medicine (Baltimore). 2016;95(31):e4396. doi: 10.1097/MD.0000000000004396.
8. Baade P, Coory M. Trends in melanoma mortality in Australia: 1950–2002 and their implications for melanoma control. Aust N Z J Public Health 2005; 29:383–386.
9. Iannacone MR, Green AC. Towards skin cancer prevention and early detection: evolution of skin cancer awareness campaigns in Australia. Melanoma Manag. 2014; 1(1): 75–84.
10. Goulart JM, Quigley EA, Dusza S, Jewell ST, Alexander G, Asgari MM, Eide MJ, Fletcher SW, Geller AC, Marghoob AA, Weinstock MA, Halpern AC; INFORMED (INternet curriculum FOR Melanoma Early Detection) Group. Skin Cancer Education for Primary Care Physicians: A Systematic Review of Published Evaluated Interventions. J Gen Intern Med. 2011; 26(9):1027-35. doi: 10.1007/s11606-011-1692-y.
11. Swann R, McPhail S, Witt J, Shand B, Abel GA, Hiom S, Rashbass J, Lyratzopoulos G, Rubin G; National Cancer Diagnosis Audit Steering Group. Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit. Br J Gen Pract. 2018; 68(666):e63-e72. doi: 10.3399/bjgp17X694169
12. Faster Diagnosis Standard - Diagnosing cancer earlier and faster. NHS England. URL https://www.england.nhs.uk/cancer/early-diagnosis/https://www.england.nh... [Accessed 29 April 2020]
13. O'Brien JC, Chong BF. Reducing outpatient dermatology clinic wait times in a safety net health system in Dallas, Texas J Am Acad Dermatol. 2016; 75(3): 631–632. doi: 10.1016/j.jaad.2016.04.043