The role of Primary Care Physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review

Abstract

Background: Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors may influence their decisions to investigate cancer, but this is poorly understood. Objective: To synthesize evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer. Methods: We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referral decisions for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice. Data extraction and synthesis: Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We therefore performed a narrative synthesis. Results: 29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical interpretation of symptoms as suspicious or alarm symptoms prompted more investigations than non-alarm symptoms in relation to any cancer. ‘Gut feeling’ predicted a subsequent cancer diagnosis, facilitated decisions to investigate non-specific symptoms, and was linked to years of experience. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive. Conclusions: Clinical judgement helped PCPs recognize higher-risk presentations and make effective testing and referral decisions leading to a cancer diagnosis. In the absence of alarm symptoms or ‘gut feelings’ PCPs may not suspect cancer and require strategies to identify patients with non-alarm and non-specific symptoms who need testing or referral.