Pathways of Care for Patients with Pancreatic Cancer: The Primary Care-Specialist Interface in Contemporary Practice.
Abstracts
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Introduction: Evidence of improved outcome after surgery for pancreatic cancer in high-volume tertiary centres has led to governmental guidance for better co-ordination and delivery of care. This study examines pathways of care for pancreatic cancer in order to delineate patterns of referral and access to specialists. Methods: Structured questionnaires were sent to family practitioners (GPs), gastroenterologists and gastrointestinal surgeons (including general and specialist HPB surgeons) practising within the Greater Manchester and Cheshire network (a major conurbation with a population of 3.5 million). The questionnaire addressed volume of caseload, modes of action and whether gating (a barrier to referral) was employed. The study population consisted of 391 GPs, 22 gastroenterologists in referring hospitals and 18 gastrointestinal surgeons. The network is served by 4 specialist HPB surgeons (2 were excluded as they were involved in study design). Data are expressed as median (range). Results: For GPs, number of patients with pancreatic cancer seen per annum was 0 (0-4). Painless jaundice was the commonest presenting symptom according to 48% (188) of GPs. For patients <40 yrs, 78% (298 of 384) investigate prior to referral, 14% (53) refer immediately to physicians and 8% (33) to surgeons, while for those older than 40 the percentages are 50 (191), 24 (94) and 26% (99) respectively. Some form of gating is employed by 76% (295) of primary care doctors. The most frequent reason for non-referral was compliance with patient's requests (43%) followed by significant co-morbidity (34%) and compliance with the patient's family's request (16%). For gastroenterologists, the median number of cases was 3 (1-16) per annum. In a patient with suspected pancreatic cancer, 64% would stage all patients, 57% would refer according to staging and 21% referred all to surgeons. Eight (62%) gastroenterologists involve a multidisciplinary team in assessment. Surgeons treated 2 (0-36) patients. Fourteen (78%) referred to specialists. Twelve employed stenting for jaundice and none used surgical bypass as a primary option. Conclusions: The findings of this unique study apply principally to the study base population. However, clear lessons are evident that not all patients with suspected pancreatic cancer have the benefit of access to a specialist opinion, multidisciplinary involvement is limited and that there is lack of uniformity in the involvement of specialist pancreatic cancer surgeons. |
