Background:
Myeloma is a rare, destructive bone marrow cancer, recognised as 'hard to diagnose'. Timelier diagnosis may have potential to lead to earlier stage diagnosis and prolonged survival. The aims of this thesis were to:
• Calculate intervals to diagnosis/treatment;
• Determine factors contributing to journey length; and
• Determine how timelier diagnosis may be achieved.
Methods:
Systematic Review: Standard techniques were used to map the myeloma diagnostic journey. This informed:
Phase I: Quantitative survey of newly diagnosed myeloma patients, their GPs, and their haematologists;
Phase II: Qualitative interview study with patients and their GPs
Phase Ill: Synthesis of findings to make recommendations for policy and practice.
Results:
Systematic review: Longer primary care and diagnostic intervals occurred. Early
symptoms were vague, with multiple GP consultations and more emergency
presentations. Later stage diagnosis, greater numbers of complications and poorer outcomes occurred with longer intervals. Evidence was limited and unable to inform policy and practice.
Phase I: The patient, primary care and total intervals were longer than any other cancer type. The secondary care interval was longer than the primary care interval. The three most important symptoms were muscle/joint pain, fatigue and bone pain. >80% participants initially presented to primary care, a median of three consultations occurred. Longer intervals were associated with consulting different GPs. There was low use of physical examination, radiography of symptomatic areas and protein electrophoresis. Patients were referred to multiple secondary care teams (n=15), <50% had an urgent suspected cancer referral. Longer secondary care intervals were associated with routine referrals.
Phase II: All patients initially blamed symptoms on ageing. Delayed help-seeking
resulted in rapid deterioration and unscheduled presentation to secondary care. GPs did not recognise symptoms were sinister, and delayed investigation. Patients were not encouraged to come back if symptoms persisted. Overall GPs failed to suspect myeloma.
Discussion:
A fragile and complex diagnostic journey was seen for myeloma.
Recommendations from this thesis:
GPs should:
• Suspect myeloma in patients presenting with fatigue or pain in muscles, joints or bones; and
• Have a lower threshold for examining patients and ordering radiographs and
protein electrophoresis of serum or urine.