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Delayed Diagnosis of Cancer in Primary Care: What do our Complaints tell us?
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Complaints made to the Health and Disability Commissioner
serve a number of purposes, including the opportunity for learning
and quality improvement. This is true at the individual
complaint level, where shortcomings can be identified in particular
cases and changes made to address those issues. In addition,
there is considerable benefit in being able to look across subsets
of HDC's complaints in order to identify trends and patterns, and
provide feedback to the sector on those findings.
This week, HDC published its first in-depth topical analysis of
such findings: "Delayed Diagnosis of Cancer in Primary Care:
Complaints to the Health and Disability Commissioner:
2004-2013". This is an analysis of all complaints made to HDC
in the last ten years in which the HDC expert clinical advisor
considered that aspects of the primary care management had
contributed to a delay in cancer diagnosis. We selected this
topic for our first such analysis as it touches on three important
- Primary care - the primary care sector is an important and high
volume part of the New Zealand health care system. General
practitioners perform around 15 million consultations per year, and
often act as gatekeepers to the rest of the health care
- Diagnosis - concerns about diagnosis appear frequently in
complaints to the HDC, with 36% of all complaints about general
practitioners citing such issues.
- Cancer - cancer is the leading cause of death in New Zealand.
In many cases, earlier diagnosis leads to improved
Over the last ten years, 243 general practitioners have been
complained about in relation to a delayed diagnosis of cancer, with
the number of complaints per year increasing significantly over
that time. While we note that this increase is consistent
with general complaint trends, complaints about cancer misdiagnosis
now comprise a significantly larger percentage of all complaints
about general practitioners than was the case a decade ago.
Colorectal and lung cancers were the cancers most commonly at
issue in the complaints, and the diagnostic delays were often
lengthy. Comparatively, complaints about the delayed diagnosis of
breast cancer were less common and involved shorter delays.
These results were consistent with the international
The factors leading to a delayed diagnosis most commonly
identified by our expert clinical advisors related to:
- the cancer presenting with non-specific or atypical
- poor communication with secondary care;
- appropriate referrals not being made;
- inappropriate reliance on negative test results; and
- the GP failing to adequately take, review or consider relevant
The delayed diagnosis factors observed varied by type of cancer
involved. Delayed colorectal cancer diagnosis was significantly
associated with the failure to conduct an appropriate examination,
and the treating of symptoms in isolation, compared to other cancer
types; while issues of co-morbidities drawing focus, and
inappropriate reliance on test results were characteristic of
complaints about a delayed diagnosis of lung cancer. We found
that delayed diagnosis of skin cancer was significantly associated
with the patient not reporting their symptoms, and delay in
prostate cancer diagnosis was strongly associated with the failure
to follow-up test results.
Cancer can be difficult to diagnose. While the findings
summarised above are not unexpected given the aetiology of
particular cancers and the similar results reported in
international studies, there are various learnings that arise, both
for general practitioners and for their patients. One of the
key objectives achieved by the HDC report is to bring together the
clinical recommendations made in the cases, and make them more
readily accessible, with a view to improving quality of care.
For general practitioners, the cases, and the trends and themes
that emerge from them, suggest that additional focus could be given
- undertaking clinically indicated examinations and tests;
- examining patients in the context of their past history;
- ensuring comprehensive documentation is kept;
- being aware of the limitations of diagnostic testing (eg, false
- considering all clinically relevant differential
- continuing to hold a suspicion for cancer despite
- not treating symptoms in isolation;
- providing safety-netting advice to patients;
- having robust follow-up systems; and
- advocating for patients in the secondary care system.
For patients, diagnostic delay may be lessened by ensuring:
- attendance at follow-up appointments;
- the reporting of all symptoms to the general practitioner;
- proactively following up on test results and referrals.
We are very pleased to have published this report, and trust
that the information collated and shared through it will prove
useful both for those providing services and for those who are
recipients of those services.
The full report can be downloaded
Anthony Hill, Health and Disability
Assisted by Dr Katie Elkin, Associate Commissioner Legal and
Strategic Relations and Natasha Davidson, Analyst - Research and
NZ Doctor, April 2015
 Ministry of Health. Cancer: Registrations and Deaths 2011.
Wellington: Ministry of Health; 2014