Safety in primary care relating to melanoma diagnosis – what can we learn from interviews with patients recently diagnosed with melanoma?

Problem

Timely diagnosis of malignant melanoma is key to improved patient experience, treatment outcomes and survival. Compared to other cancers, a majority of melanoma cases are rapidly referred from primary care. However, in up to 10% of cases, patients experience multiple consultations with their GP before being referred to secondary care. We know little about patients’ experiences of these multiple primary care consultations. Our aim is to identify critical moments in the patient’s diagnostic journey, such as opportunities for safety-netting or referral, which could be contributing to avoidable prolongation of time to diagnosis.

Approach

The study comprises a secondary analysis of a large dataset of in-depth interviews with 63 patients from two diverse UK regions, conducted within ten weeks of their diagnosis with malignant cutaneous melanoma. The original research informed the Department of Health Be Clear on Cancer community campaign. Ongoing analysis focuses on the encounters with primary care practitioners (GPs and nurses), is informed by a framework approach, and uses the concept of ‘missed opportunity’ drawn from the patient safety literature.

Findings

30 participants (13 women, 17 men) were diagnosed with thicker melanoma (>2mm Breslow thickness) and 33 with thinner (≤1mm) melanomas (19 women, 14 men). 14 patients (21%) reported more than one consultation in primary care prior to referral.We have focused our analysis on these patients’ experiences of repeated primary care consultations and in particular their accounts of safety-netting. Skin lesions were frequently described by patients as ‘tiny’ and, in the absence of troublesome symptoms, were not necessarily viewed as potentially sinister. Because patients were uncertain whether their skin lesion was worthy of medical time, the skin lesion was often presented to the doctor at the end of a consultation about other complaints, as ‘an afterthought’. In some cases, reassurance by the doctor in the first consultation about the mole led to patients withdrawing from subsequent self-monitoring. Patients who were advised to ‘keep an eye’ on their moles described the challenges of monitoring their changing body with multiplying freckles and moles. Returning to the GP for review was often not viewed as urgent, and many patients were surprised that the lesion could not ‘just be chopped out’ by the GP.

Consequences

By analysing the first-hand experiences of patients – acting as the single witness to the entire diagnostic course – our qualitative study sheds light on a process which remains inaccessible via quantitative methodological approaches. We have observed that patients’ accounts of safety-netting in primary care consultations differ from recommended clinical standards of safety-netting, and we have sought to explore potential barriers for doctors to implementing high quality safety-netting in consultations relating to skin lesions in primary care.