Clinical decision-making in patients that could have cancer: a vignette study comparing the Baltic states with the Nordic countries

Alexander Rosendahl, Anet Vanaveski, Liina Pilv-Toom, Michael Harris

Background:
One-year relative cancer survival rates in the Baltic States (Estonia, Latvia and Lithuania) are lower than the European mean. Lower one-year relative cancer survival rates are considered an indicator of a more advanced disease at diagnosis. In contrast, the one-year relative cancer survival rates in the Nordic countries (Denmark, Finland, Norway and Sweden) are higher than the European mean.

Research questions:
How does the management of patients with a low but significant risk of cancer in a primary care setting differ between the Baltic States and Nordic Countries?

Method:
Primary care practitioners (PCPs) participated in an online questionnaire that asked for demographic data and practice characteristics, and gave four vignettes of patients presenting with symptoms that could indicate cancer. Participants were asked what their immediate clinical actions would be with these patients.

Results:
Questionnaires were completed by 455 PCPs: 138 from the Baltic states and 317 from the Nordic countries. There were no significant regional differences in prescribing rates. PCPs in the Baltic states were significantly more likely to arrange active follow-up than their Nordic colleagues (79.7%, vs. 59.1% respectively, P=<0.001) and to take diagnostic action (arrange a test and/or refer to a specialist, 90.6% vs. 61.0%, P=<0.001). They were significantly less likely to use a ‘wait and see’ approach (10.9% vs. 22.4%, P=<0.001).

Conclusions:
While one-year relative cancer survival rates are poorer in the Baltic states than in the Nordic countries, this does not seem to be due to delays in PCPs’ clinical actions. Further research is needed to investigate whether the survival differences are due to socio-demographic factors, to delays in other parts of their healthcare systems, or to differences in cancer treatment.

Points for discussion:
Although PCPs in the Baltic states are more likely to take diagnostic action more quickly than their Nordic colleagues, their cancer survival rates are lower. Why do EGPRN members think this may be? What is the best way to investigate this?