Breaking barriers: enhancing cancer detection in younger patients by overcoming diagnostic bias in primary care

Primary care physicians are o`en the first point of contact for paMents, posiMoning them uniquely to detect early signs of cancer. However, the age-related bias that younger paMents are less likely to have serious condiMons such as cancer can lead to significant delays in diagnosis. 1,5 This is especially concerning given that certain cancers in young paMents can be more aggressive and progress rapidly, such as in breast cancer. 6 Therefore, the main argument posited in this view point is that primary care physicians must acMvely work to overcome diagnosMc biases that impede the early detecMon of cancer in younger paMents.-DiagnosMc bias in younger paMents DiagnosMc bias towards younger paMents has the potenMal to lead to significant delays in idenMfying serious condiMons such as cancer. Interviews with young adults with cancer, revealed that in many cases the paMent and/or the clinician assumed it unlikely they would have cancer due to their age, resulMng in delayed diagnosis in most cases. 7 This bias is even noted in cancer invesMgaMon clinical guidance, with many guidelines having strict age cut-offs for invesMgaMng certain symptoms, such as under the UK's two-week wait pathways (although some do contain overriding caveats for serious clinician concern). 8 Younger individuals presenMng with atypical symptoms can be presumed by clinicians to have benign condiMons, 9 a presumpMon likely rooted in the significantly lower staMsMcal prevalence of cancer within this demographic, 5,10 something elsewhere termed epidemiological opMmism bias. 11 This bias is further exacerbated by the tendency of some primary care physicians to prioriMse more common and less severe diagnoses. 6 Studies have demonstrated that general pracMMoners are less likely to suspect malignancy in younger paMents, which can result in delays in diagnosis and treatment. 10,12 Research indicates that when younger paMents present with symptoms such as unexplained weight loss, persistent pain, or unusual lumps, these signs are o`en a^ributed to benign causes like stress, infecMons, or minor injuries. For instance, a study by Domme^ et al. 10 found that the likelihood of cancer being iniMally misdiagnosed in younger individuals was substanMally higher compared to older adults. This misdiagnosis o`en leads to mulMple consultaMons and a significant delay before appropriate invesMgaMons are conducted.A notable example is the misdiagnosis of Hodgkin lymphoma in younger paMents, which o`en presents with non-specific symptoms such as faMgue, fever, and lymphadenopathy. A delay in recognising these symptoms as potenMal indicators of cancer can severely impact prognosis. 10,13 Similarly, younger paMents with colorectal cancer o`en have a delay in diagnosis, 14 due to both paMent and doctor delay, and in some cases can also receive misdiagnosis as common benign condiMons, such as haemorrhoids. 15 The tendency to overlook serious condiMons in younger paMents highlights the urgent need for heightened awareness and consideraMon of cancer as a differenMal diagnosis. Studies such as those by Lyratzopoulos et al. 16 have underscored the importance of considering a wider range of potenMal diagnoses to prevent delays that can compromise treatment outcomes. By recognising and challenging these biases, we hope primary care physicians can improve diagnosMc accuracy and ensure more Mmely intervenMon, ulMmately enhancing paMent care and survival rates.The necessity of considering cancer as a potenMal diagnosis in younger paMents cannot be overstated. When cancer is not included as a differenMal diagnosis, criMcal Mme may be lost, leading to more advanced disease stages at the Mme of diagnosis. This delay can diminish the efficacy of treatment and worsens paMent prognosis, making early and accurate diagnosis paramount. 10,11,17 For example, a study by Swann et al. 18 reflects that delayed cancer diagnosis in younger paMents o`en results in more aggressive disease progression and reduced survival rates. Conducted as a clinical audit in English general pracMces, data was collected on 17,042 paMents newly diagnosed with cancer in 2014, noMng that diagnosMc delays occurred in 22% of cases due to paMent, clinician, or system factors.The thoroughness of the diagnosMc process is crucial in miMgaMng these delays. Primary care physicians must adopt a comprehensive and systemaMc approach to evaluaMng symptoms, irrespecMve of the paMent's age. This involves maintaining a high index of suspicion and conducMng appropriate invesMgaMons even when iniMal symptoms are non-specific. As noted by Black et al. 19 , implemenMng a structured diagnosMc protocol can enhance early detecMon rates and improve clinical outcomes.Vigilance in idenMfying potenMal cancer signs is imperaMve. Whilst of course the majority of presentaMons in primary care are not due to cancer, we would propose a dual approach of working towards a most likely diagnosis, whilst also considering serious differenMal diagnoses. For instance, non-specific symptoms such as abdominal pain, or unexplained weight loss, should prompt consideraMon of malignancy and inclusion of appropriate invesMgaMons regardless of paMent age and whether malignancy is the most likely diagnosis. The integraMon of decision support tools and evidence-based guidelines in primary care pracMce can aid clinicians in making more informed diagnosMc decisions. 20,21,27 AddiMonally, a proacMve stance, as recommended by O'Sullivan et al. 22 , involves rouMne updates to clinical guidelines and conMnuous professional development to keep abreast of emerging trends in cancer presentaMon and invesMgaMon.Beyond challenging diagnosMc biases to improve clinician recogniMon of potenMal cancers in younger paMents, there must be be^er support for clinicians in then making further decisions about invesMgaMons. An invesMgaMon can be judged in terms of its appropriateness, which is the balance of risk and benefit of any invesMgaMon for a specific paMent. 23 Unfortunately, there is generally a lack of research into the appropriateness of invesMgaMons specifically for cancer in younger people presenMng to primary care. 24 Changing this is vital to be^er inform guidelines and decision support tools, so that clinicians are well supported in making decisions about the invesMgaMons needed to diagnose cancer.Apart from the potenMal benefit of an accurate diagnosis, there are innumerable risks of an invesMgaMon a clinician will be weighing up, such as: false reassurance and paMent disengagement following a false negaMve result; paMent anxiety and further invesMgaMons resulMng from either false posiMve results or non-symptomaMc incidental findings; and the risks of direct harm from any invesMgaMon, for example radiaMon exposure. More broadly, clinicians will also be considering the wider implicaMons of any invesMgaMon, including the costs to the healthcare system and the risk of lengthening waiMng Mmes for invesMgaMons for other paMents. These risks are especially pronounced in younger paMents presenMng to primary care, as the vast majority of presentaMons, will not be due to cancer. To make more confident decisions about invesMgaMons, clinicians must be given enhanced guidelines for managing invesMgaMons for potenMal cancer in younger people, as well as be^er data to backup their decisions. This research and guidance should also account for possible lead-Mme bias, which would be the potenMal for any increase in invesMgaMon in younger people for cancer, to lead to earlier detecMon but not necessarily truly enhanced survival. 25 -Training and awareness programs The implementaMon of comprehensive training and awareness programs for general pracMMoners (GPs) is criMcal in addressing diagnosMc biases and improving the accuracy of cancer detecMon in younger paMents. Such programs are designed to enhance clinicians' awareness of their biases, be they conscious or unconscious, and equip them with the necessary skills to recognise atypical presentaMons of cancer. These educaMonal iniMaMves can significantly alter diagnosMc pracMces and improve paMent outcomes (Table 2). An excellent example of this is Bowel Cancer UK's 'Never Too Young' iniMaMve. 26 EffecMve training programs focus on several key areas. Firstly, they emphasise the importance of a thorough and systemaMc approach to diagnosis, encouraging GPs to consider a broad differenMal diagnosis that includes malignancies, regardless of the paMent's age. 19 According to a study by Walter et al. 28 , training that incorporates case-based learning and simulaMon exercises can improve diagnosMc accuracy by providing GPs with pracMcal experience in idenMfying cancer symptoms in younger paMents. These programs also highlight the significance of early detecMon and the potenMal consequences of delayed diagnosis, reinforcing the need for vigilance and overcoming diagnosMc bias in clinical pracMce. Furthermore, awareness iniMaMves that target diagnosMc bias can help clinicians recognise and miMgate their own preconceived noMons. A study by Staal et al. 29 examined the importance of fostering a broad differenMal diagnosMc approach, as narrowing the focus prematurely can overlook potenMal key diagnoses. IncorporaMng reflecMve pracMce, where physicians regularly review and criMcally analyse their diagnosMc decisions, can foster a culture of self-awareness, openness and conMnuous improvement.In addiMon to formal training, ongoing professional development and access to updated clinical guidelines are essenMal. Regular workshops, educaMonal courses, and peer-reviewed journals help keep GPs up to date with the latest evidence-based pracMces and emerging trends in cancer diagnosis. For instance, the integraMon of decision support tools, as recommended by Schmidt et al. 30 , can assist GPs in making more informed decisions by providing contemporary guidance based on current clinical data.The necessity to overcome diagnosMc biases in primary care to enhance early cancer detecMon in younger paMents has been examined in the preceding secMons. The central points underscored the detrimental impact of age-related biases, the importance of including cancer in differenMal diagnoses for younger paMents, and the vital role of training and awareness programs. 1,10 Addressing these biases has significant implicaMons for clinical pracMce, paMent outcomes, and the broader healthcare system.One of the primary implicaMons for pracMce is the potenMal improvement in early cancer detecMon rates among younger paMents. 17 Early diagnosis is crucial as it o`en leads to be^er prognosMc outcomes and more effecMve treatment opMons. 5 By ensuring that cancer is considered as a possible diagnosis irrespecMve of paMent age, primary care physicians can help miMgate the risks associated with delayed diagnosis. 19,21 Moreover, addressing diagnosMc biases can enhance the overall quality of paMent care. When physicians adopt a more inclusive diagnosMc process, they are likely to conduct more thorough evaluaMons, thereby improving the accuracy of their diagnoses. 20,22 This comprehensive approach not only benefits the paMents by providing Mmely and appropriate care but also reinforces trust in the healthcare system. To acMvely engage primary care physicians in miMgaMng diagnosMc biases, ongoing educaMon and awareness-raising must be emphasised. Professional development programs that focus on recognising and overcoming diagnosMc biases should be mandated. 22 Furthermore, implemenMng decision support algorithms in primary care sepngs can significantly aid in reducing diagnosMc errors. Algorithms can provide evidence-based guidance and highlight potenMal malignancies based on presenMng symptoms, regardless of paMent age. The use of arMficial intelligence (AI) in primary care is one area that may see future expansion and work alongside this. AI tools can analyse large datasets to idenMfy pa^erns that may not be immediately apparent to human clinicians, which could offer enhanced diagnosMcs and in the future. 31 However, this is dependent on the specifics of any AI development and implementaMon, and there are concerns being raised of AI amplifying and entrenching the exisMng human diagnosMc biases of those designing and developing it. 32,33 Primary care sepngs should also advocate for policy changes that support regular training and the integraMon of diagnosMc support tools. Policymakers and healthcare administrators need to allocate resources (both in terms of finances and clinician Mme) towards these iniMaMves, recognising their long-term benefits in improving paMent outcomes and reducing healthcare costs associated with late-stage cancer treatments, 28 alongside the important moral imperaMve to challenge factors that disadvantage younger people with cancer. CollaboraMons with academic insMtuMons, professional organisaMons, and chariMes, can help facilitate the development and disseminaMon of effecMve training and policy changes. 26,27,34,35 Future research should focus on several key areas of cancer diagnosis in younger people. Firstly, it is vital research looks to further develop and validate diagnosMc algorithms that are tailored to younger paMent populaMons, so that clinicians can be be^er supported in their decision making. Studies should also invesMgate the effecMveness of different training methodologies in reducing diagnosMc biases and improving early detecMon rates. 13,18,19,36,37 Emerging populaMon-based evidence supports this trend as parMcularly urgent. Sifaki-Pistolla et al. 38 demonstrated a significant increase in the incidence of colorectal cancer among age groups below 50 years during the past 30 years in the Greek populaMon, while further projecMon indicated that there is also a trend to be projected. These findings set the challenge for updaMng the guidelines by pupng an accent on young age groups early in the course of intervenMons.AddiMonally, research on paMent outcomes following the implementaMon of bias reducMon strategies can provide valuable insights into the pracMcal benefits of these iniMaMves. There is a broader picture here as well, which has innumerable areas where future research would be helpful, including research looking to understand and intervene in paMent factors related to delayed presentaMon in younger people with cancer, as well as research examining the underlying reasons for the rising incidence of cancer diagnosis in younger people. Besides, cultural and behavioural factors play an important role in the influence of delays in diagnosis. Oikonomidou et al. indicated that in rural Greece, paMents o`en refused diagnosMc procedures such as endoscopy due to fears, misconcepMons, and compeMng life prioriMes. These barriers underline the need for culturally sensiMve strategies to enhance compliance and early detecMon. 39 -PaMent-centred care strategies Addressing diagnosMc biases in primary care not only requires systemic and educaMonal intervenMons but also necessitates a shi` towards more paMent-centred care strategies. These strategies place the paMent at the heart of the diagnosMc process, ensuring that their concerns and symptoms are thoroughly evaluated and addressed. One effecMve paMent-centred strategy is the implementaMon of extended consultaMon Mmes for complex cases, allowing GPs to conduct more comprehensive histories and examinaMons, and consider a wider range of differenMal diagnoses. Research by Epstein et al. 34 suggests that longer consultaMon Mmes are associated with improved diagnosMc accuracy, parMcularly in cases presenMng with atypical symptoms.Another crucial aspect of paMent-centred care is the acMve involvement of paMents in their diagnosMc journey. This can be achieved through shared decision-making, where paMents are encouraged to parMcipate more acMvely in discussions about their symptoms, invesMgaMons, and differenMal diagnoses. Providing paMents with detailed informaMon about their symptoms can empower them to advocate for their own health. A study by Charles et al. 35 found that paMent involvement in the diagnosMc process leads to higher saMsfacMon and be^er health outcomes. Concurrently, improving communicaMon channels between GPs and paMents is essenMal. Timely follow-ups and open lines of communicaMon can help in monitoring the progression of symptoms and making appropriate adjustments to the diagnosMc approach. ImplemenMng electronic health records (EHR) with paMent portals can facilitate this communicaMon.PaMent educaMon is a criMcal public health and policy component of paMent-centred care. EducaMng paMents about the signs and symptoms of cancer, regardless of their age, can raise awareness and prompt earlier medical consultaMons. Community outreach programs and educaMonal campaigns, as highlighted by Young and Robb 36 have been shown to improve public awareness of cancer symptoms, which can lead to more Mmely presentaMon and diagnosis.IntegraMng mulMdisciplinary teams into primary care can also enhance paMent-centred care. CollaboraMon with specialists such as oncologists, radiologists, and pathologists can provide a more comprehensive approach to diagnosis and treatment planning. 35,36,37 Lastly, fostering a supporMve and empatheMc clinical environment is paramount. Primary care physicians should be trained in empatheMc communicaMon, which involves acMvely listening to paMents, validaMng their concerns, and expressing genuine care and understanding. EmpatheMc interacMons have been shown to build stronger paMent-provider relaMonships, increase paMent trust, and improve adherence to recommended diagnosMc procedures. 37 Addressing diagnosMc biases in primary care is paramount for improving the detecMon of cancer in younger paMents. Overcoming these biases requires a mulMfaceted approach, including comprehensive training programs to enhance clinical awareness, the integraMon of decision support tools, and systemic changes to support conMnuous professional development. Furthermore, adopMng paMent-centred care strategies, such as extended consultaMon Mmes, shared decision-making, and improved communicaMon, can significantly enhance diagnosMc accuracy and paMent outcomes. By challenging diagnosMc biases, and fostering an environment of vigilance and empathy, we hope primary care physicians can be^er idenMfy and diagnose cancer in younger paMents, ulMmately leading to more Mmely and effecMve treatments. This proacMve and inclusive approach not only benefits paMents but also wider healthcare systems.