Wickramasinghe, Bethany; (2024) Exploring the value of prescriptions activity in improving early cancer detection in primary care: a mixed methods approach. Doctoral thesis (Ph.D), UCL (University College London).

Text Bethany Wickramasinghe - PhD Thesis - public.pdf - Accepted Version Access restricted to UCL open access staff until 1 December 2025. Download (6MB)

Abstract

When patients consult their GP about low-risk non-specific symptoms, medication is often prescribed in line with a relevant working diagnosis. Such symptoms can be associated with several different diagnoses of varying severity, but in some patients, will be an early sign of as-yet-undiagnosed-cancer. Therefore, for patients with non-specific symptoms, investigating related prescribing activity could reveal mechanisms for improving early cancer detection. Population-level research shows that pre-diagnostic prescribing patterns can indicate earlier diagnostic opportunities. However, UK evidence is limited and does not consider how prescribing activity relates to specific clinical circumstances and presenting symptoms. Examining the patient behaviours driving primary care interactions, and the clinical reasoning driving prescribing decisions is required. This mixed-methods thesis expands the scope of prescription-defined opportunities for earlier cancer detection, triangulating these against their contributory patient and GP factors. It integrates theories of patient cognition, clinical reasoning, diagnostic and medication safety research. Three empirical studies are presented, contextualised by clinical guidelines and the Model of Pathways to Treatment. They utilise primary care electronic health records, the UK Cancer Registry, qualitative interview data encapsulating patient experiences of primary care prescribing to manage non-specific symptoms, and vignette-elicited GP perspectives on such prescribing. A framework for improving patient safety in the context of primary care prescribing is presented based on the following new evidence: 1) population-level prescribing for dyspnoea management indicates earlier diagnostic opportunities for lung cancer. 2) prescriptions can validate or invalidate patient health behaviours based on the perceived act and effects of the prescription. 3) GP-patient understanding of the prescribing rationale, its relevance to the illness trajectory and diagnostic process are often misaligned. 4) GP perceptions and practices of prescribing and safety-netting during diagnostic uncertainty often overlap. These findings have direct implications for designing interventions to shorten diagnostic intervals for cancers characterised by non-specific symptoms treatable by medication.

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