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Differences in experiences of care between patients diagnosed with metastatic cancer of known and unknown primaries: mixed-method findings from the 2013 cancer patient experience survey in England
  1. Richard Wagland1,
  2. Mike Bracher2,
  3. Allison Drosdowsky3,
  4. Alison Richardson4,
  5. John Symons5,
  6. Linda Mileshkin6,
  7. Penny Schofield7
  1. 1 Faculty of Health Sciences, University of Southampton, Southampton, UK
  2. 2 Department of Human Sciences and Public Health, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
  3. 3 Department of Cancer Experiences Research, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
  4. 4 Academy of Research, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
  5. 5 Cancer of Unknown Primary CUP Foundation Jo’s Friends, Newbury, West Berkshire, UK
  6. 6 Division of Cancer Medicine, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
  7. 7 Department of Psychology, Swinburne University of Technology, Melbourne, Australia
  1. Correspondence to Dr Richard Wagland; r.wagland{at}


Objectives To explore differences in experiences of care reported in the Cancer Patient Experience Survey (CPES) between patients with cancer of unknown primary (CUP) and those with metastatic disease of known primary (non-CUP); to determine insights pertaining to the experiences of care for CUP respondents from free-text comments.

Design Two separate, but related, studies, involving secondary analysis of existing data. Using frequency matching of CUP and non-CUP patients, statistical comparisons of responses to CPES questions were conducted. Free-text comments from CUP respondents were analysed thematically.

Setting and participants The CPES questionnaire comprises 63 closed questions measuring 8 areas that relate to experience of care and 3 free-text questions. Questionnaires were mailed to all adult patients (aged ≥16 years) in England with cancer admitted to hospital between 1 September 2013 and 30 November 2013.

Results Matched analysis of closed response items from 2992 patients found significant differences between CUP (n=1496) and non-CUP patients (n=1496): CUP patients were more likely to want more written information about their type of cancer and tests received, to receive their diagnosis from a general practitioner (GP) and have seen allied health professionals, but less likely to have understood explanations of their condition or had surgery. Freetext responses (n=3055) were coded into 17 categories and provided deeper insight regarding patient information and interactions with GPs. CPES data may include a preponderance of patients with favourable CUP subtypes and patients initially identified as CUP but whose primary was subsequently identified.

Conclusions These are the first large-scale studies to explore the experiences of care of CUP patients. The significant differences identified between the experiences of CUP and non-CUP patients suggest CUP patients require more psychosocial support and specific interventions to manage diagnostic uncertainty and the multiple investigations many CUP patients face. Substantial limitations were identified with the CPES data, emphasising the need for prospective studies.

  • cancer of unknown primary
  • patient experience
  • communication
  • health services research

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  • Contributors PS, RW and AR conceived the idea of the study and acquisition of the data. PS was responsible for the design of the quantitative study, RW for design of the qualitative study. AD was responsible for undertaking quantitative data analysis. MB and RW were responsible for undertaking analysis of qualitative data. PS, LM, AR, JS, AD, MB and RW were all involved with interpretation of the results from both studies. The initial draft of the paper was produced by RW and MB and circulated repeatedly between all authors for critical revision. All authors read and approved the final manuscript.

  • Funding This work was supported by the Cancer of Unknown Primary (CUP) Foundation and Cancer Australia. Additional funding was provided by the ‘Adventures in Research’ funding stream at the University of Southampton.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Source data for the study are closed question responses and free text responses to the Cancer Patient Experience Survey in England for 2013. These data are available from the survey provider (Quality Health, UK) —email:

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