Exeter Collaboration for Academic Primary Care (APEx) Blog
Exeter Collaboration for Academic Primary Care (APEx) Blog
Posted by ma403
18 March 2026
Cancer is one of the leading causes of mortality worldwide and in the United Kingdom, and timely diagnosis is known to significantly affect survival outcomes. However, a range of factors can affect the timeliness of diagnosis. These include social and systemic factors (including but not limited to age, socioeconomic deprivation, gender, and ethnicity) as well as personal factors (including limited symptom awareness, fear of diagnosis, or embarrassment). Existing literature also suggests that the presence of one or more long-term conditions can impact the diagnostic process. Several mechanisms have been proposed to explain this relationship, such as alternative explanations, competing demands, the surveillance effect etc. Despite these insights, important questions remain about how long-term conditions shape the pathways to cancer diagnosis.
Within the context of a larger project â SPOCC: Spotting Cancer Among Comorbidities (NIHR)â we conducted qualitative research with patients living with long-term conditions and with clinicians working in primary care (GPs and practice nurses). Based on the existing literature, we identified six conditions that appear to be associated with a higher risk of delayed cancer diagnosis: anxiety and/or depression, chronic obstructive pulmonary disease (COPD), obesity (body mass index âĽ30 kg/m²), diabetes, multimorbidity (defined as four or more long-term conditions), and Parkinsonâs disease.
Inclusion and exclusion criteria were set before recruitment for both groups. Patients were recruited through general practices and charities. Clinicians were recruited through the collaborated practices. In total, we conducted 75 interviews with patients and 28 interviews with clinicians.
Our analysis combined deductive and inductive approaches. While we observed mechanisms already described in the literature, we also identified an additional theme that emerged strongly across interviews: legitimacy. Across all patient groups â though particularly among those with anxiety â participants described struggling to demonstrate that their symptoms were legitimate and deserving of further investigation for cancer. Clinicians, meanwhile, often described searching for sufficient evidence to justify investigation. This led us to reflect on a broader question: who is considered a legitimate patient, and what role do pre-existing conditions play in shaping this perception?
We conceptualise legitimacy as a continuous process of internal evaluation undertaken by both patients and clinicians when deciding whether symptoms warrant further investigation. While the candidacy framework helps explain the structural processes through which individuals access healthcare, legitimacy captures the moral politics operating within that process. This moral dimension involves an ongoing negotiation about whether decisions are perceived as right or wrong. Patients may ask themselves whether their decision to seek medical advice â based on their own interpretation of symptoms â is justified. Clinicians, in turn, evaluate whether pursuing further investigation is appropriate based on the available evidence, including symptom presentation and articulation, chronology, test results, medical history, age, sex, and the presence of chronic conditions.
However, it is not possible to discuss this moral dimension without considering its social context. The internal evaluations undertaken by both patients and clinicians are shaped by broader social meanings attached to characteristics such as age, sex, and particular health conditions. Social meanings refer to the ideas, values, and assumptions that societies attach to certain characteristics and that guide how we interpret situations and make judgements about others. These meanings help explain why, for example, anxiety may sometimes become a âblanketâ explanation for symptoms, with individuals implicitly viewed as hypochondriacs. Similarly, clinicians may be more likely to interpret symptoms in older patients with multimorbidity as a ânormal part of ageingâ.
By foregrounding legitimacy as an analytical lens, this study extends existing frameworks of access to care and cancer diagnosis. While the candidacy framework captures the structural negotiation of healthcare access, legitimacy draws attention to the moral judgements embedded within these interactions. Future research should further theorise the role of legitimacy in diagnostic decision-making and examine how it operates across different conditions, healthcare settings, and sociocultural contexts. Such work could help uncover how implicit assumptions about particular conditions or patient groups shape diagnostic trajectories.
For more see: Valasaki M, Carter M, Winder R, et al How do primary care consultation dynamics affect the timeliness of cancer diagnosis in people with one or more long-term conditions? A qualitative study BMJ Open 2025;15:e103288. doi: 10.1136/bmjopen-2025-103288