Urgent cancer referrals: how well are they working and can they be improved?

Published on Aug 26, 2021in British Journal of General Practice4.19
· DOI :10.3399/BJGP21X716801
Richard D Neal1
Estimated H-index: 1
(University of Exeter),
Lesley Smith9
Estimated H-index: 9
(University of Leeds)
Source
Abstract
Urgent GP cancer referrals, often referred to as 2-week wait (2WW) referrals in England (with equivalent processes in the devolved nations), have changed the landscape of cancer diagnosis in the UK. The data presented by Round et al ,1 demonstrate this starkly: referrals have increased hugely over the past decade and the detection rate (DR; the percentage of new cancer cases treated resulting from a 2WW referral) has increased from 41% to 52% over this period. This is especially good news as patients whose cancer is diagnosed after a 2WW referral are more likely to have earlier stage disease, and therefore have better outcomes, than those diagnosed through other routes. Indeed, Round et al estimate that if DRs hadn’t increased, then 165 899 fewer cancers would have been diagnosed through this pathway over the past decade in England, and many of these would subsequently have had more advanced stage disease, less well tolerated treatments, and poorer outcomes as a result. One of the downsides of the increase in 2WW referrals is that conversion rates (the percentage of 2WW referrals resulting in a cancer diagnosis) have fallen, meaning that the 2WW referral system is becoming less efficient, and many more patients are being referred who do not have cancer. These outcomes are all a predictable consequence of the liberalising of risk thresholds underpinning the referral guidance by the National Institute for Health and Care Excellence (NICE) in 2015. The study also highlighted significant variation between practices, and identified factors that might contribute to the variation in detection rate (larger practices, younger GPs, and more deprived populations). While these may not be amenable to intervention, reasons for these associations need exploring further. The study raises important questions that we …
References9
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#1Thomas Round ('KCL': King's College London)H-Index: 10
#2Mark Ashworth ('KCL': King's College London)H-Index: 36
Last. Henrik Møller ('KCL': King's College London)H-Index: 95
view all 4 authors...
Background: There is substantial variation in use of urgent suspected cancer referral (two week wait/2WW) between practices. Aim: To examine change in use of 2WW referrals in England over ten years (2009/10 to 2018/19) and practice and population factors associated with cancer detection. Design and Setting: Retrospective cross-sectional study of English general practices and their 2WW referral and cancer waiting times (CWT) detection data (all cancers other than non melanoma skin cancers) 2009/1...
1 CitationsSource
#1Stefanie Disbeschl (Bangor University)H-Index: 1
#2Alun Wyn Surgey (Bangor University)H-Index: 1
Last. Clare Wilkinson (Bangor University)H-Index: 36
view all 15 authors...
BACKGROUND Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its ...
1 CitationsSource
#1Saoirse Dolly (Guy's and St Thomas' NHS Foundation Trust)H-Index: 3
#2Geraint Jones (Guy's and St Thomas' NHS Foundation Trust)
Last. Luigi Vincenzo De Michele (Guy's and St Thomas' NHS Foundation Trust)
view all 14 authors...
BACKGROUND Rapid Diagnostic Clinics (RDC) are being expanded nationally by NHS England. Guy's RDC established a pathway for GPs and internal referrals for patients with symptoms concerning for malignancy not suitable for a site-specific 2WW referral. However, little data assessing the effectiveness of RDC models are available in an English population. METHODS We evaluated all patients referred to Guy's RDC between December 2016 and June 2019 (n = 1341) to assess the rate of cancer diagnoses, fre...
2 CitationsSource
#1Suzanne E. Scott ('KCL': King's College London)H-Index: 23
#2Richard Oakley (Guy's and St Thomas' NHS Foundation Trust)H-Index: 13
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Abstract Objectives Very little is known about those who receive a negative (benign) result after referral for suspected cancer, including their risk for future cancer. This service evaluation aimed to track the occurrence of cancer (of any type) in the 5 years after an appointment for suspected head and neck cancer (HNC) and compare to those referred to hospital for routine ear nose and throat reasons. Materials & methods Patient identifiers of referrals to one hospital Trust with either a) sus...
2 CitationsSource
#1Rachel Parsonage (Bangor University)H-Index: 3
#2Julia Hiscock (Bangor University)H-Index: 10
Last. Richard D Neal (University of Leeds)H-Index: 52
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Background Earlier cancer diagnosis is crucial in improving cancer survival. The International Cancer Benchmarking Partnership Module 4 (ICBP4) is a quantitative survey study that explores the reasons for delays in diagnosis and treatment of breast, colorectal, lung, and ovarian cancer. To further understand the associated diagnostic processes, it is also important to explore the patient perspectives expressed in the free-text comments. Aim To use the free-text data provided by patients completi...
16 CitationsSource
#1Brian D Nicholson (University of Oxford)H-Index: 15
#2David Mant (University of Oxford)H-Index: 78
Last. Clare Bankhead (University of Oxford)H-Index: 31
view all 3 authors...
#### What you need to know Patients present daily about symptoms that could represent a new diagnosis of cancer.1 Some will present with easily recognised high risk symptoms such as dysphagia (5% likelihood of cancer if age >55 years), postmenopausal bleeding (4% likelihood if age >55 years), or haemoptysis (2% likelihood if age >40 years). But most will have vague or non-specific symptoms such as cough, fatigue, or abdominal pain.2 3 4 As these symptoms are shared with benign, chronic, or self ...
33 CitationsSource
#1Brian D Nicholson (University of Oxford)H-Index: 15
#2David Mant (University of Oxford)H-Index: 78
Last. Peter W Rose (University of Oxford)H-Index: 40
view all 8 authors...
Background Variation in cancer survival persists between comparable nations and appears to be due, in part, to primary care practitioners (PCPs) having different thresholds for acting definitively in response to cancer-related symptoms. Aim To explore whether cancer guidelines, and adherence to them, differ between jurisdictions and impacts on PCPs' propensity to take definitive action on cancer-related symptoms. Design and setting A secondary analysis of survey data from six countries (10 juris...
23 CitationsSource
#1Richard D Neal (Bangor University)H-Index: 52
#2Iain Robbé (MUN: Memorial University of Newfoundland)H-Index: 2
Last. Jane A. Hanson (Welsh Government)H-Index: 6
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Aim This paper aims to provide a detailed analysis of the diagnostic process of lung cancer from a primary-care perspective. Background Diagnosing lung cancer at a stage where curative treatment is possible remains a challenge. Beginning to understand the complexity and difficulty in the diagnostic journey should enable the development of interventions in order to facilitate timelier diagnosis. Methods A national study of significant events was conducted whereby general practitioners (GPs) in Wa...
16 CitationsSource
#1Cristina Renzi (UCL: University College London)H-Index: 13
#2Katriina L. Whitaker (UCL: University College London)H-Index: 22
Last. Jane Wardle (UCL: University College London)H-Index: 158
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Objectives This literature review examined research into the impact of a previous ‘all-clear’ or non-cancer diagnosis following symptomatic presentation (‘false alarm’) on symptom attribution and delays in help seeking for subsequent possible cancer symptoms. Design and setting The comprehensive literature review included original research based on quantitative, qualitative and mixed data collection methods. We used a combination of search strategies, including in-depth searches of electronic da...
36 CitationsSource
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