Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study

Abstract

ObjeCtiveTo assess the overall effect of the English urgent referral pathway on cancer survival. Setting general practices in England.DeSign Cohort study. Linked information from the national Cancer Waiting Times database, NHS Exeter database, and National Cancer Register was used to estimate mortality in patients in relation to the propensity of their general practice to use the urgent referral pathway.PartiCiPantS 215 284 patients with cancer, diagnosed or first treated in England in 2009 and followed up to 2013. OutCOme meaSureHazard ratios for death from any cause, as estimated from a Cox proportional hazards regression.reSultS During four years of follow-up, 91 620 deaths occurred, of which 51 606 (56%) occurred within the first year after diagnosis. Two measures of the propensity to use urgent referral, the standardised referral ratio and the detection rate, were associated with reduced mortality. The hazard ratio for the combination of high referral ratio and high detection rate was 0.96 (95% confidence interval 0.94 to 0.99), applying to 16% (n=34 758) of the study population. Patients with cancer who were registered with general practices with the lowest use of urgent referral had an excess mortality (hazard ratio 1.07 (95% confidence interval 1.05 to 1.08); 37% (n=79 416) of the study population). The comparator group for these two hazard ratios was the remaining 47% (n=101 110) of the study population. This result in mortality was consistent for different types of cancer (apart from breast cancer) and with other stratifications of the dataset, and was not sensitive to adjustment for potential confounders and other details of the statistical model. COnCluSiOnSUse of the urgent referral pathway could be efficacious. General practices that consistently have a low propensity to use urgent referrals could consider increasing the use of this pathway to improve the survival of their patients with cancer.

Development of an algorithm to identify urgent referrals for suspected cancer from the Danish Primary Care Referral Database

“…Nevertheless, Denmark still lags behind most of the European countries in cancer survival 3. Research has revealed that high use of urgent referrals among general practitioners (GPs) and short time to diagnosis may improve the prognosis 4–8. However, selecting patients for urgent cancer referral is a complex process; each GP is involved in the diagnosis of only 8–10 new cancer patients per year, but patients with potential cancer symptoms consult GPs on a daily basis 9,10.…”

Access to primary care: creative solutions are needed

“…For truly effective care, GPs must have ready access to specialists when serious disease is suspected. New data on the use of the 2-week cancer waiting rules 11 suggest that patient outcomes are superior in practices that use the 2-week wait more frequently than those who do not, for example. Open access for GPs to relevant imaging services is also important, and the judicious establishment of one-stop clinics for specific conditions, such as dyspepsia, chest pain, or gynaecological problems, also has a part to play in ensuring that patients are diagnosed and managed expeditiously.…”

The Gateway‐C project: helping GPs to detect cancer earlier

“…Evidence from over 215,000 cancer patients in England between 2009 and 2013 found that patients from GP practices with low rates of urgent (ie two-week) referral had excess mortality irrespective of cancer type (except breast cancer), while propensity to use urgent referral was associated with reduced mortality. 2 Unfortunately, though, time constraints on GPs, who have to deal with complex symptoms and difficulties associated with extracting key diagnostic information from patients, mean it is not uncommon that these symptoms can be missed.…”