Variation in ‘fast-track’ referrals for suspected cancer by patient characteristic and cancer diagnosis: evidence from 670 000 patients with cancers of 35 different sites

Abstract

Background:In England, ‘fast-track’ (also known as ‘two-week wait’) general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups.Methods:We examined data from 669 220 patients with 35 cancers diagnosed in 2006–2010 following either fast-track or ‘routine’ primary-to-secondary care referrals using ‘Routes to Diagnosis’ data. We estimated the proportion of fast-track referrals by sociodemographic characteristic and cancer site and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer.Results:There were large variations in the odds of fast-track referral by cancer (P<0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35, respectively, using rectal cancer as reference); whereas patients with brain cancer and leukaemias least likely (adjusted odds ratios 0.05 and 0.09, respectively, for brain cancer and acute myeloid leukaemia). There were sex, age and deprivation differences in the odds of fast-track referral (P<0.013) that varied in their size and direction for patients with different cancers (P<0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer.Conclusions:Fast-track referrals are less likely for cancers characterised by nonspecific presenting symptoms and patients belonging to low cancer incidence demographic groups. Interventions beyond clinical guidelines for ‘alarm’ symptoms are needed to improve diagnostic timeliness.

Sociodemographic disparities in stage-specific incidences of endometrial cancer: a registry-based study in West Sweden, 1995–2016

“…EC in younger, pre-menopausal women is more often characterized by unspecific presenting symptoms. Younger patients are less likely to have fast-track referrals than elderly women [25]. The result in question concerns peri-menopausal and post-menopausal women, and may be a consequence of more frequent delay in contacting the general practitioner or gynecologist when irregular vaginal bleeding occurs in those with a low level of education.…”

Direct access cancer testing in primary care: a systematic review of use and clinical outcomes

“…As a result, patients with lower but not no risk symptoms were less likely to be referred urgently, experienced delays in diagnosis, and were more likely to be diagnosed with cancer as an emergency. 93,94 The move to improving access to diagnostic testing for lower-risk symptoms in the 2015 NG12 NICE guidelines was based on emerging primary care research. 95 NG12 set a referral threshold of a 3% risk of cancer, recommending combinations of clinical features for DA testing.…”

Diagnostic spectrum and time intervals in Sweden’s first diagnostic center for patients with nonspecific symptoms of cancer

“…Fast-track referral is typically based on alarm symptoms such as macroscopic hematuria, rectal bleeding or a lump in the breast, but only about half of the patients in primary care showed such symptoms [15,16]. In primary care, many patients with cancer show only general or nonspecific symptoms, such as fatigue, weight-loss, fever, or anemia [16,17] and fast-track referral is less likely for these latter subgroups [18]. Results from five case-control studies in the UK (the CAPER studies) confirm that many patients with common cancers do not have evident alarm symptoms, but low-risk symptoms, and may thus not qualify for urgent referral [19].…”