Evidence
Alert

GPs who make the most urgent referrals for cancer see the fewest cancer deaths among their patients

GP practices across England vary in how frequently they make urgent referrals for suspected cancer. Patients from general practices which make the most urgent referrals are more likely to have their cancer diagnosed at an early stage. A new study found that they are about 4% less likely to die within 5 years. This is similar to the difference in cancer survival between the UK and other better-performing countries.

National Institute for Health and Care Excellence (NICE) guidelines state that people with symptoms that suggest cancer, should be able to see a specialist within two weeks of being referred by their GP. This study provides a reminder that use of this referral scheme may make a significant difference to patients’ chances of survival. The finding may be particularly relevant now because urgent cancer referrals fell significantly in March/April 2020 during the COVID-19 pandemic.

What’s the issue?

Survival rates for cancer are lower in the UK than in comparable countries. One possible reason for lower survival rates is later detection and diagnosis of cancer. 

GPs’ urgent cancer referral rates have been published since 2009. Practices vary in how often they use the urgent referral scheme. A previous study using data from 2009 found that referral rates were linked to cancer patient deaths. This study is the first to use referral data over a number of years to look at all cancers grouped together, and separately, the most common types (breast, colorectal, lung and prostate). It investigated the impact of higher rates of urgent referrals on cancer stage at diagnosis, and rates of death. 

What’s new?

This cohort study included all 1.4 million patients diagnosed with cancer in England (excluding non-melanoma skin cancer) between 2011 and 2015 from Public Health England’s National Cancer Registration and Analysis Service (NCRAS). This data was linked to GP practice referral data from the Cancer Waiting Times database, which recorded urgent referrals.

The age and sex of each practice population was taken into account. GP practices were then ranked from lowest to highest according to their use of urgent cancer referral rates, averaged over five years. The researchers divided the practices into five groups of equal size. They found that:

  • for all cancers, patients from highest-referring practices were 4% less likely to have died within 5 years, compared with patients from lowest-referring practices
  • for all cancers, patients from highest-referring practices were 3% less likely to have been diagnosed at a late stage (three or four) compared with patients from lowest-referring practices
  • for individual cancer types, the patients from highest-referring practices were 5% less likely to die from colorectal cancer and lung cancer, 4% less likely to die from breast cancer and 12% less likely to die from prostate cancer
  • for individual cancers, the patients from highest-referring practices were 8% less likely to have late-stage (stage 3 or 4) lung cancer, 5% less likely to have late-stage breast cancer and 9% less likely to have late-stage prostate cancer. They were no more or less likely to have late-stage colorectal cancer
  • patients not registered with a general practice, or where practice data was not available, were 15% more likely to have died within five years. 

Why is this important?

This research supports increasing the number of urgent referrals as part of efforts to improve the UK’s cancer survival rates, including more cancers diagnosed at an earlier stage. 

NICE guidelines were updated in 2015. This change meant that more people became eligible for urgent referral. People can now be referred if there is a 3%, rather than 5% or higher, chance of them having cancer. This study supports the policy of lowering the threshold and making urgent referrals more widely available. 

Practices which follow the updated guidelines are likely to have higher rates of urgent cancer referrals, and to increase demand for diagnostic services. Access to both general practice and cancer diagnostic services has been challenged during the COVID-19 pandemic. However, general practices are open (although operating differently) and people have been urged to check out symptoms that could be due to cancer

What’s next?

Researcher Thomas Round says people in the UK need to be aware of potentially worrying symptoms to look out for such as abnormal bleeding. He stresses that people should not delay if they have worrying symptoms, particularly during the COVID-19 situation. The reduction in urgent cancer referrals seen in recent months could potentially result in late cancer diagnoses and an increase in deaths, he warns.

In addition, he says health service providers need to work together to ensure that people with potential cancer symptoms and their healthcare professional are able to access urgent diagnostic services. Infection control procedures necessary because of COVID-19 make it harder to carry out procedures such as endoscopy.

The health economic impact of lowering the threshold for cancer referral (as in the NICE guidelines) needs to be studied, given the stretched resources of the NHS. The researchers say it may be necessary to carry out additional risk assessments and tests in primary care before referral. This may be especially true for colorectal cancer, where the study did not find that higher referrals led to earlier stage at diagnosis.

You may be interested to read

The full study: Round T and others. Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study. Br J Gen Pract 2020; 70: e389-e398

NICE guidelines on cancer referral: Suspected cancer: recognition and referral. NICE guideline [NG12] Published date: 23 June 2015. Last updated: 26 July 2017. 

Cancer data including referral rates at practice, local and national levels, by Cancer Services data, Public Health England

Conflict of interest

The authors declare no conflicts of interest.

Funding

Thomas Round is funded by an NIHR Doctoral Research Fellowship for this research project.

Commentaries

Study author

It’s worth noting that people who were not registered with a GP practice, or their practice had closed, had significantly worse outcomes than others. This reinforces that across the population, primary care is effective at reducing mortality, including via diagnostic tests and referral if necessary.

General practice can sometimes feel like it’s between a rock and a hard place. Patients want to be referred, but secondary care may tell us that we’re referring too many people and that they are overloaded. It’s about having that conversation with secondary care colleagues. In order for us to improve cancer survival, more patients who turn out not to have cancer will have to be seen. Currently around 7 out of 100 patients urgently referred are diagnosed with cancer, and this is likely to reduce further for us to pick up more early stage cancers.

Thomas Round, GP and NIHR Doctoral Research Fellow, School of Population Health and Environmental Sciences, King’s College London and National Cancer Registration and Analysis Service, Public Health England

Researcher

The study could alert commissioners (CCGs, and Cancer Alliances) to variations in the use of urgent referrals by individual general practices over a period of time. Commissioners may be able to work with the lower referring practices to identify reasons why they refer less often and to see if referral rates could or should be increased. If so, the study is likely to have a beneficial effect on mortality and stage at diagnosis.

The numbers of two-week wait referrals have increased 10% year on year since 2015 when the study ended. If replicated on the most recent 5 year data, there may be different findings. The study does not explain the reasons behind the findings. For example, why is it that some practices refer more and why is it that their patients do better? It is not as simple as 'more is better'. It may be more likely that these practices follow NICE guidelines.

Richard Neal, Professor of Primary Care Oncology at the University of Leeds