interviews

Urgent referral for suspected cancer linked to saving lives

Professor Henrik Møller, epidemiologist at King’s College London, discusses how use of the two-week urgent referral for suspected cancer by GPs is variable in England, and what this means for patients.

A “clinically relevant” link between the low use of the two-week urgent referral for suspected cancer in general practices and an increased risk of death has been found by researchers at King’s College London. 

The study – supported by Cancer Research UK and the National Institute for Health Research Biomedical Research Centre (NIHR BRC) at Guy’s and St Thomas’ NHS Foundation Trust – examined data from 215,284 English cancer patients, from 8,049 general practices in England who were diagnosed or first treated in 2009 and monitored up to 2013. 

Practices with a high referral ratio and those with a high detection rate had reduced cancer mortality, the researchers found, although the conversion rate showed no association. 

For instance, high referring practices had a 4% improved mortality rate, while patients from low referring practices had a 7% worse mortality rate, compared with patients from practices with intermediate referral rates. 

To associate each patient with a general practice, the records were linked by NHS number, through the open Exeter portal tracing service, to the NHS Exeter database. For verification of the cancer diagnosis and survival follow-up, the records were also linked with the National Cancer Register by NHS number, date of diagnosis, and cancer type. 

GP usage ‘variable’ 

Lead author Professor Henrik Møller, epidemiologist at King’s College London, told us: “The frequency between general practices in the use of the two-week urgent referral route for suspected cancer is variable.” 

He added this is not least because each individual GP sees few cancer patients in their practice, and are unable to learn directly from their own experience what the “optimum frequency” would be. 

The urgent referral pathway for patients with suspected cancer has been available in England since the early 2000s, but its impact on cancer survival is unknown. 

The researchers say the results suggest that use of the urgent referral pathway is effective, and practices that consistently have a low propensity to use urgent referrals could consider increasing its use to improve the survival of their patients with cancer. 

Discussing the potential financial impact of this suggestion, Prof Møller said: “We are aware that the increased use of urgent referral could be costly in terms of diagnostic and clinical resource, and consider that the cost effectiveness of increasing activity within the urgent referral pathway for suspected cancer should be explored in detail.”

NICE guidance 

Since 2009, the use of urgent referral in England has increased by more than 50% to over 1.2 million referrals per year. And updated NICE guidance on urgent referral for suspected cancer has lowered the threshold for referral, and has been modelled to potentially increase referrals to two million per year. 

Dr Richard Roope, cancer lead for the Royal College of GPs and Cancer Research UK, said: “The recent publication of the NICE Guidance for Suspected Cancer, and the Cancer Task Force, gives GPs the opportunity to lower the threshold for referring those with symptoms that could be caused by cancer, which will have the benefit of diagnosing more cancers at an earlier stage, with its associated better outcomes.” 

He added that it could also result in reduced numbers of consultations to reach a diagnosis, which would be “universally welcomed” in the face of the pressures currently facing primary care. 

“However, this can only be achieved if general practice is better resourced and GPs are given greater access to diagnostic tools such as CT and MRI scans,” said Dr Roope. 

“Our access is one of the worst in Europe and better access would mean we are able to refer even more appropriately, avoiding unnecessary distress for our patients and alleviating pressures on secondary care.” 

Prof Møller told us that each GP in a year – indeed in a career – will have only limited numbers of encounters with specific types of cancer, usually an “inadequate number” for them to learn robustly from their own practice what the right thing to do is. For that reason, he suggests something at a higher level is needed in order to inform these colleagues. 

“I can imagine two things to help them. Firstly, an analysis of the kind we’re publishing, which does not focus on outcomes for each individual practice but identifies a pattern of behaviour and then asks the question whether that pattern is associated with poor or beneficial outcomes,” said Prof Møller.

“Secondly, NICE has issued guidelines to GPs about what it considers to be good policies for use of the urgent referral. That was updated as recently as two months ago. If each GP was in doubt about doing the right thing, the NICE guidance is there. The NICE guidance, in my opinion, is the authority on this matter.” 

Researchers revealed the association between use of the urgent referral pathway and mortality is consistent for the main types of cancer (except breast cancer). They also noted that referral decisions involve a multifactorial process, taking account of a patient’s demographic features, medical history, help-seeking behaviour, and preferences, rather than simply responding to symptoms of possible cancer and relating these to guidelines. 

Importance of early diagnosis 

Sara Hiom, Cancer Research UK’s director of early diagnosis, described the research as “crucial evidence”, which shows that the earlier a cancer patient is diagnosed, the better the chances of survival. 

Dr Roope stated, though, that across the UK GPs are already doing a good job of appropriately referring patients that they suspect of having cancer – 75% of patients found to have cancer are referred after only one or two GP consultations. 

“This research paper reinforces what we already know – early diagnosis of cancer results in better outcomes,” he said. 

“During the study period those practices that referred a higher proportion of patients with symptoms indicating cancer using the urgent referral route had higher detection rates. Overall for England, the detection rate has increased from 42.9% in 2010 to 48.8% in 2014, which is to be welcomed. It is clear that detection rates should be the benchmark used, and not the proportion of urgent referrals diagnosed with cancer.” 

Future work 

The analysis of the results has led the researchers to define new questions for future studies. Firstly, they say it should be established whether the general association between use of urgent referral and mortality of patients with cancer can be replicated in a more recent period. Secondly, it is necessary to understand how stable practice referral and detection rates are, year on year. And thirdly, the characteristics of practices with low referral and detection rates needs further study. 

Prof Møller said: “The differences we have established in our analysis are not of a trivial magnitude. They are of a magnitude that would contribute quite importantly to the mortality of cancer patients in the country, which we know is too high when we compare with those from other European countries with similar health care systems and good quality data. 

“This research is a contribution to an ongoing debate. We know something after this analysis that we didn’t know before.” 

Cancer Research UK’s Sara Hiom added that it has never been clearer that reducing late diagnosis saves lives and “this research adds to our understanding of what can be done about it”. 

She added that Cancer Research UK is committed to investing in early diagnosis research to support GPs refer suspected cancer as “early as practically possible”. 

Prof Møller and his colleagues are now seeking the opportunity to do a more detailed and more direct research on GP referral. 

“We would like to be more detailed with respect to particular types of cancer,” he said, “and be more current and also include focus groups and intervention in selected practices to see how referral patterns are formed and how they might be changed.”

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