Around one in every three people will be diagnosed with a malignant tumour in their lifetime, making early detection of cancer one of the key aims of healthcare. It is well recognised that presentations to healthcare are heterogeneous, and that diagnosis is often not straightforward.1 Nonetheless, the majority of patients present symptomatically to primary care,2 whose pivotal role in early detection has been recognised in the NICE guidelines.3 The latter’s most recent edition has also lowered the risk threshold for referral under the 2-week wait,3 which itself was implemented back in 2000.4
Studies support the widely held belief that early detection and treatment of cancer improves outcomes in terms of cure or prolonged survival.5,6 In a challenge to primary care’s traditional ‘gatekeeper’ role, evidence also suggests that higher referral rates correlate with better outcomes in this domain.7
Chorleywood Health Centre is a 4-doctor undergraduate and postgraduate teaching practice with a list size of 6,900. The practice is located in a Hertfordshire commuter town just to the North-West of metropolitan London. Although a predominantly affluent area, a substantial elderly population accounts for a high prevalence of chronic disease, including cancer, for which the practice is on the 73rd centile for prevalence nationally.8
This study is a retrospective survey of 20 consecutive recent cancer diagnoses, analysing patient pathways to diagnosis, and critically analysing the key question of whether there was any delay in referral by the practice, or in setting up diagnostic processes in the case of patients presenting directly to, or within, secondary care. The study is not concerned with post-diagnostic clinical pathways or outcomes.
A search was done using the practice’s computer system (EMIS) to produce a list of the last 25 patients consecutively diagnosed with a malignant tumour. The list was checked for coding accuracy, and two patients were found whose first confirmed diagnosis was earlier than had actually been coded; these errors were corrected.
Of the 23 remaining patients, the records of the 20 consecutive most recently diagnosed ones were analysed. The following criteria were noted:
- Age at diagnosis
- Site of initial presentation
- The route of referral
- The number of consultations prior to referral (which included the initial presentation), and the number of investigative appointments. This was recorded only for those patients presenting initially to the practice, and used to analyse if there was any delay in referral. As these presentations were almost entirely during the Covid-19 pandemic, ‘consultation’ was defined as any patient interaction, whether by telephone, video call or face-to-face appointment.
The 20 patients studied were diagnosed between February and December 2020, equating to an average of one new cancer diagnosis every 2 weeks for the practice population.
The youngest patient was 37 and the oldest 94 at the time of diagnosis. The average age at diagnosis was 67 years.
There were 10 men and 10 women.
- Breast: 8
- Bladder: 3
- Prostate: 2
- Colorectal: 2
- Oesophageal: 1
- Peritoneal: 1
- Lung: 1
- Leukaemia: 1
- Melanoma: 1
Breast cancer was by far the most common tumour, followed by bladder, prostate and colorectal cancer, with all others registering just one case.
Site of initial presentation
- GP practice: 14
- Emergency department self-referral: 2
- Pre-existing outpatient surveillance: 2
- Surveillance mammography: 1
- Specialist to specialist lateral referral: 1
Route of referral
- NHS 2-week wait by practice: 11
- Private referral by practice: 3
- Emergency department following self-referral: 2
- Outpatient clinic: 4
Number of consultations prior to referral
Of the 14 patients presenting to the practice, six had a single presentation at which the decision to refer was made, seven had 2 consultations and one patient had 3 consultations.
Among this cohort, nine had no investigative clinical contact prior to referral, whist five had a single contact; none required more than this.
There did not appear to be any delays in referral by the practice. The pathways appeared similarly efficient for the 2 patients who self-referred to the emergency department, and the 4 whose diagnosis was made through outpatients.
Summary and discussion
The limitations of a small sample over a relatively short period of time are acknowledged. Nevertheless, the data is commensurate with the relatively high incidence and prevalence of cancer within the practice population.8 Most diagnoses occurred in older people; however, the mean age was relatively young in actuarial terms, owing mainly to the very high proportion of cases of breast cancer in younger women.
A significant majority of initial presentations were to the practice, in keeping with the national pattern.2 Among those diagnosed in secondary care, most were detected by routine outpatient surveillance, with just two self-referring to the emergency department.
The majority of patients whose diagnosis was suspected within the practice were referred and treated under the 2-week wait, with a small number electing to go privately, where in each case management was prompt.
Patients with cancer diagnosed via presentation to the emergency department have been widely studied. In the US, the high proportion doing so has been cited by some as reflecting the failure to develop a coordinated primary health care.9 However, even in the UK, around 20% of diagnoses are made this way,10 and generally portend worse outcomes, being associated as they are with later presentation and more aggressive tumour types such as pancreatic cancer.11
The two patients in this series are too small a number from which to draw statistical conclusions. However, their individual pathways illustrate how overlapping patient, doctor, and system-related factors all contribute to the heterogeneity of presentation, and potentially longer cancer diagnostic intervals.12 One patient diagnosed with bladder cancer had acute onset, severe haematuria, whilst the other, diagnosed with oesophageal cancer, hardly ever sought medical care despite having pre-existing long term conditions, eventually presenting with significant dysphagia.
Notwithstanding this, overall it is encouraging that, from a medical perspective, referrals were made promptly once there was reasonable clinical suspicion.
For more news and articles on cancer diagnosis and referral go to our oncology section
Edin Lakasing, General Practitioner and Trainer, Chorleywood Health Centre, 15 Lower Road, Chorleywood, Hertfordshire
Iman Darwish, FY2 doctor, Watford General Hospital, 60 Vicarage Road, Watford, Hertfordshire WD18 0HB.
Joanna Fursse, Practice Manager, Chorleywood Health Centre, 15 Lower Road, Chorleywood, Hertfordshire WD3 5EA.
Competing interests: none
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- Hamilton W. Five misconceptions in cancer diagnosis.Br J Gen Pract 2009; 59 (563): 441-447.
- National Institute for Health and Care Excellence. Suspected cancer: recognition and referral NG12, 2015. https://www.nice.org.uk/guidance/ng12/resources/suspected-cancer-recognition-and-referral-pdf-1837268071621 (accessed 12 Feb 2021).
- Department of Health HSC, 2000/013: referral guidelines for suspected cancer, 2000. http://allcatsrgrey.org.uk/wp/download/nhs_circulars/health-service-circular/dh_4012253.pdf (accessed 12 Feb 2021).
- Abdel-Rahman M, Stockdon D, Rachet B, et al. What if cancer survival in Britain were the same as in Europe: how many deaths are avoidable? Br J Cancer 2009; 101: Suppl 2 :S115-24.
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- Round T, Gildea C, Ashworth Mand Møller H. Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study. British Journal of General Practice 2020; 70 (695): e389-e398.
- QOF database. https://www.gpcontract.co.uk/browse/E82064/Cancer/11 (accessed 12 Feb 2021).
- Hargarten SW, Richards MJ, Anderson AJ. Cancer presentation in the emergency department: a failure of primary care. Am J Emerg Med 1992 Jul; 10(4): 290-3.
- Herbert A, Abel GA, Winters S, McPhail S, Elliss-Brookes L and Lyratzopoulos G. Cancer diagnoses after emergency GP referral or A&E attendance in England: determinants and time trends in Routes to Diagnosis data, 2006–2015. British Journal of General Practice 2019; 69 (687): e724-e730.
- McPhail S, Elliss-Brookes L, Shelton J, et al. (2013) Emergency presentation of cancer and short–term mortality. Br J Cancer 109(8):2027–2034.
- Round T, Steed L, Shankleman J, et al. Primary care delays in diagnosing cancer: what is causing them and what can we do about them? J R Soc Med 2013; 106 (11): 437-440.