Cancer referralsThe Detect Cancer Early (DCE) Programme is a programme of work to improve survival for people with cancer in Scotland by diagnosing and treating the disease at an earlier stage.1 One of its ambitions is to increase public awareness of the national cancer screening programmes and also the early signs and symptoms of cancer to encourage them to seek help earlier.

It also aims to improve informed decision-making around screening programme participation as well as primary care recognition and referral behaviour. Diagnostic capacity will be increased; however, since the launch of the DCE programme there has been a 6.5% increase in recorded early stage diagnosis for breast, lung and colorectal cancers combined. The programme is particularly focused on reducing inequalities and has seen the largest increase in stage 1 diagnoses in the most deprived areas of Scotland, this is a 14% overall increase from baseline.

The DCE programme encourages referral activity that is aligned with national guidelines and that allows flexibility for clinical suspicion. It also promotes local implementation of pathways that accelerate triaged investigation and decision making for people who present with non-specific symptoms that could indicate cancer.

More than 32,000 patients were diagnosed with cancer in Scotland in 2013, which was a 12% increase in the past decade. It is anticipated that this will increase to 40,000 a year by 2027, with 110 new diagnoses per day.

An individual GP will see on average seven to eight new cases of cancer per annum (based on list size of approximately 1,500). A practice with a list size of approximately 5,500 will see an average of four to five cases per annum of patients with each of the most common cancers, which are lung, breast and colorectal cancer.


Scottish referral guidelines

The aim of the Scottish Referral Guidelines are to facilitate appropriate referral between primary and secondary care when cancer is suspected. They also help identify those patients most likely to have cancer and who need urgent assessment by a specialist, as well as those patients who are unlikely to have it—looking at how to manage a non-urgent referral in the primary care setting.


Alarm symptoms

A study evaluated the association between alarm symptoms and the subsequent diagnosis of cancer in a large population-based study in primary care. It looked at the positive predictive value of first occurrence of haematuria, haemoptysis, dysphagia, or rectal bleeding for diagnoses of neoplasms of the urinary tract, respiratory tract, oesophagus, or colon and rectum during three years after symptom onset. Likelihood ratio and sensitivity were also estimated (Figure 1).

It found that new onset of alarm symptoms are associated with an increased likelihood of a diagnosis of cancer, especially in men and in people aged over 65 years. These data provide support for the early evaluation of alarm symptoms in an attempt to identify underlying cancers at an earlier and more amenable stage.2


Urgent referral audit

In the 2008 Urgent Referral Audit, carried out by NHS Greater Glasgow and Clyde, 149 practices collected data on all urgent referrals for suspected cancer from January 2008 to the end of June 2008. The population base was 819,647 and the total number of referrals included were 5,692. The rate of referral was 6.9 per 1,000 of the population.

The proportion of referrals when some cancer was diagnosed as suspected was 16.5%; the proportion of referrals where any cancer was diagnosed (n=1092) was 19.2%, and the proportion of referrals where referral complied with Scottish Referral Guidelines was 88.7%.

Given the number of actual cancer diagnoses was 1,092 from a population base of 819,647, over a six-month period this would equate to 13,772 cancer diagnoses annually within Scotland through the ‘urgent referral with a suspicion of cancer’ route. Clearly there are other issues to consider.


Gatekeeper function

As British and Danish citizens have a poorer cancer prognosis than citizens from other countries, a study hypothesised that their low cancer survival could be partly rooted in the gatekeeper function undertaken by general practice in these two countries. It aimed to test the association between principles of gatekeeper systems and cancer survival.

This hypothesis was tested in an ecologic study on the association between three principles of gatekeeper systems and cancer survival in 19 European countries for which valid and full data were available. These three principles were: urgent referral pathway, non-specific serious symptoms and low-risk-but-notno- risk symptoms.

It was found that healthcare systems with a gatekeeper system do have a significantly lower oneyear relative cancer survival than systems without such gatekeeper functions. This could suggest that in some countries where GPs were good gatekeepers the GPs had become too reluctant to refer early to diagnostic investigations. Further, that access to diagnostic services in the initial phase was slow or rationed, resulting in patients not receiving timely cancer investigations. It was strongly recommended that further research be conducted to confirm or reject the study hypothesis on this possible serious adverse effect of gatekeeping.3


Impact of delay

Another study compared the components of diagnostic delay (the patient, primary care, referral, secondary care) for six cancers—breast, colorectal, lung, ovarian, prostate and non-Hodgkin’s lymphoma—to compare delays in patients who saw their GP prior to diagnosis with those who did not. Secondary data analysis of The National Survey of NHS Patients: Cancer was undertaken in 65,192 patients. Breast cancer patients experienced the shortest total delays (mean 55.2 days), followed by lung (88.5), ovarian (90.3), non-Hodgkin’s lymphoma (102.8), colorectal (125.7) and prostate (148.5).

Trends were similar for all components of delay. Compared with patient and primary care delays, referral delays and secondary care delays were much shorter. Patients who saw their GP prior to diagnosis experienced considerably longer total diagnostic delays than those who did not.

There were significant differences in all components of delay between the six cancers. Reducing diagnostic delays with the intention of increasing the proportion of early stage cancers may improve cancer survival in the UK, which is poorer than most other European countries. This is important as some 75–85% of all cancer patients start in general practice by presenting signs/symptoms.4


Danish cancer pathway

A Danish cancer pathway has been implemented for patients with serious non-specific symptoms and signs of cancer (NSSC-CPP). The initiative is one of several to improve the long diagnostic interval and the poor survival of Danish cancer patients. However, little is known about the patients investigated under this pathway. A study aimed to describe the characteristics of patients referred from general practice to the NSSC-CPP and to estimate the cancer probability and distribution in this population.

The mean age of all 1,278 included patients was 65.9 years, and 47.5% were men. In total, 16.2% of all patients had a cancer diagnosis after six months; the most common types were lung cancer (17.9%), colorectal cancer (12.6%), hematopoietic tissue cancer (10.1%) and pancreatic cancer (9.2%). All patients in combination had more than 80 different symptoms and 51 different clinical findings at referral. Most symptoms were non-specific and vague; weight loss and fatigue were present in more than half of all cases.

The three most common clinical findings were ‘affected general condition’ (35.8 %), ‘GP’s gut feeling’ (22.5 %) and ‘findings from the abdomen’ (13.0 %). A strong association was found between GP-estimated cancer risk at referral and probability of cancer.

In total, 16.2 % of the patients referred through the NSSC-CPP had cancer. The GP’s gut feeling was a common reason for referral, which proved to be a strong predictor of cancer. The GP’s overall estimation of the patient’s risk of cancer at referral was associated with the probability of finding cancer.5


Emergency presentation of cancer

People diagnosed with cancer following emergency presentation have poorer short-term survival, which could signify that there was a missed opportunity for earlier diagnosis in primary care.

A study analysed primary care and regional data for 1802 cancer patients from Northeast Scotland and found that emergency presentations equalled 20% (n=365) and 28% of these had no relevant prior GP contact. Of those with prior GP contact 30% were admitted, while waiting to be seen in secondary care, and 19% were missed opportunities for earlier diagnosis.

Associated predictors were no prior GP contact; having lung, colorectal and upper GI cancer, and ethnicity.

One of the conclusions was that emergency cancer presentation is more complex than previously thought. Patient delay, prolonged referral pathways and missed opportunities by GPs all contribute, but emergency presentation can also represent effective care. Resources, therefore, should be used proportionately to raise public and GP awareness and improve post-referral pathways.6



1. Cancer-Early (accessed 26/07/17)

2. Jones R. Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ 2007; 334(7602): 1040

3. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? An ecologic study. Br J Gen Pract 2011; 61(589): e508–12

4. Allgar VL, Neal RD. Delays in the diagnosis of six cancers: analysis of data from the National Survey of NHS Patients: Cancer. Br J Cancer 2005; 92(11): 1959–70

5. Ingeman M, Christensen MD, Bro F, et al. The Danish cancer pathway for patients with serious non-specific symptoms and signs of cancer–a cross-sectional study of patient characteristics and cancer probability. BMC Cancer 2015; 15: 421

6. Murchie P, et al. Does Emergency Presentation of Cancer Represent Poor Performance in Primary Care? Insights From a Novel Analysis of Linked Primary and Secondary Care Data. Br J Cancer 2017; 116(9): 1148–58