A study recently published in the BMJ reported that six out of 10 patients in England with ‘red flag’ symptoms did not receive an urgent referral for specialist assessment within a two-week period, contrary to clinical guidelines.

According to the research, nearly 4% of these patients went on to receive a cancer diagnosis within the next 12 months.

The data was based on 48,715 patients who visited their GP in 2014 and 2015 with any one of the six ‘red flag’ symptoms: dysphagia; postmenopausal bleeding; anaemia; rectal bleeding; haematuria; and a breast lump.

The study’s authors question whether “clinical judgement is good enough”

The average age of these patients was 60, but ranged by presenting symptom, of which the most common were a breast lump (33%) and rectal bleeding (27%).

Overall, 40% (19,670) of patients received an urgent referral within two weeks of seeing their GP, however, rates varied substantially both among clinicians and among practices.

Although the study’s authors account for several possible explanations for why urgent referrals weren’t made or included (such as an emergency admission, an out of hours consultation, or prior referral for another condition), they question whether widespread “clinical judgement is good enough”.

They conclude: “Stricter adherence to the guidelines and increased awareness of patient groups especially at risk of long diagnostic timelines may help improve early diagnosis and ultimately cancer survival rates.”

Urgent referrals increased by nearly 44% up to 2019/20

In response to the study’s findings, Professor Martin Marshall, Chair of the RCGP, said that GPs understand the importance of identifying cancer in a timely manner and they take cancer referrals “incredibly seriously”.

"The study looks at data from 2014-15 - since then, new cancer guidance [NG12] has been published and referrals via the urgent two-week referral pathway increased by nearly 44% up to 2019/20.

“Additionally, the percentage of cancer diagnoses made through this urgent pathway has increased from 48.4% in 2014-5 to 54% in 2019-20. This is against a backdrop of increasing workload and falling GP numbers over the same period,” he explains.

Better diagnostic tools and additional training are needed to ensure better-informed referrals are made

Professor Marshall states that GPs follow clinical guidelines to ensure referrals are appropriate, but they must be careful not to over-refer as this would overload specialist services. For this reason, he says GPs often find themselves “in a position where they are criticised for referring both too much and too little.”

Better diagnostic tools in the community and additional training to use them are therefore needed to ensure better-informed referrals can be made. He also urges the government to step up and “make good on their promise of 6,000 more GPs and 26,000 more members of the practice team, as well as introducing measures to tackle the ‘undoable’ workload in general practice.”