Urgent suspected cancer referrals from general practice: audit of compliance with guidelines and referral outcomes

Abstract

An Excel spreadsheet template with defined parameters and preset drop-down options was provided to participating practices, with instructions on its use. The template was locked to prevent changes being made to it. The parameters requested were: age at referral, sex, and specific cancer suspected (bladder, brain, breast, cervical, colorectal, endometrial, gallbladder, laryngeal, leukaemia, liver, lung, lymphoma, melanoma, mesothelioma, myeloma, oesophageal, oropharyngeal, ovarian, pancreatic, prostate, renal, sarcoma, small intestine, stomach, testicular, thyroid, vulval, other AimTo examine primary care referral patterns, compliance with referral guidance, and eventual outcome for patients. Design and settingProspective audit within general practice in Scotland. MethodGPs in Scotland reviewed all urgent suspected cancer referrals over a 6-month period. They noted the final diagnosis and assessed whether the referral was in accordance with agreed referral guidelines. ResultsA total of 18 775 urgent suspected cancer referrals were analysed from 516 GP practices. The referral rate ranged from 3.7 to 24.0 per 1000 per annum; 30.8% of referrals were for patients aged under 50 years, yet this age group accounts for only 11.1% of all diagnosed cancers; 10.3% of all urgent cancer referrals were for suspected melanoma, despite this cancer accounting for only 4.1% of new cancers. The proportion of patients subsequently diagnosed with cancer was greatest for leukaemia (61.7%), prostate (52.6%), and lung cancer referrals (39.7%), and lowest for melanoma (11.8%), oesophago-gastric (11.2%), brain (10.6%), and laryngeal cancer referrals (7.8%). Compliance with referral guidelines was 90.9%. A large proportion of referrals considered to be outside the guidelines still had a cancer diagnosed (urological 15.9%, lung 8.8%, colorectal 8.4%, and breast 6.4%). ConclusionThere is wide variation in GP referral rates for suspected cancer with a greater than expected proportion of referrals for younger people. Many referrals considered to be outside the national guidelines were diagnosed with cancer, suggesting factors other than those in referral guidelines alert GPs to the possibility of cancer.

Variation in use of the 2-week referral pathway for suspected cancer: A cross-sectional analysis

“…22 A National Cancer Intelligence Network analysis of referral ratios for England has shown that 15% of practices made less than half the average number of 2WW referrals, while 10% made over 50% more than the average number of referrals. 23 The 11% conversion rate reflects the low predictive value of cancer symptoms, even those regarded as alarm symptoms, 24 while the 43% detection rate reflects the finding of a Danish study that around 50% of patients with cancer do not present with alarm symptoms.…”

Managing risk in cancer presentation, detection and referral: a qualitative study of primary care staff views

“…This led to practitioners, on occasion, subverting the referral system to ensure that patients they considered were at risk, but who did not fit the referral criteria, could be assessed in a timely manner. Such concerns are not unfounded; one study has shown that 8% of patients felt by GPs to have cancer, but who did not have symptoms which fit referral criteria for cancer, were subsequently diagnosed with cancer 19. This may be because the presenting signs and symptoms had a lower predictive value for cancer than those included in the guidelines.…”

Just stick to the facts: remember Goodhart’s law

“…Failure of algorithms to reliably detect cancer underlines the absurdity of such a simplistic approach. 4 What we did not predict was how the system's GP servants rather than its creators would be blamed.…”