Variation in suspected cancer referral pathways in primary care: comparative analysis across the International Benchmarking Cancer Partnership

Characterising the volume and variation of multiple urgent suspected cancer referrals in England, April 2013-March 2018: a national cohort study

OBJECTIVES

To establish a methodology to categorise urgent suspected cancer (USC) referrals in England and use these categories to understand individual patient referral patterns by demographic characteristics, financial year and referral pathway.

DESIGN

Cross-sectional population-based cohort study.

SETTING

From Cancer Waiting Times data, linked to demographic information held by the National Disease Registration Service, referral-level data on all USC referrals in England between 1 April 2013 and 31 March 2018.

PARTICIPANTS

After restricting records to those with an English postcode at referral and with complete demographic information, 9 524 435 referrals were identified for 7 542 592 patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

USC referrals were categorised into first and subsequent USC referrals, based primarily on intervals between referral dates. Our primary outcome was to describe the distribution of referral categories by financial year, suspected cancer referral type and four demographic variables. Our secondary aim was to understand which suspected cancer referral types were found in combination within the first 4 months.

RESULTS

During the study period, 7.5 million people had an USC referral, with one in five having more than one referral, with 9.5 million referrals in total. Referrals were categorised as first (91.1%) and subsequent (8.9%) USC referrals. The relative increase in the number of referrals across the study period was largest (78.2%) for subsequent USC referrals.Subsequent referrals were most common in the gynaecological (10%), lung (10%) and haematological cancer pathways (12%).Suspected lower gastrointestinal referrals were most frequently included in a pair of USC referrals; it was one of the five most common pairings for 14 out of 16 referral type pathways, contributing to 30% of upper gastrointestinal USC referral pairings.

CONCLUSION

Multiple USC referrals increased in the study period, particularly within a year of the first referral. Common referral pairings suggest opportunities for pathway reorganisation where common non-specific symptoms result in multiple USC referrals.

'ThinkCancer!': randomised feasibility trial of a novel practice-based early cancer diagnosis intervention

BACKGROUND

UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety-netting systems. Few interventions target whole practice teams. We developed a novel whole-practice team intervention to address this.

AIM

To test the feasibility and acceptability of a novel, complex behavioural intervention, 'ThinkCancer!', for assessment in a subsequent Phase III trial.

DESIGN & SETTING

Pragmatic, superiority pilot randomised controlled trial (RCT) with an embedded process evaluation and feasibility economic analysis in Welsh general practices.

METHOD

Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety-netting systems were assessed. Individual practice staff completed evaluation and feedback forms and qualitative interviews. The intervention was adapted and refined.

RESULTS

Trial recruitment and workshop deliveries took place between March 2020 and May 2021. Trial progression criteria for recruitment, intervention fidelity, and routine data collection were met. Staff-level fidelity, retention, and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety-netting plans in detail.

CONCLUSION

'ThinkCancer!' appears feasible and acceptable. The new iteration of the workshops was completed and the Phase III trial has been funded to assess the effectiveness and cost-effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.

Hidden systems in primary care cancer detection: an embedded qualitative intervention development study

BACKGROUND

UK cancer mortality is worse than in many other high-income countries, partly because of diagnostic delays in primary care.

AIM

To understand beliefs and behaviours of GPs, and systems of general practice teams, to inform the Think Cancer! intervention development.

DESIGN AND SETTING

An embedded qualitative study guided by behaviour change models (COM-B [Capability, Opportunity, Motivation - Behaviour] and theoretical domains framework [TDF]) in primary care in Wales, UK.

METHOD

Twenty qualitative, semi-structured telephone interviews with GPs were undertaken and four face-to-face focus groups held with practice teams. Framework analysis was used and results were mapped to multiple, overlapping components of COM-B and TDF.

RESULTS

Three themes illustrate complex, multilevel referral considerations facing GPs and practice teams; external influences and constraints; and the role of practice systems and culture. Tensions emerged between individual considerations of GPs (Capability and Motivation) and context-dependent external pressures (Opportunity). Detecting cancer was guided not only by external requirements, but also by motivational factors GPs described as part of their cancer diagnostics process. External influences on the diagnosis process often resulted from the primary-secondary care interface and social pressures. GPs adapted their behaviour to deal with this disconnect. Positive practice culture and supportive practice-based systems ameliorated these tensions and complexity.

CONCLUSION

By exploring individual GP behaviours together with practice systems and culture we contribute new understanding about how cancer diagnosis operates in primary care and how delays can be improved. We highlight commonly overlooked dynamics and tensions that are experienced by GPs as a tension between individual decision making (Capability and Motivation) and external considerations, such as pressures in secondary care (Opportunity).

Clinical activity in general practice before sarcoma diagnosis: an Australian cohort study

BACKGROUND

Increased time to diagnosis in sarcoma is associated with poor prognosis and patient outcomes. Research is needed to identify whether opportunities to expedite the diagnosis of sarcoma in general practice exist.

AIM

To examine pre-diagnostic GP clinical activity before sarcoma diagnosis.

DESIGN AND SETTING

An Australian retrospective cohort study using hospital registry data (Australian Comprehensive Cancer Outcomes and Research Database [ACCORD]) linked to two primary care datasets (Patron and MedicineInsight).

METHOD

The frequency of general practice healthcare utilisation events (general practice attendances, prescriptions, blood test, and imaging requests) were compared in 377 patients with soft tissue sarcoma (STS) and 64 patients with bone sarcoma (BS) in the year pre-diagnosis. Poisson regression models were used to calculate monthly incidence rate ratios (IRR) for the 24 months pre-diagnosis and estimate inflection points for when healthcare use started to increase from baseline.

RESULTS

In the 6 months pre-diagnosis, patients with sarcoma had a median of 3-4 general practice attendances, around one-third had a GP imaging request (33% [n = 21] BS and 36% [n = 134] STS), and approximately one in five had multiple imaging requests (19% [n = 12] BS and 21% [n = 80] STS). GP imaging requests progressively increased up to eight-fold from 6 months before sarcoma diagnosis (IRR 8.43, 95% confidence interval [CI] = 3.92 to 18.15, P<0.001) and general practice attendances increased from 3 months pre-diagnosis.

CONCLUSION

Patients with sarcoma have increased GP clinical activity from 6 months pre-diagnosis, indicating a diagnostic window where potential opportunities exist for earlier diagnosis. Interventions to help identify patients and promote appropriate use of imaging and direct specialist centre referrals could improve earlier diagnosis and patient outcomes.

Patient preferences for investigating cancer-related symptoms in Australian general practice: a discrete-choice experiment

BACKGROUND

Striking the right balance between early cancer diagnosis and the risk of excessive testing for low-risk symptoms is of paramount importance. Patient-centred care must also consider patient preferences for testing.

AIM

To investigate the diagnostic testing preferences of the Australian public for symptoms associated with oesophagogastric (OG), bowel, or lung cancer.

DESIGN AND SETTING

One of three discrete-choice experiments (DCEs) related to either OG, bowel, or lung cancer were administered to a nationally representative sample of Australians aged ≥40 years.

METHOD

Each DCE comprised three scenarios with symptom positive predictive values (PPVs) for undiagnosed cancer ranging from 1% to 3%. The numerical risk was concealed from participants. DCE attributes encompassed the testing strategy, GP familiarity, test and result waiting times, travel duration, and test cost. Preferences were estimated using conditional and mixed logit models.

RESULTS

A total of 3013 individuals participated in one of three DCEs: OG (n = 1004), bowel (n = 1006), and lung (n = 1003). Preferences were chiefly driven by waiting time and test cost, followed by the test type. There was a preference for more invasive tests. When confronted with symptoms carrying an extremely low risk (symptom PPV of ≤1%), participants were more inclined to abstain from testing.

CONCLUSION

Access-related factors, particularly waiting times and testing costs, emerged as the most pivotal elements influencing preferences, underscoring the substantial impact of these systemic factors on patient choices regarding investigations.

Trends in primary care blood tests prior to lung and colorectal cancer diagnosis-A retrospective cohort study using linked Australian data

INTRODUCTION

Abnormal results in common blood tests may occur several months before lung cancer (LC) and colorectal cancer (CRC) diagnosis. Identifying early blood markers of cancer and distinct blood test signatures could support earlier diagnosis in general practice.

METHODS

Using linked Australian primary care and hospital cancer registry data, we conducted a cohort study of 855 LC and 399 CRC patients diagnosed between 2001 and 2021. Requests and results from general practice blood tests (six acute phase reactants [APR] and six red blood cell indices [RBCI]) were examined in the 2 years before cancer diagnosis. Poisson regression models were used to estimate monthly incidence rates and examine pre-diagnostic trends in blood test use and abnormal results prior to cancer diagnosis, comparing patterns in LC and CRC patients.

RESULTS

General practice blood test requests increase from 7 months before CRC and 6 months before LC diagnosis. Abnormalities in many APR and RBCI tests increase several months before cancer diagnosis, often occur prior to or in the absence of anaemia (in 51% of CRC and 81% of LC patients with abnormalities), and are different in LC and CRC patients.

CONCLUSIONS

This study demonstrates an increase in diagnostic activity in Australian general practice several months before LC and CRC diagnosis, indicating potential opportunities for earlier diagnosis. It identifies blood test abnormalities and distinct signatures that are early markers of LC and CRC. If combined with other pre-diagnostic information, these blood tests have potential to support GPs in prioritising patients for cancer investigation of different sites to expedite diagnosis.

Referral challenges for early-onset colorectal cancer: a qualitative study in UK primary care

BACKGROUND

The incidence of early-onset colorectal cancer (EOCRC) in adults aged <50 years has increased in several Western nations. National surveys have highlighted significant barriers to accessing timely care for patients with EOCRC, which may be contributing to a late stage of presentation in this population group.

AIM

To explore awareness of the increasing incidence of EOCRC, and to understand the potential barriers or facilitators faced by GPs when referring younger adults to secondary care with features indicative of EOCRC.

DESIGN & SETTING

Qualitative methodology, via virtual semi-structured interviews with 17 GPs in Northern Ireland.

METHOD

Reflective thematic analysis was conducted with reference to Braun and Clarke's framework.

RESULTS

Three main themes were identified among participating GPs: awareness, diagnostic, and referral challenges. Awareness challenges focused on perceptions of EOCRC being solely associated with hereditary cancer syndromes, and colorectal cancer being a condition of older adults. Key diagnostic challenges centred around the commonality of lower gastrointestinal complaints and overlap in EOCRC symptoms with benign conditions. Restrictions in age-based referral guidance and a GP 'guilt complex' surrounding over-referral to secondary care summarised the referral challenges. Young females were perceived as being particularly disadvantaged with regard to delays in diagnosis.

CONCLUSION

This novel research outlines potential reasons for the diagnostic delays seen in patients with EOCRC from a GP perspective, and highlights many of the complicating factors that contribute to the diagnostic process.

Exploring GPs' assessments of their patients' cancer diagnostic processes: a questionnaire study

BACKGROUND

Most cancer diagnostic pathways start from primary care and several factors affect the diagnostic processes.

AIM

To analyse the associations between patient characteristics, symptom presentation, and cancer type and the GP's assessment of the diagnostic processes.

DESIGN AND SETTING

General practices in the North, Central, and Southern regions of Denmark were invited to participate in a questionnaire survey.

METHOD

Participating GPs received a list of patients with incident cases of cancer in the period between 1 March 2019 and 28 February 2021 based on administrative hospital data. A questionnaire was completed for each patient, addressing symptom presentation and the GP's assessment of the diagnostic process both overall and in four subcategories (the patient's role, the GP's role, the transition between primary and secondary care, and the secondary sector's role).

RESULTS

A total of 187 general practices informed on 8240 patients. For 5868 patients, diagnostic pathways started in general practice. Almost half (48.3%, 2837/5868) presented with specific cancer symptoms. GPs assessed 55.6% (3263) and 32.3% (1897) of the diagnostic processes as 'very good' and 'predominantly good', respectively; 11.9% (700) were 'predominantly poor' or 'very poor' for these 5868 patients. Long symptom duration of ≥2 months prior to GP contact and presenting with non-specific or a combination of non-specific and specific symptoms were associated with a poor overall assessment of the diagnostic process. Assessment in the four subcategories showed that the patient's role was assessed less positively than the other three categories.

CONCLUSION

A longer symptom duration and presenting without cancer-specific symptoms were associated with GPs assessing the diagnostic process as poor.

Identification of an oncological clinical pathway through questionnaires to health professionals

BACKGROUND

Clinical Pathways in Oncology can benefit patients using organized interventions to standardize and increase care efficiency. Healthcare systems should have tools to identify their oncological clinical pathways for a better institutional organization to reduce mortality rates and contain costs without compromising quality. Our objective is to determine the regional Oncology Clinical Pathway from a first basic hypothesis using questionnaires directed to healthcare professionals considered key deciders within the Pathway.

METHODS

Study design consisted of data analysis of two structured region-wide questionnaires; built using available literature on Oncology Clinical Pathways, in a Portuguese Healthcare context and pre-tested in a focus group of key deciders (Physicians and nurses with management functions) from which a design was created. Queries analyzed the patients: tumor staging at service arrival; time intervals on tumor suspicion/diagnosis confirmation and diagnosis/first treatment; referral pathway; diagnostic networks and patient Follow-up. One questionnaire was sent to key deciders directly involved with Oncology patients at a Regional Hospital. 15 physicians and 18 nurses of this sample answered the questionnaire (approx. response rate = 67%). Another questionnaire sent to healthcare professionals in Primary Healthcare Centers yielded response rate 19.2%, N = 29 physicians and 46 nurses. Finally, we performed a descriptive analysis and a Cronbach Alpha reliability analysis.

RESULTS

Our findings reveal: different appreciations of tumor staging at arrival in Primary Healthcare Centers and Regional Hospitals (the latter receiving more metastatic cases); approximately 4 weeks between tumor suspicion-diagnostic and divided opinions regarding diagnostic-treatment time intervals. Primary Healthcare Centers depend on private laboratories for diagnostics confirmation, while the Hospitals resolve this locally. Referral pathways indicate almost half of the patients being sent from primary healthcare centers to National Reference Hospitals instead of a Regional Hospital. Patient follow-up is developed throughout the institutions, however, is more established at Regional Hospitals. As patients advance through the Oncology Clinical Pathway and toward treatment stages the number of healthcare professionals involved reduce.

CONCLUSION

Our questionnaires enable us to understand the real pathway between the different institutions involved and the main entry points of the patients into the Oncology Clinical Pathway.

Multi-cancer early detection test in symptomatic patients referred for cancer investigation in England and Wales (SYMPLIFY): a large-scale, observational cohort study

BACKGROUND

Analysis of circulating tumour DNA could stratify cancer risk in symptomatic patients. We aimed to evaluate the performance of a methylation-based multicancer early detection (MCED) diagnostic test in symptomatic patients referred from primary care.

METHODS

We did a multicentre, prospective, observational study at National Health Service (NHS) hospital sites in England and Wales. Participants aged 18 or older referred with non-specific symptoms or symptoms potentially due to gynaecological, lung, or upper or lower gastrointestinal cancers were included and gave a blood sample when they attended for urgent investigation. Participants were excluded if they had a history of or had received treatment for an invasive or haematological malignancy diagnosed within the preceding 3 years, were taking cytotoxic or demethylating agents that might interfere with the test, or had participated in another study of a GRAIL MCED test. Patients were followed until diagnostic resolution or up to 9 months. Cell-free DNA was isolated and the MCED test performed blinded to the clinical outcome. MCED predictions were compared with the diagnosis obtained by standard care to establish the primary outcomes of overall positive and negative predictive value, sensitivity, and specificity. Outcomes were assessed in participants with a valid MCED test result and diagnostic resolution. SYMPLIFY is registered with ISRCTN (ISRCTN10226380) and has completed follow-up at all sites.

FINDINGS

6238 participants were recruited between July 7 and Nov 30, 2021, across 44 hospital sites. 387 were excluded due to staff being unable to draw blood, sample errors, participant withdrawal, or identification of ineligibility after enrolment. Of 5851 clinically evaluable participants, 376 had no MCED test result and 14 had no information as to final diagnosis, resulting in 5461 included in the final cohort for analysis with an evaluable MCED test result and diagnostic outcome (368 [6·7%] with a cancer diagnosis and 5093 [93·3%] without a cancer diagnosis). The median age of participants was 61·9 years (IQR 53·4-73·0), 3609 (66·1%) were female and 1852 (33·9%) were male. The MCED test detected a cancer signal in 323 cases, in whom 244 cancer was diagnosed, yielding a positive predictive value of 75·5% (95% CI 70·5-80·1), negative predictive value of 97·6% (97·1-98·0), sensitivity of 66·3% (61·2-71·1), and specificity of 98·4% (98·1-98·8). Sensitivity increased with increasing age and cancer stage, from 24·2% (95% CI 16·0-34·1) in stage I to 95·3% (88·5-98·7) in stage IV. For cases in which a cancer signal was detected among patients with cancer, the MCED test's prediction of the site of origin was accurate in 85·2% (95% CI 79·8-89·3) of cases. Sensitivity 80·4% (95% CI 66·1-90·6) and negative predictive value 99·1% (98·2-99·6) were highest for patients with symptoms mandating investigation for upper gastrointestinal cancer.

INTERPRETATION

This first large-scale prospective evaluation of an MCED diagnostic test in a symptomatic population demonstrates the feasibility of using an MCED test to assist clinicians with decisions regarding urgency and route of referral from primary care. Our data provide the basis for a prospective, interventional study in patients presenting to primary care with non-specific signs and symptoms.

FUNDING

GRAIL Bio UK.

Factors affecting patient decisions to undergo testing for cancer symptoms: an exploratory qualitative study in Australian general practice

BACKGROUND

Patients presenting to their GP are often concerned their symptoms may be due to cancer. However, there is a lack of evidence on the factors that influence patient decisions to undergo investigation for suspected cancer in the general practice setting.

AIM

To identify the factors influencing patient decisions to undertake investigations for suspected cancer in general practice.

DESIGN & SETTING

An exploratory qualitative, semi-structured interview study of patients attending rural and metropolitan general practices in Victoria, Australia.

METHOD

A purposive sample of 15 general practice patients aged ≥40 years participated. Thematic analysis of transcripts drew on interpretative description methodology and shared decision-making (SDM) theory.

RESULTS

Cancer-related concerns such as 'cancer worry' prompt patients to seek investigations from their GP. Participants prefer that their symptoms are investigated regardless of cancer risk. The perceived 'best test' provides the most reassurance. Trust and SDM enhance dialogue between patients and GPs about diagnostic testing strategies. Deterrents to testing included out-of-pocket costs, waiting time, travel time, and competing work and family demands.

CONCLUSION

There may be a mismatch between efforts to rationalise investigation use and patient preferences for investigation. SDM that incorporates patient concerns, facilitators, and barriers to testing may ensure appropriate and timely investigation of cancer symptoms.

Progress and priorities in reducing the time to cancer diagnosis

Key developments in early diagnosis research and policy since the publication of the highly cited BJC review "Is increased time to diagnosis and treatment associated with poorer outcomes?" by Neal et al. in 2015 are summarised. Progress achieved since 2015 is described and priorities for further research identified.