Trends in urgent referrals for suspected cancer over the last decade

Problem

Over the last decade the number of urgent referrals for suspected cancer via the two week wait (TWW) pathway has more than doubled with over 2.3 million referrals in 2019/20. This rapid increase in referrals has led to increased costs to the NHS and capacity pressures. However, most patients referred do not have cancer. Obtaining the right balance between high detection rate and low conversion rate is difficult. It is important to understand the trends and pathway use to support planning, resource allocation and evaluation of diagnostic pathways. In this study we describe and quantify changes in TWW referral, conversion and detection rates for England over the last decade across different cancer pathways.

Approach

This study used data on referral trends for England available from April 2009 to March 2020 obtained from Public Health England. Annual data were available for all cancers and site-specific data for 12 broad cancer types (breast, lower GI, lung, skin, upper GI, gynaecological, urological, head and neck, brain and CNS, haematological, sarcoma and children’s cancers). Metrics for analysis included: TWW referral rate: number of TWW referrals per 100,000 population; conversion rate: percentage of TWW referrals which resulted in a cancer diagnosis; detection rate: percentage of cases recorded as having first treatment for cancer which resulted from a TWW referral. Annual trends were analysed using Joinpoint regression to quantify changes using the average annual percentage change and detecting significant changes in trend over time.

Findings

For all cancers combined the total number of referrals increased from 902,943 in 2009/10 to 2,374,718 in 2019/20. Referrals rates increased by 9.4% per year. The annual rate of increase ranged from 5.4% for lung to 13% for sarcoma, with referral rates for lung and upper GI stabilising from 2014/15 onwards. The conversion rate decreased by 4.7% per year for all cancers combined. Decreases in conversion rates were observed for all cancer types ranging from 2% for skin cancer to 7% for breast, lower GI and brain cancers. Stable trends were observed in more recent periods (since 2014-2016) for lung, upper GI and urological cancers. For all cancers combined the detection rate increased from 42.3% in 2009/10 to 53.5% in 2019/20. Generally, the detection rate increased across cancer types ranging from 2% for upper GI to 5% for sarcomas and haematological malignancies. However, for breast and lung cancer the detection rate decreased by 0.8% and 1.6% per year, respectively.

Consequences

These findings are important for future planning of diagnostic and cancer services, particularly given the increased pressures on referral pathways following the coronavirus pandemic. Understanding variation in trends by cancer type may help identify key factors influencing and driving these changes which has implications for future referral policies.