Association between use of the urgent cancer referral pathway and cancer survival: national cohort study

The problem

The urgent referral pathway for patients with suspected cancer has been available to GPs in England since the early 2000s. Comparison of the survival of urgently referred patients and other patients shows conflicting results, depending on type of cancer and symptoms. The overall impact of the urgent referral mechanism on cancer survival is not known.

The approach

We used the dataset of urgent referrals and cancer diagnoses from the English national Cancer Waiting Times database of patients with first hospital appointment or treatment in 2009. This dataset contained records of 865,494 urgent referrals for suspected cancer and 215,284 cancers from 8049 GP practices. These records were linked to the NHS Exeter database to associate each patient with a GP practice, and with the national cancer register for verification of the cancer diagnosis and survival follow-up.We used three metrics in relation to GP practice's propensity to use urgent suspect cancer referrals:1. Practice referral ratio: The indirectly standardised number of urgent GP referrals for suspected cancer.2. Practice conversion rate: The percentage of urgent GP referrals for suspected cancer resulting in a diagnosis of cancer.3. Practice detection rate: The percentage cancers which resulted from an urgent GP referral. This is the sensitivity of the selection of patients for urgent referral by GPs in the practice.Cox proportional hazard regression analysis was used to quantify the hazard of death from in relation to referral ratio, conversion rate and detection rate. All analyses were adjusted for age and sex of the individual patient, and adjustment was also made for the main types of cancer (colorectal, lung, breast, prostate, other).

Findings

Two measures of this propensity (referral ratio and detection rate) were both independently associated with reduced mortality. Conversion rate was not associated with mortality. The 27% of cancer patients registered with GP practices with both a low standardised referral ratio and a low detection rate had a significant excess mortality (hazard ratio: 1.07; 95% CI: 1.05-1.08). This result was found consistently for different types of cancer and other stratifications of the dataset, and was not sensitive to adjustment for potential confounders of the statistical model.

Consequences

These results suggest that urgent referral is efficacious. GP practices that currently have a low propensity to use urgent referral could increase their use of it and thereby plausibly increase the survival of their cancer patients.

Credits

• Thomas Round, Public Health England, Sheffield, UK
• Henrik Møller, Public Health England, Sheffield, UK
• Carolynn Gildea, University of Durham, Stockton on Tees, UK
• David Meechan, University of Durham, Stockton on Tees, UK
• Greg Rubin, Aarhus University, Aarhus, Denmark
• Peter Vedsted