Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: Analysis of national primary care audit data

G. P. Rubin*, C. L. Saunders, G. A. Abel, S. Mcphail, G. Lyratzopoulos, R. D. Neal

*Corresponding author for this work

    Research output: Contribution to journalArticlepeer-review

    31 Citations (Scopus)


    Background:For patients with symptoms of possible cancer who do not fulfil the criteria for urgent referral, initial investigation in primary care has been advocated in the United Kingdom and supported by additional resources. The consequence of this strategy for the timeliness of diagnosis is unknown.Methods:We analysed data from the English National Audit of Cancer Diagnosis in Primary Care on patients with lung (1494), colorectal (2111), stomach (246), oesophagus (513), pancreas (327), and ovarian (345) cancer relating to the ordering of investigations by the General Practitioner and their nature. Presenting symptoms were categorised according to National Institute for Health and Care Excellence (NICE) guidance on referral for suspected cancer. We used linear regression to estimate the mean difference in primary-care interval by cancer, after adjustment for age, gender, and the symptomatic presentation category.Results:Primary-care investigations were undertaken in 3198/5036 (64%) of cases. The median primary-care interval was 16 days (IQR 5-45) for patients undergoing investigation and 0 days (IQR 0-10) for those not investigated. Among patients whose symptoms mandated urgent referral to secondary care according to NICE guidelines, between 37% (oesophagus) and 75% (pancreas) were first investigated in primary care. In multivariable linear regression analyses stratified by cancer site, adjustment for age, sex, and NICE referral category explained little of the observed prolongation associated with investigation.Interpretation:For six specified cancers, investigation in primary care was associated with later referral for specialist assessment. This effect was independent of the nature of symptoms. Some patients for whom urgent referral is mandated by NICE guidance are nevertheless investigated before referral. Reducing the intervals between test order, test performance, and reporting can help reduce the prolongation of primary-care intervals associated with investigation use. Alternative models of assessment should be considered.

    Original languageEnglish
    Pages (from-to)676-687
    Number of pages12
    JournalBritish Journal of Cancer
    Issue number4
    Publication statusPublished - 17 Feb 2015

    Bibliographical note

    Funding Information:
    RDN receives funding from Public Health Wales and Betsi Cadwaladr University Health Board. GL is supported by a PostDoctoral Fellowship by the National Institute for Health Research (PDF-2011-04-047). We are grateful to all primary-care professionals in participating practices for collecting, collating and submitting anonymous data to the National Audit of Cancer Diagnosis in Primary Care; Cancer Networks, the Royal College of General Practitioners and the National Cancer Action Team for supporting the audit, and the National Clinical Intelligence Network (NCIN) for providing the data. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the RCGP, the National Institute for Health Research or the Department of Health.

    Publisher Copyright:
    © 2015 Cancer Research UK.


    • cancer
    • delay
    • diagnostic test
    • primary care
    • referral


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