Urgent suspected cancer referrals from general practice

There has been some interesting debate around the reasons for the difference in UK cancer survival rates compared with other developed countries. Of concern, late diagnosis has been identified as the major contributor to the observed poor survival in England compared to other European countries, with the gatekeeper role of the GP raised as a possible explanation.¹ Clearly this is a complex area, but I think addressing the following two important issues will be critical.

First, an obvious solution to avoiding delayed diagnosis may be for GPs to adopt a lower threshold for referring patients with lower risk symptoms, rather than adopting a watch and wait strategy. However, at the same time, GPs are under greater pressure to reduce the costs associated with referrals to secondary care and subsequent unnecessary investigation. The challenge will be how to reconcile the conflicting issues of needing to diagnose cancer early while avoiding overwhelming secondary care services. The evidence presented from Australia where there are good cancer survival rates, and where GPs have better access to investigations such as computerised tomography suggests that better access to such investigations could be a solution for the UK. Increasing consultation times would allow more time to explore symptoms and signs. Clearly more research is needed here.

Second, fast track referrals are expected to comply with the 2-week wait referral criteria. However, the evidence for its effectiveness is limited and as Baughan et al have demonstrated, a significant proportion of patients whose referral did not comply with the urgent suspected cancer guidelines did have a diagnosis of cancer.² It provides a compelling case for clinical judgement in addition to using the guidelines. Moreover, it suggests that the guidelines need to be updated to reflect the increasing body of evidence on the positive predictive value of key symptoms and signs.³