60% of ‘Red Flag’ Cancer Signs Not Referred Urgently

New study
According to a recent and new study in the UK, 60% of patients with key symptoms possibly indicating cancer were not referred urgently (within two weeks) contrary to guideline recommendations.

Close to 4% of them were consequently diagnosed with cancer in the following 12 months, in comparison to 10% who did receive a referral.

New Study

The study was led by the University of Exeter in collaboration with University College London and funded by Cancer Research UK. The research, published earlier this month in October 2021 resulted from an analysis of nearly 49,000 patient records who had visited their GP and reported cancer warning signs for the first time, with red flag features including a breast lump, blood in urine, difficulty swallowing, iron-deficiency anaemia, rectal bleeding, and spotting or bleeding post-menopause.

Researchers studied records from the Clinical Practice Research Datalink, and data on hospital visits and cancer registration data between 2014 and 2015, where six out of ten patients were not referred for cancer investigation within two weeks of the first visit. Of the 29,045 patients not referred, 1,047 developed cancers within a year afterwards.

The study further discovered that the probability of a patient being issued an urgent referral varied depending on their age, the type of red flag feature, the practice they attended, the clinician they saw, and whether they had comorbidities.

Increased risk of death with later diagnosis

Early diagnosis and prompt treatment are crucial to cancer survival chances, with every four-week delay in treatment increasing the risk of death by 10%.

Separately, Breast Cancer Now has warned that almost 12,000 women could be living with undiagnosed breast cancer after missing out on screening due to the pandemic.

The study’s lead author, Dr Bianca Wiering of the University of Exeter Medical School noted that the thousands of patients who were not referred and went on to develop cancer could mean a missed opportunity for earlier diagnosis and that the authors believe this could be improved by a stricter adherence to guidelines, as well as increased awareness of these symptoms in the age groups of patients, including and perhaps specifically younger ones, where they were frequently missed.

However, Dr Wiering also cautioned that this issue does not just lie with GPs and emphasised the need to ensure the access and availability to services to provide the tests and referrals needed. Dr Gary Abel also from the University of Exeter Medical School added that huge progress has been made in the last decade to improve cancer diagnosis in the UK.

Dr Jodie Moffat, head of early diagnosis at Cancer Research UK, which funded the study, commented: “Working out who could have cancer from the hundreds or thousands of people a GP sees each year is a hugely difficult task. Referral guidelines, which give GPs advice on who might benefit from urgent cancer referrals or testing, are intended to help diagnose cancer earlier. So it’s worrying if people with red flag symptoms aren’t being referred.”

However, she also noted and underlined that the data are “from a little while ago, so we don’t know what the situation is now”.

Although, Dr Moffat believes that “with all the additional challenges of COVID-19, it’s vital that GPs and practice teams are supported to deliver the best care possible”, including “easy and timely access to diagnostic tests”.

Professor Martin Marshall, chair of the Royal College of GPs, said the study predates the latest guidelines and that what the research does clearly show is the importance of clinical judgement in making a decision to refer.

He further commented: “GPs follow clinical guidance to ensure that referrals are appropriate and are sensitive to the risks of over-referring patients because this would risk overloading specialist services and would not be helpful to patients or the NHS.

GPs find themselves in a position where they are criticised for referring both too much and too little: what would help is better access to diagnostic tools in the community and additional training to use them and interpret the results so that better-informed referrals can be made.”

The research was published by BMJ Quality & Safety on October 4.

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