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Auditing the diagnosis of cancer in primary care: the experience in Scotland

Auditing the diagnosis of cancer in primary care: the experience in Scotland British Journal of Cancer (2009) 101, S87 – S91 & 2009 Cancer Research UK All rights reserved 0007 – 0920/09 $32.00 www.bjcancer.com Full Paper Auditing the diagnosis of cancer in primary care: the experience in Scotland ,1 2 3 P Baughan , B O’Neill and E Fletcher 1 2 Forth Valley Lead Cancer Team, Falkirk and District Royal Infirmary, Trust HQ, Westburn Avenue, Falkirk FK1 5SU, UK; Chair of Scottish Primary Care Cancer Group, Springwell House, Edinburgh, UK; Health Intelligence Unit, NHS Lothian, Edinburgh, UK INTRODUCTION: This paper reports on an ongoing primary care audit of cancer referrals undertaken in Scotland in 2006–2007 and 2007–2008. METHODS: General practitioners (GPs) in Scotland were asked to review all new cancer diagnoses within their practice during the preceding year. RESULTS: 4181 patients were identified in year 1 and 12 294 in year 2. The pathway taken for patients to present to, and be referred from, their GP has been analysed for 7430 of the 12 294 patients identified within year 2 across five separate health boards. The time from first symptoms to presentation to a GP varied between tumour types, being the longest (median 30 days) for head and neck cancers and the shortest (median 2 days) for bladder cancer. In all, 25% of patients within the following tumour groups waited longer than 2 months to present to their GP following first symptoms: prostate, colorectal, melanoma and head and neck cancers. Once patients had presented to their GP, those with prostate and lung cancer were referred later (median time 11 days) than those with breast cancer (median time 2 days). The priority with which GPs referred patients varied considerably between tumour groups (breast cancer 77.5% ‘urgent’ compared with prostate cancer 44.7% ‘urgent’). In one health board the proportion of cancer patients being referred urgently increased from 46% to 58% between the first and second audit. CONCLUSION: Our data show that there are very different patterns of presentation and referral for patients with cancer, with some tumour groups being more likely to be associated with a delayed diagnosis than others. British Journal of Cancer (2009) 101, S87 – S91. doi:10.1038/sj.bjc.6605397 www.bjcancer.com & 2009 Cancer Research UK Keywords: primary care; delays in diagnosis; referral pathway Early presentation, prompt investigation and timely access to Targets have been introduced in an attempt to ensure that definitive treatment unquestionably improves the experience of patients suspected of having cancer are seen and investigated patients, although there is some doubt about when and whether promptly, then fast-tracked for definitive treatment to cure or delays affect outcomes with many cancers (Richards et al, 1999; palliate their cancer. In both England (Secretary of State for Jensen et al, 2007; Neal et al, 2007; Chen et al, 2008; Hamilton, Health, 1997) and Scotland (SEHD, 2001), there is a 62-day target 2009). from referral to treatment for patients whose referral is marked Different countries have different systems for allowing access to urgent and for those referred as an emergency (including self- specialist services. In the United Kingdom, other than diagnoses referral to accident and emergency departments). In England (but made through the three screening services (breast, cervical and not in Scotland), there is also a 2-week target from urgent referral more recently, colorectal cancers), patients usually first present to to first assessment by specialist services (Secretary of State for their general practitioners (GPs). GPs have an important function Health, 1997). in assessing which patterns of symptoms are most likely to be The aim of this study is to gain a better understanding of how suggestive of cancer. If cancer is suspected, patients may be quickly patients with cancer initially present to their GP, and how referred immediately on first presentation for specialist assessment they are then referred to secondary care for further investigation and investigations, or they may have initial investigations and and treatment. review within primary care and then be referred when the results of tests are available. Specific guidelines have been developed in Scotland and MATERIALS AND METHODS elsewhere to support GPs in referral decisions for patients with suspected cancer (National Institute for Health and Clinical On two separate occasions between 2005 and 2008, GPs in most Excellence, 2005; Scottish Executive Health Department (SEHD), health boards in Scotland were asked to review all new cancer 2007; Scottish Government, 2009). diagnoses within their practice during the preceding year. It was hoped that by engaging practices in a cancer-review process, it *Correspondence: Dr P Baughan; E-mail: [email protected] would be possible to consolidate knowledge around the early parts Auditing the diagnosis of cancer in primary care P Baughan et al S88 Table 1 Components of cancer diagnosis review 1400 Patient diagnosis Date patient first noticed symptoms Date patient first reported symptoms to primary care Date of decision to refer Date referral sent Priority given to referral (e.g. emergency, urgent, routine) Use of any specific cancer referral pro forma 200 Method of sending referral (e.g. electronic, secure fax, post) Date patient first seen by specialist Date patient told the diagnosis Date GP informed of diagnosis Reflective comments on patient pathway through primary care Diagnosis group Abbreviation: GP¼ general practitioner. Figure 1 Distribution of cancers within analysis. of the cancer journey including typical presentation of cancers, symptom development and when and how to refer for further investigation. The first audit took place in 2006–2007 and involved Table 2 Distribution of cancers within analysis reviewing all patients diagnosed with cancer in 2005–2006; the Number of second took place in 2007–2008, relating to patients diagnosed in Diagnosis group referrals 2006–2007. Engagement with the study was facilitated by the enhanced service component of the General Medical Services Bladder 439 Contract, which enabled a payment for participating practices. Breast 1250 Participating GPs across Scotland were asked to review the Cervical 69 clinical notes of each new patient diagnosed with cancer and were Colorectal 1074 given guidance regarding how to record the items listed in Table 1 Head and neck 273 onto a standard electronic template. They were then asked to Leukaemia 181 Lung 981 reflect on the patient journey and to comment on ways that it Lymphoma 260 could have been improved. Patients with cancer detected through Melanoma 353 the national screening programmes were excluded from the study, Other 667 as were those with non-melanoma skin cancer. Other urological 258 Data were available from five health boards across Scotland Ovarian 152 during the first review, and from nine health boards during the Prostate 874 second (Scotland is served by 11 mainland and three island health Upper GI 599 boards), and work is currently underway to amalgamate these data Abbreviation: GI¼ gastrointestinal. across the whole of Scotland. The results in this paper relate to the initial analysis of the second year’s data, taken from five of the nine participating health boards. Comparative data from one health board relating to priority of referral over the two separate years of Bladder Median time Other urological the audit have also been included. Leukaemia Cervical Breast RESULTS Lung Lymphoma In all, 4181 patients were identified with a new diagnosis of cancer Ovarian during year 1 and 12 294 in year 2. This compares with a total of Upper GI B27 000 new cases of cancer diagnosed each year in Scotland Prostate (Information Services Division, 2008). In the first year of the audit, Other Colorectal each health board collected data in different ways, making Melanoma collation difficult. Arrangements in year 2 were more systematic, Head and Neck allowing data to be collected on 12 294 patients with cancer. 0 1020304050607080 Detailed analysis has been conducted on data for 7430 of the 12 294 Median time (days) patients. Data on the remaining 4864 patients are not yet analysed. Figure 2 Median time from first noticing symptoms to first presentation The 7430 cases analysed were identified by 540 GP practices from with a GP. five different health boards in Scotland. The cases covered all major tumour types (Figure 1; Table 2) and reflected a similar pattern to that reported nationally (Information Services Division, 2008). took the longest to present (median time 30 days). Patients with This paper focuses on the analysis of the following: melanoma (median time 26 days) and colorectal cancer (median time 21 days) also presented comparatively late. In all, 25% of (a) time from patient first noticing symptoms to first presentation patients with the following cancers waited longer than 1 month with a GP, before first presenting: breast, lung, lymphoma, ovarian and upper (b) time from first presentation to time of referral, (c) priority of referral from primary to secondary care. gastrointestinal. For prostate, colorectal, melanoma, and head and neck cancers, the same proportion of patients, 25%, waited 2 months or more to first present to a GP. Time from patient first noticing symptoms to first The shortest times between first noticing a sign or symptom and presentation with a GP first presentation to a GP were for patients with bladder cancer The time taken for patients to present to a GP varied according to (median time 2 days), leukaemia (4 days), cervical cancer (6.5 tumour site (Figure 2; Table 3). Patients with head and neck cancer days) and breast cancer (7 days). British Journal of Cancer (2009) 101(S2), S87 – S91 & 2009 Cancer Research UK Breast Colorectal Lung Prostate Other Upper GI Bladder Melanoma Head and neck Lymphoma Other urological Leukaemia Ovarian Cervical Diagnosis Cases Auditing the diagnosis of cancer in primary care P Baughan et al S89 Table 3 Median time from first noticing symptoms to first presentation Other Routine Urgent Emergency with a GP 100% Median Inter-quartile 90% Diagnosis group time (days) range (days) 80% 70% Bladder 2.0 14.0 Breast 7.0 30.0 60% Cervical 6.5 48.0 50% Colorectal 21.0 59.0 Head and neck 30.0 54.0 40% Leukaemia 4.0 23.0 30% Lung 9.5 31.0 20% Lymphoma 10.0 31.0 Melanoma 26.0 70.0 10% Other 15 58.0 0% Other urological 3.0 16.5 Breast Colorectal Lung Prostate Ovarian 11.0 29.0 Diagnosis Prostate 14.0 61.0 Upper GI 14.0 43.0 Figure 4 Priority of referral by tumour group for breast, colorectal, lung and prostate cancers. Abbreviation: GI¼ gastrointestinal. Table 5 Priority of referral by tumour group for breast, colorectal, lung and prostate cancers Breast Median time Melanoma Ovarian % of referrals sent as priority Other urological Other Diagnosis Emergency Urgent Routine Other Head and Neck Colorectal Breast 1.0 77.5 13.5 8.0 Upper GI Colorectal 11.7 50.6 23.0 14.8 Leukaemia Lung 11.5 70.7 9.1 8.7 Cervical Prostate 3.8 44.7 38.6 12.9 Lymphoma Bladder Due to the effects of rounding, row totals may not equal 100% exactly. Prostate Lung 0 5 10 15 20 25 30 35 40 longer within the primary care part of the journey before being Median time (days) referred to secondary care (lung cancer 11 days, prostate cancer Figure 3 Median time from first presentation to time of referral. 11 days). In all, 25% of patients with lung cancer and upper gastrointestinal cancer were not referred for 1 month or more following initial presentation. Table 4 Median time from first presentation to time of referral Priority of referral from primary to secondary care Median Inter-quartile Diagnosis group time (days) range (days) One of the most important factors determining time to diagnosis was the priority with which the GP sent the referral. When the Bladder 6.0 19.0 referral priority was examined for the four most common Breast 1.0 3.0 cancers (Figure 4; Table 5), a much higher proportion of Cervical 5.0 22.0 patients with breast cancer (969; 77.5%) and lung cancer (694; Colorectal 4.5 21.0 70.7%) were referred ‘urgently’ to secondary care compared with Head and neck 4.0 14.0 Leukaemia 5.0 21.0 colorectal cancer (543; 50.6%) and prostate cancer (391; 44.7%). Lung 11.0 28.0 Patients with colorectal and lung cancer were more likely than Lymphoma 6.0 22.0 prostate or breast cancer patients to present as an emergency Melanoma 2.0 6.0 admission, and of these four tumour groups, patients with prostate Other 4.0 21.0 cancer had the highest likelihood of being referred to hospital Other urological 4.0 23.0 ‘routinely’ (337; 38.6%). The category ‘other’ included referrals Ovarian 4.0 15.5 that were marked as ‘soon’ and referrals to private hospitals or Prostate 11.0 19.0 clinics. Upper GI 5.0 34.0 When referral priority data were compared within one of the Abbreviation: GI¼ gastrointestinal. five health boards over the two separate time periods (following an intensive GP education programme), the proportion of all cancers presenting to GPs that were referred ‘urgently’ increased from 340 out of 739 referrals (46%) in 2005–2006 to 545 out of 940 referrals Time from first presentation to time of referral (58%) in 2006–2007 (Figure 5). The difference in the total number The time taken for a GP to refer a patient with a suspicion of of cancers diagnosed from year 1 to year 2 is accounted for by a cancer also varied according to tumour group (Figure 3; Table 4). slight increase in the number of GP practices taking part in the Patients with breast cancer and melanoma were referred quickly audit during the second year. (median times 1 day and 2 days, respectively), whereas for other The extent to which the priority of referral contributed to delays tumour groups (notably lung and prostate), patients spent much in diagnosis was evident when the time to first see a hospital & 2009 Cancer Research UK British Journal of Cancer (2009) 101(S2), S87 – S91 Diagnosis % of referrals sent as Auditing the diagnosis of cancer in primary care P Baughan et al S90 melanoma and head and neck cancers took longer than 2 months to present to a GP following the first symptom or sign of cancer. 2006/07 9 58 18 15 Emergency Limited research has been done on what causes patients to delay Urgent presenting for advice or referral (Ramirez et al, 1999; Burgess Routine et al, 2001), but it is clear that many patients are not aware Other of the common symptoms and signs that might suggest a diagnosis 2005/06 10 46 28 16 of cancer. Although there have been occasional public education and other campaigns to raise awareness and encourage early 0% 20% 40% 60% 80% 100% presentation, there is little objective measurement of their Proportion of referrals effectiveness. A recent study examined attempts to positively Number of cancers: 739 in 2005 – 06 influence and subsequently evaluate interventions to encourage and 940 in 2006 – 07 early presentation of women with breast cancer (Burgess et al, Figure 5 Proportion of patients referred by priority group within one 2009). health board over 2 successive years. GPs can influence the time from first presentation to referral. The delay in referral for both lung and prostate cancer patients can be explained by recommendations that initial assessments and investigations be completed before referral (e.g. chest X-ray in Urgent referrals suspected lung cancer and evaluation of prostate-specific antigen Breast Routine referrals in prostate cancer) (SEHD, 2007). For some tumour groups, less than half of all newly diagnosed Colorectal cancers were referred urgently. Of the four commonest tumour groups, marked differences were noted between the proportions of breast cancer patients referred urgently (969; 77.5%) compared Lung with colorectal (543; 50.6%) and prostate cancer patients (391; 44.7%). The importance of referring a patient with cancer ‘urgently’ is Prostate that these patients are actively ‘fast-tracked’ through the hospital diagnostic system to ensure compliance with the 62-day target from urgent referral to treatment (SEHD, 2001). As ‘routine’ and 0 102030405060708090 Median time (days) ‘soon’ referrals are not subject to these targets, they are not prioritised and invariably take much longer to start treatment Figure 6 Median time from referral sent to first seen by specialist. following the date of referral. With this audit, GPs were given the opportunity to comment on each individual patient’s pathway to diagnosis. On reflection, many Table 6 How referral priority influenced time to see specialist GPs indicated that they should have referred their patient more urgently than they did; however, the most common explanation Median time to see from GPs was that the patient did not have the classic symptoms specialist (days) and signs described within the urgent cancer referral guidelines. Referral guidelines for some tumours may not always favour Diagnosis Routine Urgent patients with early symptoms of cancer. One study (Neal et al, 2007) found that for lung cancer (a tumour with a poor prognosis), Breast 22.0 14.0 referral guidelines were prioritising those with more advanced Colorectal 40.5 15.0 disease. However, the same was not found for patients with Lung 28.0 11.0 colorectal, ovarian or prostate cancer. Prostate 32.0 17.0 Despite doubt about the benefit of urgent referral pathways, one encouraging finding was the change in the proportion of patients referred urgently within one health board during the two separate years of the study. This change was also noted within several specialist was examined. When the four commonest tumour different health boards and may reflect increasing awareness of groups were examined, the time taken to see a specialist was guidelines on the part of referrers and the increased priority that considerably longer if the patient was referred routinely (Figure 6; cancer has been given in Scotland in recent years. Data are awaited Table 6). The median time for a patient with lung cancer to see a from a further audit (again through the enhanced service specialist was 11 days for an urgent referral, yet 28 days for a component of the General Medical Services Contract) to examine routine referral. the compliance of all urgent suspected cancer referrals with current referral guidelines. By engaging with 540 different GP practices across five health boards, there is a risk of variable data capture depending on the DISCUSSION thoroughness with which individual GPs reviewed their clinical This study has yielded valuable information about the primary notes. The development of clear guidance for data collection and care pathway for over 16 000 patients diagnosed with cancer in the rigorous checking of all data submitted will have helped to Scotland over two separate periods. Detailed analysis of 7430 reduce this variability. However, by engaging with GPs across patients from five separate health boards has been reported in this Scotland in the collection of these data, it has been possible to paper. This has highlighted differences in the way that individual facilitate education around the typical presentation of cancer. cancers present to, and are referred by, GPs. Comments written by GPs undertaking this audit provide a wealth Patients with head and neck cancers, melanomas and colorectal of information. Individual practices were frequently very open cancers waited comparatively longer before seeking help from about their shortcomings and appeared to provide perceptive their GP. When the inter-quartile ranges were examined, it is analysis of the diagnostic journey. Significant event analysis has apparent that 25% patients with prostate cancer, colorectal cancer, become an embedded part of reflective learning by GPs and forms British Journal of Cancer (2009) 101(S2), S87 – S91 & 2009 Cancer Research UK Year of diagnosis Diagnosis Auditing the diagnosis of cancer in primary care P Baughan et al S91 a component of the annual appraisal system. Data from this audit ACKNOWLEDGEMENTS facilitated significant event analyses within many of the GP We are grateful to GP colleagues who conducted the audit and practices taking part. specifically members of the Scottish Primary Care Cancer Group Although doubt has been cast on the benefit of cancer waiting who supported the process and to Jennifer Keatings, Information time targets, whether 2-week waits or 62-day targets (Jones et al, Officer, West of Scotland Managed Clinical Network for Cancer for 2001), and some have shown a perverse adverse effect on breast help in the collation and analysis of the data. cancer referrals (Potter et al, 2007), public opinion and published evidence supports the benefit of prompt recognition, prompt referral and early effective treatment for patients with cancer. Primary care health professionals have an important function in Conflict of interest early diagnosis. The authors declare no conflict of interest. REFERENCES Burgess C, Hunter MS, Ramirez AJ (2001) A qualitative study of delay Neal RD, Allgar VL, Ali N, Leese B, Heywood P, Proctor G, Evans J (2007) among women reporting symptoms of breast cancer. Br J Gen Pract 51: Stage, survival and delay in lung, colorectal, prostate and ovarian cancer: 967–971 comparison between diagnostic routes. Br J Gen Pract 57: 212–219 Burgess C, Linsell L, Kapari M, Omar L, Mitchell M, Whelehan P, Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, Richards MA, Ramirez AJ (2009) Promoting early presentation of breast Sahu AK, Cawthorn SJ (2007) Referral patterns, cancer diagnoses, and cancer by older women: a preliminary evaluation of a one-to-one health waiting times after introduction of two week wait rule for breast cancer: professional-delivered intervention. J Psychosom Res 67: 377–385 prospective cohort study. BMJ 335: 288–290 Chen Z, King W, Pearcey R, Kerba M, Mackillop WJ (2008) The Ramirez AJ, Westcombe A, Burgess CC, Sutton S, Littlejohns P, Richards relationship between waiting time for radiotherapy and clinical out- MA (1999) Factors predicting delayed presentation of symptomatic comes: a systematic review of the literature. Radiother Oncol 87: 3–16 breast cancer: a systematic review. Lancet 353: 1127–1131 Hamilton W (2009) Five misconceptions in cancer diagnosis. Br J Gen Pract Richards MA, Westcombe A, Love SB, Littlejohns P, Ramirez AJ (1999) 59: 441–447 Influence of delay on survival in patients with breast cancer: a systematic Information Services Division. NHS National Services Division (2008) review. Lancet 353: 1119– 1126 Cancer in Scotland. ISD: Edinburgh Scottish Executive Health Department (2001) Cancer in Scotland: Action for Jensen AR, Nellemann HM, Overgaard J (2007) Tumour progression in Change. SEHD: Edinburgh waiting time for radiotherapy in head and neck cancer. Radiother Oncol Scottish Executive Health Department (2007) Scottish Referral Guidelines 84: 5–10 for Suspected Cancer. SEHD: Edinburgh Jones R, Rubin G, Hungin P (2001) Is the two week rule for cancer referrals Scottish Government (2009) Scottish Referral Guidelines for Suspected working? BMJ 322: 1555–1556 Cancer. Quick Reference Guide. Scottish Government: Edinburgh National Institute for Health and Clinical Excellence (2005) Referral Secretary of State for Health (1997) The New NHS, Modern, Dependable. Guidelines for Suspected Cancer. NICE: London Stationery Office: London & 2009 Cancer Research UK British Journal of Cancer (2009) 101(S2), S87 – S91 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png British Journal of Cancer Springer Journals

Auditing the diagnosis of cancer in primary care: the experience in Scotland

Baughan, P; O'Neill, B; Fletcher, E
British Journal of Cancer , Volume 101 (2) – Dec 3, 2009
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Springer Journals
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Copyright © 2009 by The Author(s)
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Biomedicine; Biomedicine, general; Cancer Research; Epidemiology; Molecular Medicine; Oncology; Drug Resistance
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0007-0920
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1532-1827
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10.1038/sj.bjc.6605397
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British Journal of Cancer (2009) 101, S87 – S91 & 2009 Cancer Research UK All rights reserved 0007 – 0920/09 $32.00 www.bjcancer.com Full Paper Auditing the diagnosis of cancer in primary care: the experience in Scotland ,1 2 3 P Baughan , B O’Neill and E Fletcher 1 2 Forth Valley Lead Cancer Team, Falkirk and District Royal Infirmary, Trust HQ, Westburn Avenue, Falkirk FK1 5SU, UK; Chair of Scottish Primary Care Cancer Group, Springwell House, Edinburgh, UK; Health Intelligence Unit, NHS Lothian, Edinburgh, UK INTRODUCTION: This paper reports on an ongoing primary care audit of cancer referrals undertaken in Scotland in 2006–2007 and 2007–2008. METHODS: General practitioners (GPs) in Scotland were asked to review all new cancer diagnoses within their practice during the preceding year. RESULTS: 4181 patients were identified in year 1 and 12 294 in year 2. The pathway taken for patients to present to, and be referred from, their GP has been analysed for 7430 of the 12 294 patients identified within year 2 across five separate health boards. The time from first symptoms to presentation to a GP varied between tumour types, being the longest (median 30 days) for head and neck cancers and the shortest (median 2 days) for bladder cancer. In all, 25% of patients within the following tumour groups waited longer than 2 months to present to their GP following first symptoms: prostate, colorectal, melanoma and head and neck cancers. Once patients had presented to their GP, those with prostate and lung cancer were referred later (median time 11 days) than those with breast cancer (median time 2 days). The priority with which GPs referred patients varied considerably between tumour groups (breast cancer 77.5% ‘urgent’ compared with prostate cancer 44.7% ‘urgent’). In one health board the proportion of cancer patients being referred urgently increased from 46% to 58% between the first and second audit. CONCLUSION: Our data show that there are very different patterns of presentation and referral for patients with cancer, with some tumour groups being more likely to be associated with a delayed diagnosis than others. British Journal of Cancer (2009) 101, S87 – S91. doi:10.1038/sj.bjc.6605397 www.bjcancer.com & 2009 Cancer Research UK Keywords: primary care; delays in diagnosis; referral pathway Early presentation, prompt investigation and timely access to Targets have been introduced in an attempt to ensure that definitive treatment unquestionably improves the experience of patients suspected of having cancer are seen and investigated patients, although there is some doubt about when and whether promptly, then fast-tracked for definitive treatment to cure or delays affect outcomes with many cancers (Richards et al, 1999; palliate their cancer. In both England (Secretary of State for Jensen et al, 2007; Neal et al, 2007; Chen et al, 2008; Hamilton, Health, 1997) and Scotland (SEHD, 2001), there is a 62-day target 2009). from referral to treatment for patients whose referral is marked Different countries have different systems for allowing access to urgent and for those referred as an emergency (including self- specialist services. In the United Kingdom, other than diagnoses referral to accident and emergency departments). In England (but made through the three screening services (breast, cervical and not in Scotland), there is also a 2-week target from urgent referral more recently, colorectal cancers), patients usually first present to to first assessment by specialist services (Secretary of State for their general practitioners (GPs). GPs have an important function Health, 1997). in assessing which patterns of symptoms are most likely to be The aim of this study is to gain a better understanding of how suggestive of cancer. If cancer is suspected, patients may be quickly patients with cancer initially present to their GP, and how referred immediately on first presentation for specialist assessment they are then referred to secondary care for further investigation and investigations, or they may have initial investigations and and treatment. review within primary care and then be referred when the results of tests are available. Specific guidelines have been developed in Scotland and MATERIALS AND METHODS elsewhere to support GPs in referral decisions for patients with suspected cancer (National Institute for Health and Clinical On two separate occasions between 2005 and 2008, GPs in most Excellence, 2005; Scottish Executive Health Department (SEHD), health boards in Scotland were asked to review all new cancer 2007; Scottish Government, 2009). diagnoses within their practice during the preceding year. It was hoped that by engaging practices in a cancer-review process, it *Correspondence: Dr P Baughan; E-mail: [email protected] would be possible to consolidate knowledge around the early parts Auditing the diagnosis of cancer in primary care P Baughan et al S88 Table 1 Components of cancer diagnosis review 1400 Patient diagnosis Date patient first noticed symptoms Date patient first reported symptoms to primary care Date of decision to refer Date referral sent Priority given to referral (e.g. emergency, urgent, routine) Use of any specific cancer referral pro forma 200 Method of sending referral (e.g. electronic, secure fax, post) Date patient first seen by specialist Date patient told the diagnosis Date GP informed of diagnosis Reflective comments on patient pathway through primary care Diagnosis group Abbreviation: GP¼ general practitioner. Figure 1 Distribution of cancers within analysis. of the cancer journey including typical presentation of cancers, symptom development and when and how to refer for further investigation. The first audit took place in 2006–2007 and involved Table 2 Distribution of cancers within analysis reviewing all patients diagnosed with cancer in 2005–2006; the Number of second took place in 2007–2008, relating to patients diagnosed in Diagnosis group referrals 2006–2007. Engagement with the study was facilitated by the enhanced service component of the General Medical Services Bladder 439 Contract, which enabled a payment for participating practices. Breast 1250 Participating GPs across Scotland were asked to review the Cervical 69 clinical notes of each new patient diagnosed with cancer and were Colorectal 1074 given guidance regarding how to record the items listed in Table 1 Head and neck 273 onto a standard electronic template. They were then asked to Leukaemia 181 Lung 981 reflect on the patient journey and to comment on ways that it Lymphoma 260 could have been improved. Patients with cancer detected through Melanoma 353 the national screening programmes were excluded from the study, Other 667 as were those with non-melanoma skin cancer. Other urological 258 Data were available from five health boards across Scotland Ovarian 152 during the first review, and from nine health boards during the Prostate 874 second (Scotland is served by 11 mainland and three island health Upper GI 599 boards), and work is currently underway to amalgamate these data Abbreviation: GI¼ gastrointestinal. across the whole of Scotland. The results in this paper relate to the initial analysis of the second year’s data, taken from five of the nine participating health boards. Comparative data from one health board relating to priority of referral over the two separate years of Bladder Median time Other urological the audit have also been included. Leukaemia Cervical Breast RESULTS Lung Lymphoma In all, 4181 patients were identified with a new diagnosis of cancer Ovarian during year 1 and 12 294 in year 2. This compares with a total of Upper GI B27 000 new cases of cancer diagnosed each year in Scotland Prostate (Information Services Division, 2008). In the first year of the audit, Other Colorectal each health board collected data in different ways, making Melanoma collation difficult. Arrangements in year 2 were more systematic, Head and Neck allowing data to be collected on 12 294 patients with cancer. 0 1020304050607080 Detailed analysis has been conducted on data for 7430 of the 12 294 Median time (days) patients. Data on the remaining 4864 patients are not yet analysed. Figure 2 Median time from first noticing symptoms to first presentation The 7430 cases analysed were identified by 540 GP practices from with a GP. five different health boards in Scotland. The cases covered all major tumour types (Figure 1; Table 2) and reflected a similar pattern to that reported nationally (Information Services Division, 2008). took the longest to present (median time 30 days). Patients with This paper focuses on the analysis of the following: melanoma (median time 26 days) and colorectal cancer (median time 21 days) also presented comparatively late. In all, 25% of (a) time from patient first noticing symptoms to first presentation patients with the following cancers waited longer than 1 month with a GP, before first presenting: breast, lung, lymphoma, ovarian and upper (b) time from first presentation to time of referral, (c) priority of referral from primary to secondary care. gastrointestinal. For prostate, colorectal, melanoma, and head and neck cancers, the same proportion of patients, 25%, waited 2 months or more to first present to a GP. Time from patient first noticing symptoms to first The shortest times between first noticing a sign or symptom and presentation with a GP first presentation to a GP were for patients with bladder cancer The time taken for patients to present to a GP varied according to (median time 2 days), leukaemia (4 days), cervical cancer (6.5 tumour site (Figure 2; Table 3). Patients with head and neck cancer days) and breast cancer (7 days). British Journal of Cancer (2009) 101(S2), S87 – S91 & 2009 Cancer Research UK Breast Colorectal Lung Prostate Other Upper GI Bladder Melanoma Head and neck Lymphoma Other urological Leukaemia Ovarian Cervical Diagnosis Cases Auditing the diagnosis of cancer in primary care P Baughan et al S89 Table 3 Median time from first noticing symptoms to first presentation Other Routine Urgent Emergency with a GP 100% Median Inter-quartile 90% Diagnosis group time (days) range (days) 80% 70% Bladder 2.0 14.0 Breast 7.0 30.0 60% Cervical 6.5 48.0 50% Colorectal 21.0 59.0 Head and neck 30.0 54.0 40% Leukaemia 4.0 23.0 30% Lung 9.5 31.0 20% Lymphoma 10.0 31.0 Melanoma 26.0 70.0 10% Other 15 58.0 0% Other urological 3.0 16.5 Breast Colorectal Lung Prostate Ovarian 11.0 29.0 Diagnosis Prostate 14.0 61.0 Upper GI 14.0 43.0 Figure 4 Priority of referral by tumour group for breast, colorectal, lung and prostate cancers. Abbreviation: GI¼ gastrointestinal. Table 5 Priority of referral by tumour group for breast, colorectal, lung and prostate cancers Breast Median time Melanoma Ovarian % of referrals sent as priority Other urological Other Diagnosis Emergency Urgent Routine Other Head and Neck Colorectal Breast 1.0 77.5 13.5 8.0 Upper GI Colorectal 11.7 50.6 23.0 14.8 Leukaemia Lung 11.5 70.7 9.1 8.7 Cervical Prostate 3.8 44.7 38.6 12.9 Lymphoma Bladder Due to the effects of rounding, row totals may not equal 100% exactly. Prostate Lung 0 5 10 15 20 25 30 35 40 longer within the primary care part of the journey before being Median time (days) referred to secondary care (lung cancer 11 days, prostate cancer Figure 3 Median time from first presentation to time of referral. 11 days). In all, 25% of patients with lung cancer and upper gastrointestinal cancer were not referred for 1 month or more following initial presentation. Table 4 Median time from first presentation to time of referral Priority of referral from primary to secondary care Median Inter-quartile Diagnosis group time (days) range (days) One of the most important factors determining time to diagnosis was the priority with which the GP sent the referral. When the Bladder 6.0 19.0 referral priority was examined for the four most common Breast 1.0 3.0 cancers (Figure 4; Table 5), a much higher proportion of Cervical 5.0 22.0 patients with breast cancer (969; 77.5%) and lung cancer (694; Colorectal 4.5 21.0 70.7%) were referred ‘urgently’ to secondary care compared with Head and neck 4.0 14.0 Leukaemia 5.0 21.0 colorectal cancer (543; 50.6%) and prostate cancer (391; 44.7%). Lung 11.0 28.0 Patients with colorectal and lung cancer were more likely than Lymphoma 6.0 22.0 prostate or breast cancer patients to present as an emergency Melanoma 2.0 6.0 admission, and of these four tumour groups, patients with prostate Other 4.0 21.0 cancer had the highest likelihood of being referred to hospital Other urological 4.0 23.0 ‘routinely’ (337; 38.6%). The category ‘other’ included referrals Ovarian 4.0 15.5 that were marked as ‘soon’ and referrals to private hospitals or Prostate 11.0 19.0 clinics. Upper GI 5.0 34.0 When referral priority data were compared within one of the Abbreviation: GI¼ gastrointestinal. five health boards over the two separate time periods (following an intensive GP education programme), the proportion of all cancers presenting to GPs that were referred ‘urgently’ increased from 340 out of 739 referrals (46%) in 2005–2006 to 545 out of 940 referrals Time from first presentation to time of referral (58%) in 2006–2007 (Figure 5). The difference in the total number The time taken for a GP to refer a patient with a suspicion of of cancers diagnosed from year 1 to year 2 is accounted for by a cancer also varied according to tumour group (Figure 3; Table 4). slight increase in the number of GP practices taking part in the Patients with breast cancer and melanoma were referred quickly audit during the second year. (median times 1 day and 2 days, respectively), whereas for other The extent to which the priority of referral contributed to delays tumour groups (notably lung and prostate), patients spent much in diagnosis was evident when the time to first see a hospital & 2009 Cancer Research UK British Journal of Cancer (2009) 101(S2), S87 – S91 Diagnosis % of referrals sent as Auditing the diagnosis of cancer in primary care P Baughan et al S90 melanoma and head and neck cancers took longer than 2 months to present to a GP following the first symptom or sign of cancer. 2006/07 9 58 18 15 Emergency Limited research has been done on what causes patients to delay Urgent presenting for advice or referral (Ramirez et al, 1999; Burgess Routine et al, 2001), but it is clear that many patients are not aware Other of the common symptoms and signs that might suggest a diagnosis 2005/06 10 46 28 16 of cancer. Although there have been occasional public education and other campaigns to raise awareness and encourage early 0% 20% 40% 60% 80% 100% presentation, there is little objective measurement of their Proportion of referrals effectiveness. A recent study examined attempts to positively Number of cancers: 739 in 2005 – 06 influence and subsequently evaluate interventions to encourage and 940 in 2006 – 07 early presentation of women with breast cancer (Burgess et al, Figure 5 Proportion of patients referred by priority group within one 2009). health board over 2 successive years. GPs can influence the time from first presentation to referral. The delay in referral for both lung and prostate cancer patients can be explained by recommendations that initial assessments and investigations be completed before referral (e.g. chest X-ray in Urgent referrals suspected lung cancer and evaluation of prostate-specific antigen Breast Routine referrals in prostate cancer) (SEHD, 2007). For some tumour groups, less than half of all newly diagnosed Colorectal cancers were referred urgently. Of the four commonest tumour groups, marked differences were noted between the proportions of breast cancer patients referred urgently (969; 77.5%) compared Lung with colorectal (543; 50.6%) and prostate cancer patients (391; 44.7%). The importance of referring a patient with cancer ‘urgently’ is Prostate that these patients are actively ‘fast-tracked’ through the hospital diagnostic system to ensure compliance with the 62-day target from urgent referral to treatment (SEHD, 2001). As ‘routine’ and 0 102030405060708090 Median time (days) ‘soon’ referrals are not subject to these targets, they are not prioritised and invariably take much longer to start treatment Figure 6 Median time from referral sent to first seen by specialist. following the date of referral. With this audit, GPs were given the opportunity to comment on each individual patient’s pathway to diagnosis. On reflection, many Table 6 How referral priority influenced time to see specialist GPs indicated that they should have referred their patient more urgently than they did; however, the most common explanation Median time to see from GPs was that the patient did not have the classic symptoms specialist (days) and signs described within the urgent cancer referral guidelines. Referral guidelines for some tumours may not always favour Diagnosis Routine Urgent patients with early symptoms of cancer. One study (Neal et al, 2007) found that for lung cancer (a tumour with a poor prognosis), Breast 22.0 14.0 referral guidelines were prioritising those with more advanced Colorectal 40.5 15.0 disease. However, the same was not found for patients with Lung 28.0 11.0 colorectal, ovarian or prostate cancer. Prostate 32.0 17.0 Despite doubt about the benefit of urgent referral pathways, one encouraging finding was the change in the proportion of patients referred urgently within one health board during the two separate years of the study. This change was also noted within several specialist was examined. When the four commonest tumour different health boards and may reflect increasing awareness of groups were examined, the time taken to see a specialist was guidelines on the part of referrers and the increased priority that considerably longer if the patient was referred routinely (Figure 6; cancer has been given in Scotland in recent years. Data are awaited Table 6). The median time for a patient with lung cancer to see a from a further audit (again through the enhanced service specialist was 11 days for an urgent referral, yet 28 days for a component of the General Medical Services Contract) to examine routine referral. the compliance of all urgent suspected cancer referrals with current referral guidelines. By engaging with 540 different GP practices across five health boards, there is a risk of variable data capture depending on the DISCUSSION thoroughness with which individual GPs reviewed their clinical This study has yielded valuable information about the primary notes. The development of clear guidance for data collection and care pathway for over 16 000 patients diagnosed with cancer in the rigorous checking of all data submitted will have helped to Scotland over two separate periods. Detailed analysis of 7430 reduce this variability. However, by engaging with GPs across patients from five separate health boards has been reported in this Scotland in the collection of these data, it has been possible to paper. This has highlighted differences in the way that individual facilitate education around the typical presentation of cancer. cancers present to, and are referred by, GPs. Comments written by GPs undertaking this audit provide a wealth Patients with head and neck cancers, melanomas and colorectal of information. Individual practices were frequently very open cancers waited comparatively longer before seeking help from about their shortcomings and appeared to provide perceptive their GP. When the inter-quartile ranges were examined, it is analysis of the diagnostic journey. Significant event analysis has apparent that 25% patients with prostate cancer, colorectal cancer, become an embedded part of reflective learning by GPs and forms British Journal of Cancer (2009) 101(S2), S87 – S91 & 2009 Cancer Research UK Year of diagnosis Diagnosis Auditing the diagnosis of cancer in primary care P Baughan et al S91 a component of the annual appraisal system. Data from this audit ACKNOWLEDGEMENTS facilitated significant event analyses within many of the GP We are grateful to GP colleagues who conducted the audit and practices taking part. specifically members of the Scottish Primary Care Cancer Group Although doubt has been cast on the benefit of cancer waiting who supported the process and to Jennifer Keatings, Information time targets, whether 2-week waits or 62-day targets (Jones et al, Officer, West of Scotland Managed Clinical Network for Cancer for 2001), and some have shown a perverse adverse effect on breast help in the collation and analysis of the data. cancer referrals (Potter et al, 2007), public opinion and published evidence supports the benefit of prompt recognition, prompt referral and early effective treatment for patients with cancer. Primary care health professionals have an important function in Conflict of interest early diagnosis. The authors declare no conflict of interest. REFERENCES Burgess C, Hunter MS, Ramirez AJ (2001) A qualitative study of delay Neal RD, Allgar VL, Ali N, Leese B, Heywood P, Proctor G, Evans J (2007) among women reporting symptoms of breast cancer. Br J Gen Pract 51: Stage, survival and delay in lung, colorectal, prostate and ovarian cancer: 967–971 comparison between diagnostic routes. Br J Gen Pract 57: 212–219 Burgess C, Linsell L, Kapari M, Omar L, Mitchell M, Whelehan P, Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, Richards MA, Ramirez AJ (2009) Promoting early presentation of breast Sahu AK, Cawthorn SJ (2007) Referral patterns, cancer diagnoses, and cancer by older women: a preliminary evaluation of a one-to-one health waiting times after introduction of two week wait rule for breast cancer: professional-delivered intervention. J Psychosom Res 67: 377–385 prospective cohort study. BMJ 335: 288–290 Chen Z, King W, Pearcey R, Kerba M, Mackillop WJ (2008) The Ramirez AJ, Westcombe A, Burgess CC, Sutton S, Littlejohns P, Richards relationship between waiting time for radiotherapy and clinical out- MA (1999) Factors predicting delayed presentation of symptomatic comes: a systematic review of the literature. Radiother Oncol 87: 3–16 breast cancer: a systematic review. Lancet 353: 1127–1131 Hamilton W (2009) Five misconceptions in cancer diagnosis. Br J Gen Pract Richards MA, Westcombe A, Love SB, Littlejohns P, Ramirez AJ (1999) 59: 441–447 Influence of delay on survival in patients with breast cancer: a systematic Information Services Division. NHS National Services Division (2008) review. Lancet 353: 1119– 1126 Cancer in Scotland. ISD: Edinburgh Scottish Executive Health Department (2001) Cancer in Scotland: Action for Jensen AR, Nellemann HM, Overgaard J (2007) Tumour progression in Change. SEHD: Edinburgh waiting time for radiotherapy in head and neck cancer. Radiother Oncol Scottish Executive Health Department (2007) Scottish Referral Guidelines 84: 5–10 for Suspected Cancer. SEHD: Edinburgh Jones R, Rubin G, Hungin P (2001) Is the two week rule for cancer referrals Scottish Government (2009) Scottish Referral Guidelines for Suspected working? BMJ 322: 1555–1556 Cancer. Quick Reference Guide. Scottish Government: Edinburgh National Institute for Health and Clinical Excellence (2005) Referral Secretary of State for Health (1997) The New NHS, Modern, Dependable. Guidelines for Suspected Cancer. NICE: London Stationery Office: London & 2009 Cancer Research UK British Journal of Cancer (2009) 101(S2), S87 – S91

Journal

British Journal of Cancer – Springer Journals

Published: Dec 3, 2009

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