Urgent referrals in the UK may lower mortality in cancer patients

1. Practices with the highest rates of urgent referrals for patients with suspected cancer reduced 4-year mortality by at least 7% compared to the lowest urgent referral rate practices.

2. All cancers except breast cancer showed lower mortality with higher urgent referral rates.

Evidence Rating Level: 2 (Good)

Study Rundown: Early cancer diagnosis tends to lead towards better survival outcomes, likely because it detects lower grade cancers before they progress to less treatable forms. Therefore, the UK has put in place a system where general practitioners can get their patients with suspected cancer to specialists more quickly, using the Urgent Referral pathway. 215,284 patients with cancer were identified in this study. After splitting the patients into terciles of highest, intermediate, and lowest urgent referral practices, they showed that groups with the highest urgent referral rates had reduced 4-year mortality of 4% from the intermediate group while the lowest urgent referral rate group had an increase in mortality of 7% from the intermediate group. This effect remained true for all cancers except breast cancer. Further, socioeconomic class did not change this effect. In addition, the conversion rate for referrals was not different between the three groups.

It’s not clear whether inherent differences in general practices that have high or low urgent referral rates are driving this data. While it may be that urgent referral leads to lower staging, this could not be accurately investigated at the time of the study. In addition, the effect size is small enough that another study showing the same effect would increase the validity of the finding. Lastly, the National Institute for Heath and Care Excellence reported an average reduction in diagnostic interval to 5.4 days, which is very unlikely to change the prognosis for most cancer patients. Therefore, it is possible that indirect measures associated with high or low urgent referral rates have much more influence on mortality after cancer diagnosis. Further investigation of these factors would be very interesting in light of the findings in this current study.

Click to read the study in the BMJ

Click to read an accompanying editorial in the BMJ

Relevant Reading: Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database

In-Depth [retrospective cohort]: 215,284 patients with cancer were identified from the English national Cancer Waiting Times database and cross-referenced to general practice using the NHS Exeter database. 91,620 deaths occurred from those diagnoses within the four years of study (2009-2013), and 56% occurred within the first year. The groups were stratified based on urgent referral ratio and detection ratio rates into a 3×3 grid, and the groups with the highest, lowest, and intermediate values for both criteria were analyzed as terciles. The highest urgent referral group had a hazard ratio of 0.96 (CI₉₅ 0.94-0.98) and the lowest urgent referral group had a hazard ratio of 1.05 (CI₉₅ 1.05-1.08). For cumulative risk or mortality, the highest referral group had 47% while the lowest referral group had 52%, with the intermediate group having 49%. Differences between the highest and lowest referral rate groups were apparent for all cancers except female breast cancer. There were no significant differences between conversion rates and referral rates. Further, sensitivity analysis with socioeconomic status did not change these effects.

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