Urgent Suspected Cancer Referrals Research Articles

Predictive value of abnormal blood tests for detecting cancer in primary care patients with nonspecific abdominal symptoms: A population-based cohort study of 477,870 patients in England.

Identifying patients presenting with nonspecific abdominal symptoms who have underlying cancer is a challenge. Common blood tests are widely used to investigate these symptoms in primary care, but their predictive value for detecting cancer in this context is unknown. We quantify the predictive value of 19 abnormal blood test results for detecting underlying cancer in patients presenting with 2 nonspecific abdominal symptoms. Using data from the UK Clinical Practice Research Datalink (CPRD) linked to the National Cancer Registry, Hospital Episode Statistics and Index of Multiple Deprivation, we conducted a population-based cohort study of patients aged ≥30 presenting to English general practice with abdominal pain or bloating between January 2007 and October 2016. Positive and negative predictive values (PPV and NPV), sensitivity, and specificity for cancer diagnosis (overall and by cancer site) were calculated for 19 abnormal blood test results co-occurring in primary care within 3 months of abdominal pain or bloating presentations. A total of 9,427/425,549 (2.2%) patients with abdominal pain and 1,148/52,321 (2.2%) with abdominal bloating were diagnosed with cancer within 12 months post-presentation. For both symptoms, in both males and females aged ≥60, the PPV for cancer exceeded the 3% risk threshold used by the UK National Institute for Health and Care Excellence for recommending urgent specialist cancer referral. Concurrent blood tests were performed in two thirds of all patients (64% with abdominal pain and 70% with bloating). In patients aged 30 to 59, several blood abnormalities updated a patient's cancer risk to above the 3% threshold: For example, in females aged 50 to 59 with abdominal bloating, pre-blood test cancer risk of 1.6% increased to: 10% with raised ferritin, 9% with low albumin, 8% with raised platelets, 6% with raised inflammatory markers, and 4% with anaemia. Compared to risk assessment solely based on presenting symptom, age and sex, for every 1,000 patients with abdominal bloating, assessment incorporating information from blood test results would result in 63 additional urgent suspected cancer referrals and would identify 3 extra cancer patients through this route (a 16% relative increase in cancer diagnosis yield). Study limitations include reliance on completeness of coding of symptoms in primary care records and possible variation in PPVs if extrapolated to healthcare settings with higher or lower rates of blood test use. In patients consulting with nonspecific abdominal symptoms, the assessment of cancer risk based on symptoms, age and sex alone can be substantially enhanced by considering additional information from common blood test results. Male and female patients aged ≥60 presenting to primary care with abdominal pain or bloating warrant consideration for urgent cancer referral or investigation. Further cancer assessment should also be considered in patients aged 30 to 59 with concurrent blood test abnormalities. This approach can detect additional patients with underlying cancer through expedited referral routes and can guide decisions on specialist referrals and investigation strategies for different cancer sites.

Evaluating a novel patient pathway to manage symptomatic breast referrals (the blue flag clinic): a longitudinal observational study.

A novel referral pathway for exhibited breast symptom (EBS) referrals to manage increasing referrals of urgent suspected cancer (USC) was implemented in our trust. We report on the safety and effect on compliance with the 2-week-wait rule (2WW). A single-centre longitudinal observational study included all patients referred to a UK breast unit during 13 May 2019 to 27 March 2020 (period 1) and 8 February 2021 to 31 January 2022 (period 2). USC referrals were assessed in a one-stop clinic (red flag clinic [RFC]); EBS referrals were assessed in a new clinic in which clinical evaluation was performed and imaging occurred subsequently (blue flag clinic [BFC]). Patients were followed up to determine the symptomatic interval cancer rate. There were 9,695 referrals; 1,655 referrals (17%) were assessed in the BFC after 63 exclusions. Some 95.9% of patients had a benign clinical examination (P1/P2), 80.1% had imaging (mammogram or ultrasound) and 4% had a tissue biopsy. In total, 16/1,655 (0.97%) BFC patients and 510/7,977 (8.2%) RFC patients were diagnosed with breast cancer (breast cancer detection rate). Some 1,631 patients (with 1,639 referrals) were discharged and followed up for a median of 17 months (interquartile range 12-32) with one subsequent cancer diagnosis (symptomatic interval cancer rate, 0.06%). Implementation of the BFC pathway increased 3-month average trust performance of USC referrals with 2WW standard from 8.5% to 98.7% (period 1) and from 30% to 66% (period 2). The BFC pathway for EBS patients is safe and implementation led to improvement against the 2WW target for USC referrals, ensuring resources are prioritised to patients with the highest likelihood of breast cancer.

P29 Selfies: not ideal!

Abstract We sought to determine whether the quality of photographic referrals from primary care had been impacted by the COVID-19 pandemic. A total of 2411 referrals made in 2020, 2021 and 2022 were retrospectively reviewed. From this, data were collected on urgent suspected cancer (USC) referrals (n = 1174) made between 1 January and 31 March. For each referral, the photographs included were reviewed. Eighty-four per cent of the 271 USC referrals made in 2020 included photos, 90.3% of the 413 referrals in 2021 and 91.2% of the 490 referrals in 2022. We devised criteria to determine quantitatively the quality of photographs based on the presence of a locator image, a close-up image, a ruler, a dermatoscopic image and whether the photos were in focus. Each feature scored 1, generating a quality score of 0–5. The mean quality scores in 2020, 2021 and 2022 were 2.16, 2.13 and 2.30, respectively. A Kruskal–Wallis test was performed to determine whether there was statistical significance to the differences seen between the sample groups. The alternative hypothesis was that the distribution of the quality scores across the sample groups was unequal. An overall P-value of 0.075 was generated, which was below the threshold of 0.1; therefore, the alternative hypothesis was accepted. On paired comparison between the sample groups, there was a statistically significant increase from 2021 to 2022, with an adjusted P-value of 0.069. We also subjectively judged whether the photos from each referral had made a positive impact on the final diagnosis. Seventy-five per cent (n = 170) of referrals in 2020, 251 (67.3%) in 2021 and 356 (79.6%) in 2022 included photos that had a positive impact on the final diagnosis. To conclude, our results showed that there was a significant decrease in the quality of photographs included in USC referrals in 2021 when compared with the sample groups of 2020 and 2022, suggesting that the COVID-19 pandemic had a negative impact on the triage of USC referrals from primary care. This could be explained by the reduction in face-to-face consultations and an increase in the number of patient-provided images. The results highlight that a significant proportion of images sent by general practitioners and patients are of insufficient quality for effective review and diagnosis. Possible solutions proposed include further provision of medical photography services and education. This work will be used as a baseline for the introduction of a teledermatology service.

Dental practice to dental hospital referrals—upgraded to urgent suspected cancer pathways: A three year service review

AbstractIntroductionInappropriate General Dental Practitioner (GDP) patient referrals may delay cancer diagnoses, increasing the risk of late‐stage presentation. Urgent suspected cancer (USC) referrals from GDPs are reviewed swiftly by clinicians. Non‐USC referrals may wait up to a week before being reviewed by clinicians.Aims and objectivesTo investigate upgraded‐to‐USC GDP referrals to a University Dental Hospital (UDH) following the establishment of the pan‐Wales electronic referral management system (e‐RMS) in 2019. To examine reasons for their upgrade to the USC pathway, and to assess diagnostic outcomes, diagnostic delay and compliance with The National Institute for Health and Care Excellence (NICE) referral recommendations.MethodologyUpgraded‐to‐USC e‐Referrals were reviewed and cross‐referenced against the electronic patient management system and patient files to assess waiting times from referral date to first appointment. Each e‐Referral was reviewed to determine the reason for upgrade to a USC referral. Patient outcomes and diagnoses were also examined.Results83 patient records were identified. Upgraded e‐Referrals accounted for 18.6% of all USC e‐Referrals. The majority of upgraded e‐Referrals (66.3%) were upgraded because they included words describing key malignancy features. Malignant and oral potentially malignant disorders (OPMDs) accounted for 3.8% and 17.5% of diagnostic outcomes respectively. Overall, 18.8% of upgraded‐to‐USC e‐Referrals did not meet the NICE guideline requirement of having a first appointment within 2 weeks.ConclusionEarly diagnosis of malignancies is fundamental in improving oral cancer survival outcomes. Some GDPs' clinical judgement and referral pathway choice needs improvement. Reinforcing GDP education in regard to USC referrals will likely reduce inappropriate referrals.

Urgent suspected cancer referrals in a district general hospital: a re-audit of referrals and comparison to NICE guidelines

Urgent suspected cancer referrals in a district general hospital: a re-audit of referrals and comparison to NICE guidelines

Adapting the investigation of patients on urgent suspected cancer pathway with lower gastrointestinal symptoms across Wales during COVID-19.

The COVID-19 pandemic necessitated the introduction of revised diagnostic pathways for assessing urgent suspected cancer (USC) referrals. Combinations of faecal immunochemical testing (FIT) and minimal preparation computed tomography (CT) scans (MPCT) were used to manage referrals and prioritise access to clinical services or invasive tests. The effectiveness of these pathways across Wales is evaluated in this study. All consecutive patients referred from primary care on the USC pathway between 15 March and 15 June 2020 were included to reflect the effect of full lockdown measures. Data collected included demographics, presenting symptom(s), investigations and timelines and patient outcomes up to 90days following initial referral. A total of 1,050 patients across eight sites in Wales were included. Of these 1,050 patients, 52.6% were female with median age 68 (21-97) years; 50.5% had first-line clinical review, of which 61.1% were virtual consultations; 49.5% had primary investigations; 26.7% of patients had FIT and 13.1% had MPCT. COVID-response pathways achieved a 29.9% reduction in use of colonoscopy as first-line investigation and 79% of patients avoided face-to-face consultations altogether during this first wave of the pandemic. Overall, 6.8% of USC referrals were diagnosed with colorectal cancer (CRC). Median timescale from diagnosis to treatment for CRC was 65 (4-175) days. The negative predictive value (NPV) for FIT in this cohort was 99.6%. MPCT as the first modality had a NPV of 99.2%. A modified investigation pathway helped maintain cancer diagnosis rates during the pandemic with improved resource utilisation to that used prepandemic.

Impact of coronavirus disease 2019 on head and neck urgent suspected cancer referral pathways in rural Wales

To assess the impact of the coronavirus disease 2019 pandemic on head and neck urgent suspected cancer referral pathways in rural areas of Wales. A retrospective audit was conducted of 2234 head and neck urgent suspected cancer referrals received from January 2019 to November 2020. The referrals dropped by 35 per cent in 2020 compared to the same period in 2019. The time from general practitioner referral to the first ENT appointment improved during the pandemic (8.0 vs 10.0 days; p < 0.001). Of referrals, 92.1 per cent were seen within a 14-day period in 2020, compared with 79.6 per cent in 2019 (p < 0.001). There were no differences between 2020 and 2019 in terms of: the (confirmed cancer) conversion rate (10.6 per cent vs 9.7 per cent; p = 0.60), general practitioner referral to multidisciplinary team discussion time (35.5 vs 41.5 days; p = 0.40) or general practitioner referral to initiation of treatment time (68.0 vs 78.0 days; p = 0.16). Whilst coronavirus disease 2019 reduced the number of overall head and neck urgent suspected cancer referrals, the pathways were generally unchanged, if not slightly improved, in rural Wales.

SP4.1.5The use of Faecal Immunochemical Testing (FIT) and Minimal Preparation Computed Tomography (MPCT) during COVID-19 for Urgent Suspected Cancer (USC) referrals in patients with lower gastro-intestinal symptoms

AimsThe COVID-19 pandemic necessitated introduction of revised diagnostic pathways for assessing Urgent Suspected Cancer (USC) referrals. Combinations of FIT and MPCT were used to manage referrals and prioritise access to clinical services or invasive tests. The effectiveness of these pathways are evaluated in this study.MethodsAll consecutive patients referred from primary care on the USC pathway between 15th March – 15th June 2020 were included to reflect the effect of full lockdown measures. Data collected included demographics, presenting symptom(s), investigations and timelines and patient outcomes up to 90 days following initial referral.Results816 patients across 8 sites in Wales were included in this initial analysis. 52.7% of patients were female with median age 69 (21 – 97) years. Of the 50.7% who had first-line clinical review, 70.5% were virtual consultations. 49.3% had primary investigations, with FIT in 31% of patients and MPCT in 18.3%. This was compliant with locally agreed pathways for 77.3% of referrals. COVID-response pathways achieved a 28.5% reduction in use of colonoscopy as first-line investigation and 84.3% of patients avoided face-to-face consultations altogether during this first wave of the pandemic.Overall, 5.6% of USC referrals were diagnosed with CRC. Median timescale from diagnosis to treatment for CRC was 82 (4 – 175) days. The NPV for FIT in this cohort was 99.5%. MPCT as the first modality had a NPV of 99%.ConclusionA modified investigation pathway maintained cancer diagnosis during the pandemic with improved resource utilisation to that used previously.

COVID-19 and the emergency presentation of colorectal cancer.

AimThe COVID‐19 pandemic led to widespread disruption of colorectal cancer services during 2020. Established cancer referral pathways were modified in response to reduced diagnostic availability. The aim of this paper is to assess the impact of COVID‐19 on colorectal cancer referral, presentation and stage.MethodsThis was a single centre, retrospective cohort study performed at a tertiary referral centre. Patients diagnosed and managed with colorectal adenocarcinoma between January and December 2020 were compared with patients from 2018 and 2019 in terms of demographics, mode of presentation and pathological cancer staging.ResultsIn all, 272 patients were diagnosed with colorectal adenocarcinoma during 2020 compared with 282 in 2019 and 257 in 2018. Patients in all years were comparable for age, gender and tumour location (P > 0.05). There was a significant decrease in urgent suspected cancer referrals, diagnostic colonoscopy and radiological imaging performed between March and June 2020 compared with previous years. More patients presented as emergencies (P = 0.03) with increased rates of large bowel obstruction in 2020 compared with 2018–2019 (P = 0.01). The distribution of TNM grade was similar across the 3 years but more T4 cancers were diagnosed in 2020 versus 2018–2019 (P = 0.03).ConclusionThis study demonstrates that a relatively short‐term impact on the colorectal cancer referral pathway can have significant consequences on patient presentation leading to higher risk emergency presentation and surgery at a more advanced stage. It is therefore critical that efforts are made to make this pathway more robust to minimize the impact of other future adverse events and to consolidate the benefits of earlier diagnosis and treatment.

Evaluation of a national lung cancer symptom awareness campaign in Wales

BackgroundLung cancer is the leading cause of cancer mortality in Wales. We conducted a before- and after- study to evaluate the impact of a four-week mass-media campaign on awareness, presentation behaviour and lung cancer outcomes.MethodsPopulation-representative samples were surveyed for cough symptom recall/recognition and worry about wasting doctors’ time pre-campaign (June 2016; n = 1001) and post-campaign (September 2016; n = 1013). GP cough symptom visits, urgent suspected cancer (USC) referrals, GP-ordered radiology, new lung cancer diagnoses and stage at diagnosis were compared using routine data during the campaign (July–August 2016) and corresponding control (July–August 2015) periods.ResultsIncreased cough symptom recall (p < 0.001), recognition (p < 0.001) and decreased worry (p < 0.001) were observed. GP visits for cough increased by 29% in the target 50+ age-group during the campaign (p < 0.001) and GP-ordered chest X-rays increased by 23% (p < 0.001). There was no statistically significant change in USC referrals (p = 0.82), new (p = 0.70) or early stage (p = 0.27) diagnoses, or in routes to diagnosis.ConclusionsSymptom awareness, presentation and GP-ordered chest X-rays increased during the campaign but did not translate into increased USC referrals or clinical outcomes changes. Short campaign duration and follow-up, and the small number of new lung cancer cases observed may have hampered detection effects.

Assessing the adherence to NICE guidance for urgent suspected cancer referrals following implementation of a new 2WW MDT (OMFS/Dermatology) clinic

Introduction Non-melanoma skin cancers are the most common forms of skin cancer in the UK. As complete excision is the preferred treatment, head and neck lesions are associated with significant mortality and may pose reconstructive difficulties. Hence, NICE recommends referral for all suspected SCCs on the urgent suspected cancer (USC) pathway.

PTH-183 Upper gastrointestinal cancer red flag symptoms alone except dysphagia do not predict the presence of upper gastrointestinal tract cancer: implications for practice

Introduction The epidemiology of upper gastrointestinal (UGI) cancer is rapidly changing. Current guidelines for red flag symptoms for UGI cancer were drawn up using evidence from a past age. With the exception of dysphagia, many of the symptoms are non-specific for UGI cancer in particular dyspepsia, particularly with the rapidly declining prevalence of H. pylori and its associated gastric cancers. Aims To determine the value of individual UGI cancer red flag symptoms alone or in combination in predicting the presence of UGI and non-UGI cancers. Method Our routine practice is to investigate all patients referred under the urgent suspected cancer (USC) pathway with an oesophagogastroduodenoscopy (OGD) and a computed tomography (CT) scan if over 50 years of age and symptoms are not purely oesophageal. A retrospective case review between October 2013 to March 2014 of all referrals on the USC pathway to our district general hospital with a case review of all the UGI cancers detected by our service over a one year period (October 2013–2014). Clinical follow-up after referral was a minimum of 11 months. Results 391 patients (20–96 age range) were seen under the USC pathway between October 2013–March 2014. In total 372 and 177 patients were investigated with an OGD and a CT scan respectively; 289 and 161 respectively were patients over the age of 50. 19 cancers were detected giving a detection rate of 4.75%. Of those only nine were UGI cancers (three gastric, six oesophageal). Other cancers found included three colorectal, one pancreatic, three lung, one cholangiocarcinoma, one ovarian and one peritoneal. The table shows the symptoms distribution for both UGI and non-UGI cancers. Isolated red flag symptoms had poor predictive power. Weight loss and dysphagia in combination with other symptoms had the best predictive value. There was a similar number of UGI cancers (23) and non UGI cancers (19). Analysis of all UGI cancers n = 47 over the course of one year not necessarily presenting through the USC route (October 2013–2014) revealed that isolated dyspepsia was found in only two of 47 patients compared to iron deficiency anaemia, weight loss and dysphagia which were the sole presenting symptoms in seven, four and three patients respectively, reinforcing the findings from the USC referrals. Conclusion In modern times, isolated UGI cancer red flag symptoms particularly dyspepsia are poorly predictive of UGI cancer, and equally well predict the presence of cancer outside the UGI tract. CT scanning should be a routine part of evaluation of UGI cancer referrals in the over 50’s. Disclosure of interest None Declared.

General practice performance in referral for suspected cancer: influence of number of cases and case-mix on publicly reported data.

Background:Publicly available data show variation in GPs' use of urgent suspected cancer (USC) referral pathways. We investigated whether this could be due to small numbers of cancer cases and random case-mix, rather than due to true variation in performance.Methods:We analysed individual GP practice USC referral detection rates (proportion of the practice's cancer cases that are detected via USC) and conversion rates (proportion of the practice's USC referrals that prove to be cancer) in routinely collected data from GP practices in all of England (over 4 years) and northeast Scotland (over 7 years). We explored the effect of pooling data. We then modelled the effects of adding random case-mix to practice variation.Results:Correlations between practice detection rate and conversion rate became less positive when data were aggregated over several years. Adding random case-mix to between-practice variation indicated that the median proportion of poorly performing practices correctly identified after 25 cancer cases were examined was 20% (IQR 17 to 24) and after 100 cases was 44% (IQR 40 to 47).Conclusions:Much apparent variation in GPs' use of suspected cancer referral pathways can be attributed to random case-mix. The methods currently used to assess the quality of GP-suspected cancer referral performance, and to compare individual practices, are misleading. These should no longer be used, and more appropriate and robust methods should be developed.

G249(P) Identifying Childhood Cancer: How is the Urgent Suspected Cancer Referral Pathway performing?

BackgroundThe Urgent Suspected Cancer (USC) referral pathway was introduced by the department of health in 2000 to reduce delays in the diagnosis and treatment of cancer. The model’s efficacy has...

PWE-162 Concurrent Computerised Tomography Can Optimise the Detection of Cancer in Patients Presenting with Unexplained Anaemia

IntroductionActive investigation for gastrointestinal (GI) cancers is often triggered by “alarm symptoms”; features in the clinical presentation that may predict malignancy and warrant urgent referral. Unexplained anaemia (UA) is a...

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 …

Clinical Audit Of A Symptomatic Breast Clinic In North Wales District General Hospital

We describe an audit of our symptomatic new patient breast clinic over a period of 4 weeks. A total of 162 new patients attended over 8 consecutive clinics during 4 weeks, from 03 October 2010 to 02 November 2010, were included in the audit. Urgent suspected cancer referrals were seen significantly sooner than routine referrals. 90% of the urgent suspected cancer referrals were seen within 20 days of GP referral to the first appointment in the clinic and 30% in case of routine referrals. 100% of patients diagnosed with breast cancer had their first treatment within 62 days of an urgent GP referral with suspected breast cancer. 100% of patients diagnosed with breast cancer had their first treatment (both surgical/non-surgical) within 31 days of the decision to treat. We achieved 100%, compared to audit standards based on British Association of Surgical Oncology guidelines (BASO) for breast cancer management. Hence, we closed the audit cycle.

Urgent suspected cancer referrals from general practice: audit of compliance with guidelines and referral outcomes

Late diagnosis contributes to the UK having poorer cancer survival than many countries in Europe. Cancer referral guidelines help GPs decide which patients to refer urgently for further investigation. To examine primary care referral patterns, compliance with referral guidance, and eventual outcome for patients. Prospective audit within general practice in Scotland. GPs in Scotland reviewed all urgent suspected cancer referrals over a 6-month period. They noted the final diagnosis and assessed whether the referral was in accordance with agreed referral guidelines. A total of 18 775 urgent suspected cancer referrals were analysed from 516 GP practices. The referral rate ranged from 3.7 to 24.0 per 1000 per annum; 30.8% of referrals were for patients aged under 50 years, yet this age group accounts for only 11.1% of all diagnosed cancers; 10.3% of all urgent cancer referrals were for suspected melanoma, despite this cancer accounting for only 4.1% of new cancers. The proportion of patients subsequently diagnosed with cancer was greatest for leukaemia (61.7%), prostate (52.6%), and lung cancer referrals (39.7%), and lowest for melanoma (11.8%), oesophago-gastric (11.2%), brain (10.6%), and laryngeal cancer referrals (7.8%). Compliance with referral guidelines was 90.9%. A large proportion of referrals considered to be outside the guidelines still had a cancer diagnosed (urological 15.9%, lung 8.8%, colorectal 8.4%, and breast 6.4%). There is wide variation in GP referral rates for suspected cancer with a greater than expected proportion of referrals for younger people. Many referrals considered to be outside the national guidelines were diagnosed with cancer, suggesting factors other than those in referral guidelines alert GPs to the possibility of cancer.

Straight to colonoscopy: the ideal patient pathway for the 2-week suspected cancer referrals?

The UK has a higher mortality for colon cancer than the European average. The UK Government introduced a 2-week referral target for patients with colorectal symptoms meeting certain criteria and 62-day target for the delivery of treatment from the date of referral for those patients diagnosed with cancer. Hospitals are expected to meet 100% and 95% of these targets, respectively; therefore, an efficient and effective patient pathway is required to deliver diagnosis and treatment within this period. It is suggested that 'straight-to-test' will help this process and we have examined our implementation of 'straight-to-colonoscopy' as a method of achieving this aim. We carried out a retrospective audit of 317 patients referred under the 2-week rule over a 1-year period between October 2004 and September 2005 and were eligible for 'straight-to-colonoscopy'. Demographic data, appropriateness of referral and colonoscopy findings were obtained. The cost effectiveness and impact on waiting period were also analysed. A total of 317 patients were seen within 2 weeks. Cancer was found in 23 patients and all were treated within 62 days. Forty-four patients were determined by the specialist to have been referred inappropriately because they did not meet NICE referral guidelines. No cancer was found in any of the inappropriate referrals. The use of straight-to-test colonoscopy lead to cost savings of £26,176 (£82.57/patient) in this group compared to standard practice. There was no increase in waiting times. Straight-to-colonoscopy for urgent suspected cancer referrals is a safe, feasible and cost-effective method for delivery of the 62-day target and did not lead to increase in the endoscopy waiting list.