Blog by Dr Yin Zhou, GP and Wellcome Trust Primary Care Clinician PhD Fellow, Cancer Group at the Primary Care Unit
The fast-track (or ‘two-week-wait’) referral pathway for suspected cancer was introduced in England in 2000 to expedite investigations and shorten diagnostic intervals in symptomatic patients. The criteria for fast-track referrals are based on NICE guidelines which support GPs in prompt recognition of alarm symptoms and subsequent referral. However, in recent years it was increasingly realised that the usefulness of fast-track referrals can be limited in a proportion of patients with cancer that do not present with alarm symptoms with high enough specificity for cancer to be included in the fast-track guidelines.
Our study, recently published in the British Journal of Cancer, quantifies and highlights the strengths and limitations of the fast-track referral scheme based on alarm symptoms. We used data from 670,000 English patients with 35 different cancers diagnosed between 2006-2010 to examine the variation in fast-track vs non-fast-track GP referrals by cancer types and patient factors.
In particular, we found:
- A substantial proportion (almost half, 49.3%) of cancer patients who were diagnosed after a GP referral were referred outside the fast-track referral pathway;
- Cancers that often present with typical or alarm symptoms (breast, testicular) are more likely to be diagnosed after a fast-track referral and vice-versa for those that do not (for brain, leukaemias);
- Patients who present with typical symptoms but do not fit the ‘typical’ demographic groups are less likely to be diagnosed after a fast-track referral (for example, older men with testicular cancer, younger women with endometrial cancer). This is likely due to the low age- or sex-related risk of cancer in these patients.
Our findings reflect current scientific and practical limitations in establishing a diagnosis in patients with new symptoms of low specificity for cancer (either in the typical or atypical demographic group), most of whom do not have cancer. In the last 2 years, Multi-disciplinary Diagnostic Centres (MDCs) are being introduced across England, often as part of the ACE (Accelerate-Evaluate-Coordinate) initiative that aims to enable rapid diagnostic work-up for patients with non-specific new symptoms, other than alarm ones for which fast-track referral rules still apply. The MDCs offer ill patients with non-specific symptoms a quick route to appropriate investigations, and they are the focus of much NHS and Cancer Research UK supported implementation and evaluation activity.
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Image: Dr Jon Ferdinand at the PCU