'Red Flag' Cancer Symptoms Often Not Urgently Referred

Liam Davenport

October 05, 2021

Among patients presenting to their general practitioner with 'red flag' features suggestive of possible cancer, 60% are not being referred for urgent investigation with a specialist within 2 weeks, contrary to guideline recommendations, shows a UK analysis.

Of the patients who were not given an urgent referral, approaching 4% were diagnosed with cancer within a year, compared with almost 10% who did receive a referral.

The researchers studied the records of nearly 49,000 patients who visited their GP with alarm features, including haematuria, a breast lump, difficulty swallowing, iron-deficiency anaemia, and postmenopausal or rectal bleeding.

They found that a patient's likelihood of being given an urgent referral varied depending on what red flag feature they had, as well as on their age, whether they had comorbidities, and the clinician they saw and the practice they attended.

Missed Opportunities

The relatively large proportion of patients who were not referred but went on to develop cancer "could mean an opportunity to diagnose the cancer earlier was missed", said Lead Author Dr Bianca Wiering, University of Exeter Medical School.

"We think this could be improved by stricter adherence to the guidelines and increased awareness of the groups of patients in whom symptoms are frequently missed, including younger patients."

She continued: "It's important to note that this issue does not just lie with GPs. We also need to ensure the services to provide the tests needed on referral are well resourced, which we know is currently not always the case."

Lead Researcher Dr Gary Abel, also from University of Exeter Medical School, said that "huge progress" has been made in the last decade to improve cancer diagnosis in the UK.

He said that, as patients in the study who were given an urgent referral were "much more likely to be diagnosed with cancer in the next year than those that are not", GPs are "clearly referring the highest risk patients appropriately".

But with many not receiving an urgent referral, Dr Abel suggested that “following the guidelines more strictly would have significant benefits".

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

COVID Challenges

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."

She nevertheless underlined that the data are "from a little while ago, so we don't know what the situation is now".

However, 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".

Also commenting, Professor Martin Marshall, chair of the Royal College of GPs, said the study predates the latest guidelines: "What the research does show is the importance of clinical judgement in making a decision to refer. 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.

"GPs and our teams are currently working under intense workload and workforce pressures but referring patients they suspect of having cancer is something they take incredibly seriously. The Government needs to demonstrate its public support for general practice and urgently take steps to make good on their promise of 6,000 more GPs and 26,000 more members of the practice team – as well as introducing measures to tackle ‘undoable’ workload in general practice.”

Referral Guidelines

To improve the quality of cancer diagnoses and reduce delays, guidelines introduced in England in 2000 recommended that patients with certain features suggestive of cancer should be referred by their GP to a specialist within 2 weeks.

In 2005, the National Institute for Health and Care Excellence (NICE) defined a series of red flag features for which urgent referrals are recommended, and these were updated in 2015 primarily to lower the cancer risk threshold for inclusion to 3%.

The researchers said that, while there is evidence that the resulting NICE guidelines "are helping to improve diagnostic processes and outcomes in England, the extent to which they are adhered to is unknown".

Moreover, there is "other evidence" to indicate that there is "some variation in the quality of diagnostic care in cancer patients initially presenting to primary care".

To investigate further, the team gathered data from the primary care Clinical
Practice Research Datalink database, Hospital Episode Statistics and cancer registration data.

They focused on patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014–2015, as cancer registry data were only available up to and including 2016 at the time of data extraction.

Over the study period, there were 48,715 GP consultations with patients who had a feature for which a 2-week urgent referral would have been recommended.

The most common presenting features were breast lump, in 33% of patients, followed by rectal bleeding in 27%, dysphagia in 17%, haematuria in 13%, post-menopausal bleeding in 7% and anaemia in 3%.

The average age of the patients was 60.4 years, although averages ranged from 49.5 years for those with breast lump to 77.9 years for those with anaemia. The vast majority (80%) of patients had at least one comorbidity.

Patients from the least deprived areas were overrepresented in the sample, with 26% living in an area in the lowest quintile of the Index of Multiple Deprivation, a measure of socio-economic status.

Red Flags

Of the patients who presented with red flag features, 40.4% received an urgent referral, ranging from 68.3% for those with breast lump and 62.7% for post-menopausal bleeding to 17.7% for rectal bleeding and 16.9% for dysphagia.

In contrast, 59.6% of patients with red flag symptoms did not received an urgent referral.

Further analysis indicated that factors that were significantly associated with receiving an urgent referral were age, feature type, and the presence or absence of comorbidities (p<0.001 for all).

Compared with patients with rectal bleeding, those with a breast lump had an adjusted odds ratio for urgent referral of 16.85.

Patients aged 18–24 with red flag features had an odds ratio for urgent referral versus those aged 55–64 years of 0.20. Finally, the odds ratio for urgent referral for patients with four versus no comorbidities was 0.87.

There was also substantial variation between clinicians and practices in terms of giving urgent referrals for red flag features, the team says.

Among patients who received an urgent referral, 9.9% went on to be diagnosed with cancer within one year. This compared with 3.6% among patients who did not receive an urgent referral, ranging from 2.8% for rectal bleeding to 9.5% with iron-deficiency anaemia.

The result is that 35% of all patients diagnosed with cancer within one year of visiting their GP had not received an urgent referral within 2 weeks of their first consultation.

"Given the proportion of patients going on to be diagnosed with cancer was considerably higher in those receiving an urgent referral than those who did not, we can conclude that GP referral decision-making is not without value," the team writes.

"However, given the number of patients diagnosed with cancer after non-referral, we may question whether clinical judgement is good enough."

They add that their results show that: "Recommendations for the assessment of patients with features of possible cancer are not always followed.

"Stricter adherence to the guidelines and increased awareness of patient groups especially at risk of long diagnostic timelines may help improve early diagnosis and ultimately cancer survival rates."

This study was funded by Cancer Research UK.

All authors had financial support from Cancer Research UK for the work.

No other relevant financial relationships declared.

BMJ Qual Saf 2021. doi:10.1136/bmjqs-2021-013425


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