Approximately one fifth of primary care patients with cancer in England experience some kind of delay in receiving a diagnosis. More than half of the delays are due to clinician-related or systemic factors, the results of a national audit reveal.
The National Audit analyzed details for more than 17,000 patients diagnosed with cancer in 2014. The results were published online December 18 in the British Journal of General Practice.
Overall, the study found that patients were referred to secondary care 5 days after their initial presentation to general practice, although the time varied widely, depending on the individual cancer.
The research indicates that the time from initial presentation to definitive diagnosis was 40 days. The shortest period was seen for breast cancer patients, and the longest for prostate cancer patients.
In just more than one third of cases, the delay in diagnosis was due to patients waiting to undergo testing and for results. One fifth of diagnoses were held up because patients were waiting for a referral.
Jodie Moffat, PhD, head of early diagnosis at Cancer Research UK, commented: “This study pinpoints why delays may be happening. The message couldn’t be clearer: too many patients have waited far too long for diagnostic tests or getting the results back.
“This must change. Waiting for a diagnosis is an exceptionally anxious time for patients, so it’s vital that no one has to wait longer than necessary.”
She added: “Diagnostic services need more staff to provide tests for patients, which should speed things up in the future.”
Indeed, for Ruth Swann, PhD, a senior analyst at the National Cancer Registration and Analysis Service, Public Health England, London, the United Kingdom, who led the study, the audit is just the start of a much wider effort to tackle diagnostic delays.
“The data gathered in this audit are really rich, and we have only just scratched the surface,” she told the Cancer Research UK Science Blog. “Each general practice has received its own individual results so the practice team can identify areas where they could improve.”
Dr Swann continued: “We are now planning to do further in-depth analyses to help build a better picture of pathways to cancer diagnosis on a UK-wide level.”
Cancer Outcomes Worse Than Elsewhere
Numerous studies in recent years have revealed that England has worse cancer outcomes than other countries with comparable healthcare systems. The reason for this, at least in part, is thought to be differences in the length of time it takes to receive a definitive diagnosis.
To examine the diagnostic process for cancer and to provide a baseline for future assessments, the researchers conducted a clinical audit of general practices in England. Data on individuals diagnosed with cancer in 2014 were gathered from the English National Cancer Registry and participating practices.
In all, 439 general practices, representing 5% of the approximately 8000 practices in England, took part in the audit. After exclusions, the final sample comprised 17,042 patients, or 6% of all patients with cancer diagnosed in 2014.
The median age of patients included in the analysis was 69 years, and 50% were male. The most common diagnoses were female breast cancer, accounting for 16% of cases, followed by cancer of the lung (13%), prostate (13%), and colon/rectum (12%).
The vast majority (95%) of patients were white. The same proportion were native English speakers.
Twenty-four percent of patients had no recorded comorbidities at diagnosis; 21% had three or more comorbidities. The most common comorbidities were hypertension (38%), cardiovascular disease (21%), and arthritis/musculoskeletal disease (18%).
The researchers say that although the patients were representative of the national cohort, participating practices were likely to have fewer patients per fulltime equivalent general practitioner than those practices that did not take part, and they were less likely to be in the least deprived and the most deprived areas.
The majority (72%) of patients first presented at their general practitioner’s office or had a home visit; 7% first presented at the emergency department.
Of the patients who presented to general practice, 26% had three or fewer consultations before their referral to secondary care. The most common reasons for referral were symptoms suggestive of a different diagnosis, occurring in 11% of patients, and a conflicting comorbidity, seen in 5%.
Overall, the mean number of days between presenting with symptoms deemed relevant to cancer and the first referral for suspected cancer, termed the primary care interval (PCI), was 5 days.
The team notes that the shortest PCI was for women with breast cancer, at a median of 0.0 days. The longest was for multiple myeloma patients, at a median of 23.5 days. Eight percent of patients had to wait longer than 90 days to be referred.
The median diagnostic interval across the whole cohort was 40 days. The shortest was for patients with breast cancer (14.0 days); the longest was for patients with prostate cancer, at 55.5 days. The diagnostic interval was more than 28 days in 54% of all patients, 19% of breast cancer patients and 74% of melanoma patients.
General practitioners considered that there had been an avoidable delay in 22% of patients. Rates ranged from 7% for breast cancer patients to 34% for those with stomach cancer.
The delays were attributable to the patient in 26% of cases, to the primary/secondary care clinician in 28% of cases, and to system factors in 34%.
Thirty-four percent of diagnostic delays were due to patients waiting for tests and results, 20% were due to patients waiting for a specialist appointment, and 17% were due to patients waiting to be assessed by a general practitioner or specialist.
A further 16% of delays were due to patient factors, such as missing appointments; 7% were due to patients waiting for an appointment; and 7% were due to waiting for follow-up, for example, waiting to receive a test result.
Forty-five percent of patients underwent investigations led by primary care providers before they were referred. These ranged from 3% for patients with breast cancer to 76% for prostate cancer patients.
The researchers conclude: “The findings provide the most detailed and accurate picture to date about the diagnostic process in a large, representative, nationwide population of patients with cancer.”
“For policymakers, this audit provides a baseline against which the impact of subsequent initiatives to improve cancer diagnosis, such as the 2015 NICE guidance on recognition and referral of suspected cancer and the implementation of the Achieving World-Class Cancer Outcomes Cancer Strategy 2015-2020, can be assessed,” they continue.
It also provides “pointers to where implementation efforts might best be directed, for example, in achieving the 28-day standard from referral to diagnosis,” they add.
Ben Noble, MD, a general practitioner from Loughborough, England, agreed. He told the Science Blog: “Understanding the mechanics of how cancer is diagnosed has improved my appreciation of where I can effect change.
“As health professionals, we all have a part to play in reducing avoidable delays in diagnosis. Sometimes we might have managed a patient differently or recognized the need for system change at our place of work,” Dr Noble commented.
He pointed out that general practitioners constitute only a part of the healthcare system.
“There are larger parts of the diagnostic journey that are out of our control,” he said, “and only by working as part of a coordinated health community can large-scale improvements be made.”
The National Cancer Diagnosis Audit received support from Cancer Research UK, the National Health Service England, and the National Cancer Registration and Analysis Service. The authors have disclosed no relevant financial relationships.
Br J Gen Pract. Published online December 18, 2017. Full text