title: Cancer suspicion in general practice, urgent referral and time to diagnosis: a population-based GP survey and registry study.
abstract: BACKGROUND
  Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP's suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis.
  
  
  METHODS
  We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients' chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP's symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression.
  
  
  RESULTS
  5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient's symptoms as 'alarm' symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as 'vague' had a lower chance of being referred to a CPP than when interpreted as 'alarm' symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with 'vague' symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with 'alarm' symptoms.
  
  
  CONCLUSIONS
  GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP's choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP's symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval.
authors.affiliation: Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark. henry.jensen@feap.dk.
authors.forename: Henry
authors.initials: H
authors.lastname: Jensen
authors.forename: Marie Louise
authors.initials: ML
authors.lastname: Tørring
authors.forename: Frede
authors.initials: F
authors.lastname: Olesen
authors.forename: Jens
authors.initials: J
authors.lastname: Overgaard
authors.forename: Peter
authors.initials: P
authors.lastname: Vedsted
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D003718:Denmark / Q000453:epidemiology; D055088:Early Detection of Cancer / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D058006:General Practice; D058005:General Practitioners; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000592:standards*; D012017:Referral and Consultation / Q000592:standards / Q000706:statistics & numerical data; D012042:Registries / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D055815:Young Adult