title: Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: analysis of national primary care audit data.
abstract: BACKGROUND
  For patients with symptoms of possible cancer who do not fulfil the criteria for urgent referral, initial investigation in primary care has been advocated in the United Kingdom and supported by additional resources. The consequence of this strategy for the timeliness of diagnosis is unknown.
  
  
  METHODS
  We analysed data from the English National Audit of Cancer Diagnosis in Primary Care on patients with lung (1494), colorectal (2111), stomach (246), oesophagus (513), pancreas (327), and ovarian (345) cancer relating to the ordering of investigations by the General Practitioner and their nature. Presenting symptoms were categorised according to National Institute for Health and Care Excellence (NICE) guidance on referral for suspected cancer. We used linear regression to estimate the mean difference in primary-care interval by cancer, after adjustment for age, gender, and the symptomatic presentation category.
  
  
  RESULTS
  Primary-care investigations were undertaken in 3198/5036 (64%) of cases. The median primary-care interval was 16 days (IQR 5-45) for patients undergoing investigation and 0 days (IQR 0-10) for those not investigated. Among patients whose symptoms mandated urgent referral to secondary care according to NICE guidelines, between 37% (oesophagus) and 75% (pancreas) were first investigated in primary care. In multivariable linear regression analyses stratified by cancer site, adjustment for age, sex, and NICE referral category explained little of the observed prolongation associated with investigation.
  
  
  CONCLUSIONS
  For six specified cancers, investigation in primary care was associated with later referral for specialist assessment. This effect was independent of the nature of symptoms. Some patients for whom urgent referral is mandated by NICE guidance are nevertheless investigated before referral. Reducing the intervals between test order, test performance, and reporting can help reduce the prolongation of primary-care intervals associated with investigation use. Alternative models of assessment should be considered.
authors.affiliation: Evaluation, Research and Development Unit, School of Medicine, Pharmacy and Health, Wolfson Research Institute, University of Durham, Queen's Campus, University Boulevard, Stockton-on-Tees TS17 6BH, UK.
authors.forename: G P
authors.initials: GP
authors.lastname: Rubin
authors.affiliation: Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK.
authors.forename: C L
authors.initials: CL
authors.lastname: Saunders
authors.affiliation: Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK.
authors.forename: G A
authors.initials: GA
authors.lastname: Abel
authors.affiliation: National Cancer Intelligence Network (NCIN), Public Health England, 5th Floor, Wellington House, 135-155 Waterloo Road, London SE1 8UG, UK.
authors.forename: S
authors.initials: S
authors.lastname: McPhail
authors.affiliation: Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Cambridge CB2 0SR, UK.
authors.forename: G
authors.initials: G
authors.lastname: Lyratzopoulos
authors.affiliation: North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK.
authors.forename: R D
authors.initials: RD
authors.lastname: Neal
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D054869:Clinical Audit; D055088:Early Detection of Cancer / Q000592:standards; D005260:Female; D058006:General Practice / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis* / Q000628:therapy; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data; D012017:Referral and Consultation; D013997:Time Factors; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult