title: Primary care characteristics and stage of cancer at diagnosis using data from the national cancer registration service, quality outcomes framework and general practice information.
abstract: BACKGROUND
  Survival from cancer is worse in England than in some European countries. To improve survival, strategies in England have focused on early presentation (reducing delay to improve stage at diagnosis), improving quality of care and ensuring equity throughout the patient pathway. We assessed whether primary care characteristics were associated with later stage cancer at diagnosis (stages 3/4 versus 1/2) for female breast, lung, colorectal and prostate cancer.
  
  
  METHODS
  Data obtained from the National Cancer Registration Service, Quality Outcomes Framework, GP survey and GP workforce census, linked by practice code. Risk differences (RD) were calculated by primary care characteristics using a generalised linear model, accounting for patient clustering within practices. Models were adjusted for age, sex and an area-based deprivation measure.
  
  
  RESULTS
  For female breast cancer, being with a practice with a higher two week wait (TWW) referral rate (RD -1.8% (95 % CI -0.5% to -3.2%) p = 0.003) and a higher TWW detection rate (RD -1.7% (95 % CI -0.3% to -3.0%) p = 0.003) was associated with a lower proportion diagnosed later. Being at a practice where people thought it less easy to book at appointment was associated with a higher percentage diagnosed later (RD 1.8% (95 % CI 0.2% to 3.4%) p = 0.03). For lung cancer, being at practices with higher TWW referral rates was associated with lower proportion advanced (RD-3.6% (95 % CI -1.8%, -5.5%) p < 0.001) whereas being at practices with more patients per GP was associated with higher proportion advanced (RD1.8% (95 % CI 0.2, 3.4) p = 0.01). A higher rate of gastrointestinal investigations was associated with a lower proportion of later stage colorectal cancers (RD -2.0% (95 % CI -0.6% to -3.6%) p = 0.01). No organisational characteristics were associated with prostate cancer stage.
  
  
  CONCLUSIONS
  Easier access to primary care, faster referral and more investigation for gastrointestinal symptoms could reduce the proportion of people diagnosed later for female breast, lung and colorectal, but not prostate cancer. Differences between the four main cancers suggest different policies may be required for individual cancers to improve outcomes.
authors.affiliation: Speciality Registrar in Public Health, NHS England, South Plaza, Marlborough Street, Bristol, BS1 3NX, UK. Rebecca.maclean1@nhs.net.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Maclean
authors.affiliation: Senior Lecturer in Epidemiology, School for Social and Community Medicine, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. mona.jeffreys@bris.ac.uk.
authors.forename: Mona
authors.initials: M
authors.lastname: Jeffreys
authors.affiliation: Senior Analyst, Public Health England Knowledge and Intelligence team (South West), 1st floor, Grosvenor House, 149 Whiteladies Road, Bristol, BS8 2RA, UK. Alex.ives@phe.gov.uk.
authors.forename: Alex
authors.initials: A
authors.lastname: Ives
authors.affiliation: Research Assistant, NIHR CLAHRC West, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. timonthy.jones@bris.ac.uk.
authors.forename: Tim
authors.initials: T
authors.lastname: Jones
authors.affiliation: Public Health England Knowledge and Intelligence team (South West), 1st floor, Grosvenor House, 149 Whiteladies Road, Bristol, BS8 2RA, UK. Julia.verne@phe.gov.uk.
authors.forename: Julia
authors.initials: J
authors.lastname: Verne
authors.affiliation: School for Social and Community Medicine, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. Y.ben-shlomo@bris.ac.uk.
authors.forename: Yoav
authors.initials: Y
authors.lastname: Ben-Shlomo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D057210:Delayed Diagnosis / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis* / Q000453:epidemiology*; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care; D012042:Registries; D012306:Risk; D055815:Young Adult