title: International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data.
abstract: BACKGROUND
  Variation in cancer survival persists between comparable nations and appears to be due, in part, to primary care practitioners (PCPs) having different thresholds for acting definitively in response to cancer-related symptoms.
  
  
  OBJECTIVE
  To explore whether cancer guidelines, and adherence to them, differ between jurisdictions and impacts on PCPs' propensity to take definitive action on cancer-related symptoms.
  
  
  METHODS
  A secondary analysis of survey data from six countries (10 jurisdictions) participating in the International Cancer Benchmarking Partnership.
  
  
  METHODS
  PCPs' responses to five clinical vignettes presenting symptoms and signs of lung (n = 2), colorectal (n = 2), and ovarian cancer (n = 1) were compared with investigation and referral recommendations in cancer guidelines.
  
  
  RESULTS
  Nine jurisdictions had guidelines covering the two colorectal vignettes. For the lung vignettes, although eight jurisdictions had guidelines for the first, the second was covered by a Swedish guideline alone. Only the UK and Denmark had an ovarian cancer guideline. Survey responses of 2795 PCPs (crude response rate: 12%) were analysed. Guideline adherence ranged from 20-82%. UK adherence was lower than other jurisdictions for the lung vignette covered by the guidance (47% versus 58%; P <0.01) but similar (45% versus 46%) or higher (67% versus 38%; P <0.01) for the two colorectal vignettes. PCPs took definitive action least often when a guideline recommended a non-definitive action or made no recommendation. UK PCPs adhered to recommendations for definitive action less than their counterparts (P <0.01). There wasno association between jurisdictional guideline adherence and 1-year survival.
  
  
  CONCLUSIONS
  Cancer guideline content is variable between similarly developed nations and poor guideline adherence does not explain differential survival. Guidelines that fail to cover high-risk presentations or that recommend non-definitive action may reduce definitive diagnostic action.
authors.affiliation: University of Oxford, Oxford.
authors.forename: Brian D
authors.initials: BD
authors.lastname: Nicholson
authors.affiliation: University of Oxford, Oxford.
authors.forename: David
authors.initials: D
authors.lastname: Mant
authors.affiliation: Bangor University, Bangor.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Neal
authors.affiliation: University of Belfast, Belfast.
authors.forename: Nigel
authors.initials: N
authors.lastname: Hart
authors.affiliation: University of Exeter, Exeter.
authors.forename: Willie
authors.initials: W
authors.lastname: Hamilton
authors.affiliation: University of Oxford, Oxford.
authors.forename: Bethany
authors.initials: B
authors.lastname: Shinkins
authors.affiliation: Durham University, Durham.
authors.forename: Greg
authors.initials: G
authors.lastname: Rubin
authors.affiliation: University of Oxford, Oxford.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Rose
mesh_terms: D019468:Disease Management; D055088:Early Detection of Cancer / Q000592:standards*; D005260:Female; D014943:Global Health; D019983:Guideline Adherence; D006306:Health Surveys / Q000379:methods*; D006801:Humans; D015994:Incidence; D008297:Male; D009369:Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000592:standards*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends
keywords: diagnosis; early detection of cancer; neoplasms; practice guideline; primary health care; survival