National Audit of Cancer Diagnosis in Primary-Care

8/3/2019 National Audit of Cancer Diagnosis in Primary-Care

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Clinical Innovation and Research Centre 2011

National Audit of Cancer Diagnosis in Primary Care



National Audit o Cancer Diagnosis in Primary Care

This report was prepared by:Royal College o General Practitioners: Greg Rubin, Proessor o General Practice and Primary CareNational Cancer Intelligence Network: Sean McPhail, Senior AnalystNational Cancer Action Team: Kathy Elliott, National Lead or prevention, early diagnosis and inequalities

Please note that the views expressed within this report are the authors’ own and do not necessarily reectthe view o the Department o Health or its policies in this area.

Department o Health Gateway approval: 16345

Acknowledgements

The introduction o a National Audit o Cancer Diagnosis in Primary Care was a vision shared by ProessorSir Mike Richards, Director o Cancer Services, and Proessor Mayur Lakhani, Chairman o the Royal Collegeo General Practitioners (RCGP) at the time o the publication o the Cancer Reorm Strategy. It could nothave been realised without the support o the RCGP and the National Cancer Action Team (NCAT). TheDepartment o Health Cancer Policy Team and the National Cancer Intelligence Network (NCIN) have playedcritical roles in enabling this national report to be produced. Our thanks go to the many Cancer Networksthat participated, or supporting practices as they completed the audit and collating data or the NCIN.

Lastly, this audit would not have happened without the enthusiastic participation o the English generalpractice community. Together their eorts have produced a result that ew thought could be achieved.

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Acknowledgements ii

Foreword 5 Executive summary 6

1. Introduction 7 1.1 Background 7

1.1.1 Diagnosis o cancer in primary care 71.1.2 Audit o cancer diagnosis in primary care 71.1.3 Previous audits o cancer care 7

1.2 Aims o the audit 8 2 Audit methods 9

2.1 Design o the audit 92.2 Conduct o the audit in 2009/10 9

2.2.1 Ethics and Inormation Governance 92.2.2 Local and national analysis 10

2.3 Data collection, cleaning and categorisation 102.3.1 Stage 102.3.2 Number o times patient attended surgery 102.3.3 Investigations Ordered 102.3.4 Symptoms at presentation 102.3.5 Intervals along the patient pathway 11

2.4 Statistical Methods o Analysis 11

2.4.1 Tools 11

3 Participation and case ascertainment 123.1 Participation 123.2 Case ascertainment 12 4 Data Quality 134.1 Data completeness 134.2 Comparison to other data 14

4.2.1 By cancer type 144.2.2 By age and sex 14

4.3 Commentary 15

5 Patient characteristics 165.1 Demographic eatures 165.2 Cancer site 185.3 Commentary 18

6 Diagnostic pathway 19 6.1 Place o presentation 19

6.1.1 By cancer site 196.1.2 Association with demographics 19

6.2 GP consultations 21

6.2.1 By cancer type 216.2.2 Association with demographics 21

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6.3 Presenting symptom 236.4 Use o Investigations 25

6.4.1 Tumour type 256.4.2 Association with presenting symptom 256.4.3 Change in management 27

6.5 Routes to diagnosis 286.5.1 Demographic eatures 296.5.2 Tumour type 306.5.3 Presenting symptom 31

6.6 Commentary 32

7 Intervals in the diagnostic pathway 347.1 Patient interval 34

7.1.1 Demographic eatures 347.1.2 Tumour type 35

7.1.3 Presenting symptoms 367.1.4 Reerral route 37

7.2 Primary care interval 377.2.1 Demographic eatures 377.2.2 Tumour type 397.2.3 Presenting symptom 397.2.4 Reerral route 41

7.3 Reerral interval 417.3.1 Demographic eatures 417.3.2 Tumour type 427.3.3 Presenting symptom 43

7.3.4 Reerral route 447.4 Commentary 44

8 Cancer stage at diagnosis 458.1 Demographic actors 458.2 Tumour type 478.3 Presenting symptom 488.4 Presentation route 508.5 Commentary 50

9 Conclusions 51

10 Suggestions for improvement 52 Appendix 1: Audit Steering Group 53Appendix 2: Data Security and Data Transfer 54Appendix 3: Notes accompanying audit template 57Appendix 4: Participation 59 References 61

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Foreword

I would like to thank all the General Practitioners and practice teams whohave contributed to the collection o audit data that will help to shape ourthoughts on the primary care diagnosis o cancer.

The success around the methodology o this audit has been dependentnot only on the excellent leadership shown by the project lead, ProessorGreg Rubin and the steering group, but also the cancer network GP leadswho have helped to acilitate the collection o the data presented in thisreport .

The data show we do well in General Practice in identiying our patientswho have cancer. There are, o course, groups o patients where we dohave difculty or various reasons in making a rapid diagnosis o cancer. Sometimes these are patient,practitioner or system actors.

However, the oundations that will enable us to continue to provide a quality service are the attributeso quality General Practice - continuity o care; patient centredness and shared decision making; clinicalacumen and sound diagnostic skills.

We must also be prepared to evaluate what we do and this audit is an excellent example o how such

evaluation can provide rich messages or the uture care o our patients.

Dr Clare Gerada, Chair of Council, RCGP

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The National Awareness and Early Diagnosis Initiative (NAEDI) is intended to better understand and addressthe reasons or later diagnosis o cancer in England. An audit o cancer diagnosis in primary care wasundertaken in 2009/10 as part o this initiative.

An audit template was developed and piloted by an expert group o academic and service GPs, utilisingexperience in earlier local audits o cancer diagnosis. Inormation was collected on patient demographicsand the nature o the assessment process in primary care, including the time taken rom frst presentationto reerral. Participating cancer networks identifed GP leads or the initiative, who also validated practicereturns beore acceptance. In addition to the local analyses undertaken by these networks, the data werecollated into a single database by the NCIN. The collated data orm the basis o this report.

Data were collected on 18879 patients by 1170 practices in 20 cancer networks. Data quality was high withmost categorical felds (including stage) being close to or over 90% complete. Comparison with cancerregistry data demonstrated that the dataset was representative in respect o age, sex and distribution bycancer site.

The duration o the primary care and reerral intervals showed considerable variation by cancer site.Emergency presentation, usually associated with worse outcomes, occurred in 12.9% o all cases but rangedrom 3.7% (breast) to 39.3% (brain). In 6.0% o cases the GP believed that better access to investigationswould have reduced delay in diagnosis. This also varied considerably by site, being much greater or brain,ovary, pancreas and kidney.

This is the largest and most comprehensive study to date o the primary care pathway to cancer diagnosis.It provides detailed insights into current clinical practice that can direct initiatives to reduce the time todiagnosis or cancer, as well as raising important questions or uture research. It has raised awarenessamong GPs o their contribution to timely diagnosis o cancer and has stimulated proessional and practice

development. Many individual practices have expressed their intention to use the audit tool to regularlymonitor their perormance or the uture. Networks have used their involvement as a springboard to widerengagement with primary care, taking advantage o the other quality improvement approaches that havebeen developed alongside this audit.

We recommend:

1. That these fndings could inorm quality improvement initiatives that address the pathway to cancerdiagnosis.

2. That the fndings o this report are used to inorm plans to improve access to diagnostics as outlined inImproving Outcomes: a Strategy for Cancer .

3. The Cancer Diagnosis Audit Tool could be a useul tool or practices, Cancer Networks and ClinicalCommissioning Groups to identiy local areas or improvement and to monitor the impact o serviceimprovements.

4. That the audit o cancer diagnosis could be used systematically at a national level in order to monitor theimpact on primary care outcomes o policy in the area o early diagnosis.

5. That primary care audit could be combined with other data, rom secondary care audit or rom theAssociation o Public Health Observatories Practice Profles, or example, to generate more detailedunderstanding o actors inuencing the pathway to diagnosis.

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1.1 Background

1.1.1 Diagnosis of cancer in primary care

Over 90% o all patient contacts with health care in the UK occur in primary care. It is the setting in whichsymptoms are usually frst evaluated and where those people who need urther evaluation are identifed andreerred to specialist care. There are an estimated 300 million consultations in general practice in Englandannually,1 and they represent a major challenge in the siting o oten undierentiated symptoms in order toidentiy those patients with signifcant disease. For those patients with suspected cancer, clinical guidanceor GPs was produced by Department o Health in 2000 and then revised by NICE in 2005. This providedinormation on symptoms and signs that merited urgent reerral or urther assessment. It was supportedby a reerral pathway or suspected cancer that would ensure patients were assessed within two weeks oreerral.

The Cancer Reorm Strategy (2007) marked a new direction or improving cancer outcomes in England.

A central theme was that o achieving earlier diagnosis, predicated on the belie that delay in the periodleading up to diagnosis and subsequent treatment contributed signifcantly to the poor outcomes thatwere apparent rom the EUROCARE studies. This emphasis on the importance o early diagnosis has beenmaintained in Improving Outcomes: a Strategy for Cancer (2011).

A programme o activities spanning the cancer pathway rom frst suspicion o bodily change toconfrmation o cancer diagnosis, the NAEDI, was launched in 2008 to better understand and addressreasons or late diagnosis in England. One strand o the NAEDI work programme was a national audit ocancer diagnosis in primary care. This was intended to inorm decisions about how best to provide moresupport to primary care proessionals to ensure the earliest possible diagnosis o cancer and was to beundertaken in collaboration with the RCGP. Lessons rom the audit ‘could inorm the education and training

o GPs, including through continuous proessional development and appraisal. The audit could also assistin the development o decision aids to support healthcare proessionals in assessing symptoms and makingdecisions about urther investigation or reerral’.2

1.1.2 Audit of cancer diagnosis in primary care

Audit is the review o clinical care, using objective measures, against explicit criteria or good clinicalpractice. There are no specifc criteria that currently apply to primary care in respect o cancer diagnosis.The NICE reerral guidelines or suspected cancer contain three suggestions or audit, all o which couldpresent operational challenges. They relate to the provision o inormation about the likely diagnosis and theinvestigation or reerral at frst consultation o patients with classical eatures o cancer. Nevertheless, some

groups have designed audits o cancer diagnosis in primary care.

1.1.3 Previous audits of cancer care

National annual audits are well established or lung, colorectal, head and neck cancer and oesophago-gastriccancer. These have been managed by the NHS Inormation Centre. In all cases the audit has ocussed on thesecondary care pathway, or many aspects o which, criteria had previously been developed. The objectivein each case has been to obtain data on all patients diagnosed with the cancer in question or a specifedperiod and rom as many participant specialist units as possible. Ater several rounds, high participation rateshave been achieved. For example, 169/172 Hospital Trusts participated in the 2009 lung cancer audit and94% o all cases presenting to secondary care were included.3

Large scale audit o cancer diagnosis in primary care has previously been undertaken by the Scottish PrimaryCare Cancer Group4 and in three English areas. These audits had primarily ocussed on use o the two week

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reerral pathway but collected additional inormation about the diagnostic process. In Scotland, where tworounds o audit were completed, it was possible to discern some consequential changes, notably in relativeuse o reerral pathways. The experience in these ‘pilot’ sites provided valuable inormation about the easi-bility o undertaking such an audit, participation and completion rates.

1.2 Aims of the audit

The aim o this audit was to defne current practice in primary care cancer diagnosis and to develop criteriaor best practice, in order to improve uture cancer outcomes. The objectives were to generate insightsinto the diagnostic pathway in general practice that could inorm proessional and practice development,as well as the commissioning process or services that support the cancer diagnosis pathway. Withincancer networks the fndings were intended to stimulate clinical and service improvement and to provide abenchmark.

This audit has important dierences rom the site-specifc audits o secondary care practice that have been

published. We chose to examine current practice or all cancers. To do this in all 8100 practices in Englandwould have presented very considerable logistical and resource challenges. Instead, the ability o practices toparticipate depended on the priorities o Cancer Networks and the resources available to them.

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2.1 Design of the audit

The audit has been a collaboration between the ollowing partners:

• Department o Health Cancer Policy Team• National Cancer Action Team• National Cancer Intelligence Network• Clinical Innovation and Research Centre at the Royal College o General Practitioners.

An audit development group was established to develop a model audit template, drawing on the experienceo those involved in the Scottish audit and in the pilot audits in SE London, Manchester and Avon, Somersetand Wiltshire. The group comprised individuals responsible or these earlier audits, academic GPs active incancer diagnosis, primary care leads rom cancer networks and other stakeholders (Appendix 1). A modelaudit template was piloted by members o the development group beore being made openly available.5

A number o complementary actions were undertaken concurrently with this audit. These included a studyo the interval rom frst presentation to diagnosis or 15 cancers, using the General Practice ResearchDatabase, large-scale signifcant event audit by general practices o their most recent cases o specifedcancers6, and the development o a support structure or this programme o activity within the RCGP.

2.2 Conduct of the audit in 2009/10

In 2009 the Department o Health announced a Local Awareness and Early Diagnosis Initiative (LAEDI),directed at the 28 Cancer Networks in England and led by NCAT. Cancer Networks were asked to developlocal programmes o work which could include bringing together data to assess the needs related to earlydiagnosis o cancer; local strategies, governance and business cases; and implementation o evidence based

awareness raising or primary care service change programmes. One option oered to networks as theyormulated their LAEDI proposals was to participate in the Primary Care Cancer Audit. I this option waschosen, Networks were required to ensure that there was a GP Lead to provide clinical leadership or theaudit.

Participation in primary care cancer audit was included in 20 English Cancer Networks’ plans or a LAEDI andapproved or unding rom the NCAT and the Department o Health.

Participating practices were required to complete the audit template rom their practice clinical recordsand hospital correspondence. Participation was underpinned by a Local Enhanced Service agreement,which included the requirement that the practice team met and reviewed the completed audit prior to its

submission.

Networks identifed audit leads whose responsibility it would be to support participating practices and toreview their audit data or completeness. Additional technical support was provided by the Evaluation,Research and Development Unit (ERDU) at Durham University and by the SE London Cancer Network.Co-ordination o the overall initiative was undertaken by ERDU, on behal o the RCGP.

2.2.1 Ethics and Information Governance

Participating networks were required to gain local approval or this audit. No patient identifable data werecollected. All data submitted to the National Cancer Intelligence Network (NCIN) or analysis were held on

the same IT system and under the same inormation governance arrangements as apply to cancer registries.

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2.2.2 Local and national analysis

A major purpose o the audit was to contribute to the development o local awareness and early diagnosisinitiatives within the Cancer Networks o England during 2009/10. Participating networks undertook toanalyse and report their local data. The National Cancer Action Team produced an overview report o thisLAEDI programme and on the priorities or sharing learning in 2010/11, which included GP engagement.7

The value o undertaking an analysis o combined data rom participating networks was recognised romthe outset, in terms o more robust understandings, particularly o less common pathways and rarer cancers.It also provides a benchmark against which local fndings can be compared as well as an opportunity to setcriteria or clinical care.

2.3 Data collection, cleaning and categorisation

Returns rom participating practices were aggregated at network level. With detailed guidance to networks

rom NCIN they were then submitted and imported into a single dataset or analysis by NCIN (Appendix 3).

2.3.1 Stage

Stage at diagnosis was simplifed. We used a three stage grouping, based on the grouped staging which haspreviously been employed by cancer registries and which is described by SEER. Thus, stage was describedas confned to organ, local (regional) spread, or distant (metastatic) spread.8,9 These equate to SEER stagestwo to our, carcinoma in situ (stage one) being excluded rom the audit. Stage was determined by thepractitioner completing the template, based on inormation available in the practice records, includinghospital correspondence.

2.3.2 Number of times patient attended surgery

A lookup table was generated and dierent expressions o requency o attendance were given a singlenumerical value (or example mapping “1”, “once” and “one” to the numeric value 1). Values which ailedto match were examined and the lookup table refned until or 95.6% o patients a numeric value or thenumber o times that the patient attended surgery prior to diagnosis was extracted.

2.3.3 Investigations Ordered

Pattern matching was done within each ree text item. For example, it was recorded that the GP orderedblood tests i any o the patterns “bloods”, “b/t”, “PSA”, or “blood test” (plus others) were contained in

the data feld. The resulting matches were examined without fnding any that appeared inappropriatelymatched.

2.3.4 Symptoms at presentation

Where multiple symptoms were listed, the frst was taken as the primary symptom. Descriptions osymptoms were aggregated into cognate groups which naturally ftted the responses, by individual cancertype.

For example “breast lump” and “lump” were grouped or breast cancer. These natural groups were thenreviewed by a clinician and urther aggregated along clinically relevant lines.

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2.3.5 Intervals along the patient pathway

The patient interval was defned as the date o onset o symptoms to the frst consultation. The primary careinterval was the date o frst presentation to the date o reerral. The reerral interval was defned as the date

o reerral to the date the patient frst attended or specialist assessment in secondary care.

As well as the actual length o these intervals, they were categorised into those over 31 days, and those o31 days and less. This cut o was considered to be the generally accepted time period within which GPassessment and reerral should be completed.

2.4 Statistical Methods of Analysis

2.4.1 Tools

Data were imported and analysed within the Stata 11 sotware package.

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3.1 Participation

In total 20 Cancer Networks participated in the audit. Two networks invited practices rom selected localitieswithin their area, in both cases on the basis o socio-economic deprivation. In a third network fve out o theseven PCTs exercised a selection process or practices wishing to participate. In the remaining networks allpractices were invited to participate and no selection process was applied (Appendix 4).

The audit was conducted between April 2009 and April 2010. Most networks applied a specifed time rameor the selection o cases, which in most cases was 12 months. Participants were required to include all caseswith a date o diagnosis within that period. However, one network applied a quota to the number o cases apractice was required to submit and in another, the practices were asked to ocus on the our most commoncancers (breast, bowel, lung, prostate).

In total 1170 practices rom 20 cancer networks participated. This represents 14% o all practices inEngland, drawn rom nearly three-quarters o the 28 cancer networks.

3.2 Case ascertainment

The audit only included confrmed malignancies. It excluded screen-detected cancers, in-situ carcinomas andnon-melanotic carcinomas o the skin.

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The completeness o data in the fnal audit is displayed in table 4.1-1. For categorical felds the percentageo valid entries is shown, along with the percentage o responses that were “Not known” (or equivalent),where this was a possible response. For ree text felds where validation is not easily possible the percentageo cases were the feld had at least some text present is given.

Most categorical felds had a completion with a valid response o close to or above 90%. Fields or whichthe response is conditional have a lower percentage completion, as might be expected.

4.1 Data completeness

Table 4.1-1, Data completeness by feld.

Field Valid Not known Complete

Age 98.0% - -

Gender 99.7% - -

Ethnicity 98.3% 10.1% -

Where is this patient's country of birth? 96.6% 22.6% -

Does this patient have any problems communicating? 98.7% 1.3% -Is this patient housebound? 98.7% 2.4% -

Diagnosis 99.6% 0.1% -

Please enter further details of the diagnosis - - 86.4%

What was the stage at diagnosis? 96.0% 7.4% -

If known, enter date patient first noted symptoms or signs of cancer (dd/mm/yy) 74.3% - -

Where did the patient first present? 98.4% 0.9% -

Date patient reported symptom or sign to Primary Care (dd/mm/yy) 88.3% - -

How many times did patient attend surgery before they were referred? - - 95.6%

What was the main presenting symptom? - - 98.0%

Did the GP organise any investigations before referring? 96.3% 1.4% -

If yes, please list investigations ordered - - 48.4%

Would rapid access to investigations have altered your management of this case? 91.5% - -If yes, which investigation would have been most useful? 6.2% - -

Date Referral Sent (dd/mm/yy) 89.4% - -

Which speciality was the referral sent to? - - 94.6%

Type of referral 95.9% 2.5% -

Which Trust was the patient referred to? - - 96.0%

Date first seen or investigated by specialist (dd/mm/yy) 95.1% - -

Were there any delays informing the practice of the diagnosis? 97.0% 2.2% -

Were there any avoidable delays to this patient's journey? 95.6% - -

If Yes or unsure, please comment - - 35.2%

If patient deceased, enter Date of Death (dd/mm/yy) 16.9% - -

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4.2 Comparison to other data

The dataset was comparable to that o the cancer registries in respect o age and sex, and by distributionby cancer site with some exceptions. Lung was under-represented in the audit, while prostate was overrepresented.

4.2.1 By cancer type

Figure 4.2-1, representation o cancers in the audit by cancer type, compared to those in cancer registry data. Data source:Ofce o National Statistics. 95% confdence intervals are shown or the proportion o cancers in the audit dataset.

4.2.2 By age and sex

Figure 4.2-2, representation o cancers in the audit by age and sex, compared to those in cancer registry data. Breast cancercases are excluded. Data source: Ofce o National Statistics.

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4.3 Commentary

There was very high data completeness, close to or in excess o 90% or nearly all categorical felds. Therecording o dates in the patient pathway is also close to 90%, except or the date that the patient frstnoted signs or symptoms o cancer, which is close to 75%. The raction o ree text felds which wereinterpretable is high. For example, it is over 95% or the number o times attending surgery and mainpresenting symptom.

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Patients included in this audit were typically aged over 65 years, men comprised 52% o the total, women48% and 0.2% were unknown. A communication difculty was recorded or 6.0% o the total, while 6.9%o all patients were housebound. 78% o those included were identifed as White British. “White other” wasthe second largest identifed ethnic group (3.2%) and 12% were unknown. We were not able to identiysocio-economic status at the level o the individual, since this would have necessitated the collection opatient-identifable data.

5.1 Demographic features

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Figure 5.1-1, number o cases in the audit by age and sex.

Figure 5.1-2, number o cases in the audit by ethnicity.16



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Figure 5.1-3, number o cases in the audit by housebound status.

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Figure 5.1-4, number o cases in the audit by the presence o communication difculties.

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5.2 Cancer site

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Figure 5.2-1, number o cases in the audit by cancer type.

5.3 Commentary

Substantial numbers o cases were included or each cancer site, with over 2000 or each o the our maincancers. Even the very rare cancers (gallbladder, small intestine, vulva) were represented by over 50 cases,giving a unique opportunity to gain insights into their pathway to diagnosis.

The demographic inormation collected is useul or understanding inequalities. The audit developmentgroup believed that some eatures had a particular potential to impact on the diagnostic process in primarycare and are also commonly evident in the GP record. These included being housebound and having acommunication difculty. However, it was recognised by the group that these are not customary measureso inequality, and that those used by the National Cancer Equality Initiative are not all routinely recorded inGP records. There were over 1000 cases in each o our categories, enabling some conclusions to be drawnabout the quality o care provided to them.

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6.1 Place of presentation

Most patients frst presented to their GP with symptoms, though small numbers attended A&E oroutpatients. There were some notable variations; a signifcant minority o those with brain, lung, stomach,and kidney cancer attended A&E in the frst instance, the same being true or liver and thyroid cancers inrespect o outpatient clinics. Over 10% o housebound patients attended A&E in the frst instance with theirsymptoms.

6.1.1 By cancer site

Practice Out patients A&E Walk-in centre Other Not Known Total n

All persons 82.1% 4.1% 4.6% 0.7% 6.3% 2.3% 100% 920

Brain 66.7% 2.1% 20.1% 0.0% 7.7% 3.4% 100% 234

Breast 87.1% 2.7% 0.6% 0.1% 7.4% 2.2% 100% 3046

Cervical 88.2% 2.0% 1.3% 0.7% 5.3% 2.6% 100% 152

Colorectal 84.6% 3.4% 5.4% 0.3% 4.3% 1.9% 100% 2566

Endometrial 90.6% 1.4% 3.2% 0.2% 3.0% 1.6% 100% 435

Gallbladder 81.4% 5.7% 8.6% 0.0% 4.3% 0.0% 100% 70Laryngeal 89.9% 3.9% 0.0% 0.8% 3.9% 1.6% 100% 129

Leukaemia 78.2% 6.3% 4.5% 0.3% 7.3% 3.3% 100% 574

Liver 69.2% 12.3% 5.4% 0.8% 8.5% 3.8% 100% 130

Lung 75.7% 4.8% 9.5% 0.1% 7.8% 2.0% 100% 2014

Lymphoma 82.9% 4.6% 5.0% 0.5% 4.5% 2.5% 100% 760

Melanoma 90.9% 3.6% 0.6% 0.0% 3.6% 1.3% 100% 878

Mesothelioma 87.3% 2.5% 6.3% 0.0% 3.8% 0.0% 100% 79

Myeloma 75.0% 7.1% 8.3% 0.0% 6.0% 3.6% 100% 252

Oesophageal 89.8% 2.7% 4.0% 0.0% 2.0% 1.5% 100% 596

Oropharyngeal 79.5% 4.8% 3.1% 0.4% 9.6% 2.6% 100% 229

Ovarian 84.8% 1.4% 7.8% 0.0% 4.7% 1.2% 100% 422

Pancreatic 85.9% 2.3% 6.4% 0.5% 3.6% 1.3% 100% 390

Prostate 86.3% 4.7% 2.1% 0.2% 4.5% 2.3% 100% 2912

Renal 71.4% 6.5% 10.1% 0.8% 9.3% 2.0% 100% 398

Sarcoma 79.8% 4.2% 3.4% 0.8% 9.2% 2.5% 100% 119

Small Intestine 82.5% 1.8% 5.3% 0.0% 8.8% 1.8% 100% 57

Stomach 79.6% 2.2% 10.7% 1.3% 4.1% 2.2% 100% 319

Testicular 83.7% 2.4% 3.6% 0.0% 7.8% 2.4% 100% 166

Thyroid 79.4% 10.3% 0.8% 0.8% 7.1% 1.6% 100% 126

Vulval 88.2% 2.6% 1.3% 0.0% 6.6% 1.3% 100% 76

Other 79.5% 4.6% 4.9% 0.2% 7.6% 3.2% 100% 567

Unknown Primary 81.5% 1.1% 11.1% 0.0% 4.2% 2.1% 100% 189

No Information 29.7% 4.1% 0.0% 0.0% 2.7% 63.5% 100% 74

Total 83.3% 3.9% 4.5% 0.3% 5.7% 2.4% 100% 18879 Table 6.1-1, place o frst presentation by cancer type.

6.1.2 Association with demographics

Sex Practice Out patients A&E Walk-in centre Other Not Known Total n

Male 82.4% 4.6% 4.9% 0.3% 5.3% 2.3% 100% 9759

Female 84.3% 3.1% 4.0% 0.2% 6.1% 2.3% 100% 9066

Not Known 59.3% 1.9% 9.3% 0.0% 5.6% 24.1% 100% 54

Total 83.3% 3.9% 4.5% 0.3% 5.7% 2.4% 100% 18879 Table 6.1-2, place o frst presentation by sex.

19



Males, by ageband Practice Out patients A&E Walk-in centre Other Not Known Total n

0-24 73.1% 2.8% 8.3% 1.9% 9.3% 4.6% 100% 108

25 85.7% 1.6% 1.6% 0.0% 6.3% 4.8% 100% 63

30 81.9% 3.2% 6.4% 1.1% 4.3% 3.2% 100% 94

35 86.8% 1.6% 6.2% 0.0% 3.9% 1.6% 100% 129

40 81.2% 3.6% 7.1% 0.0% 6.1% 2.0% 100% 197

45 84.6% 1.5% 6.6% 0.4% 5.5% 1.5% 100% 272

50 83.7% 2.9% 5.9% 0.7% 4.2% 2.6% 100% 455

55 84.1% 3.6% 3.7% 0.9% 5.3% 2.3% 100% 749

60 83.6% 4.8% 3.0% 0.4% 5.8% 2.4% 100% 1256

65 83.9% 5.3% 3.8% 0.3% 5.0% 1.8% 100% 1367

70 84.6% 4.8% 4.6% 0.2% 4.6% 1.3% 100% 1534

75 82.7% 5.6% 4.1% 0.2% 4.4% 3.0% 100% 1419

80 78.5% 5.8% 6.6% 0.3% 5.7% 3.1% 100% 1135

85+ 77.9% 3.9% 7.3% 0.1% 7.8% 2.9% 100% 793

All males 82.5% 4.6% 4.8% 0.3% 5.3% 2.3% 100% 9,571 Table 6.1-3, place o frst presentation by age band, or males.

Females, by ageband Practice Out patients A&E Walk-in centre Other Not Known Total n

0-24 82.2% 1.1% 6.7% 3.3% 1.1% 5.6% 100% 90

25 84.6% 1.5% 4.6% 0.0% 4.6% 4.6% 100% 65

30 93.6% 1.8% 0.9% 0.0% 2.8% 0.9% 100% 109

35 88.1% 2.5% 2.1% 0.0% 5.3% 2.1% 100% 243

40 90.8% 1.2% 2.4% 0.0% 3.3% 2.4% 100% 424

45 91.4% 2.2% 1.9% 0.2% 2.7% 1.6% 100% 625

50 83.8% 3.2% 3.2% 0.0% 7.8% 1.9% 100% 616

55 85.9% 3.3% 2.3% 0.5% 7.0% 1.0% 100% 789

60 83.9% 3.3% 3.2% 0.1% 6.7% 2.9% 100% 947

65 83.6% 2.6% 3.0% 0.1% 7.5% 3.1% 100% 953

70 85.4% 4.1% 4.9% 0.1% 3.6% 1.8% 100% 1037

75 85.2% 3.1% 4.9% 0.2% 4.6% 2.0% 100% 1096

80 79.6% 3.9% 5.6% 0.1% 8.1% 2.7% 100% 940

85+ 77.7% 2.8% 6.7% 0.1% 10.3% 2.4% 100% 955

All females 84.3% 3.1% 4.0% 0.2% 6.2% 2.2% 100% 8889 Table 6.1-4, place o frst presentation by age band, or emales.

Communication difficulty? Practice Out patients A&E Walk-in centre Other Not Known Total n

None 84.3% 3.8% 4.3% 0.2% 5.4% 1.9% 100% 17252

Communication difficulty 74.0% 4.8% 6.9% 0.4% 10.4% 3.5% 100% 1142

Not known 69.1% 4.1% 4.9% 0.2% 5.8% 15.9% 100% 485

Total 83.3% 3.9% 4.5% 0.3% 5.7% 2.4% 100% 18879 Table 6.1-5, place o frst presentation by presence o communication difculty.

Housebound? Practice Out patients A&E Walk-in centre Other Not Known Total n

No 84.9% 3.9% 3.9% 0.3% 5.1% 1.9% 100% 16876

Yes 68.4% 3.9% 10.9% 0.2% 13.1% 3.5% 100% 1298

Not Known 71.5% 4.7% 6.5% 0.0% 6.0% 11.3% 100% 705

Total 83.3% 3.9% 4.5% 0.3% 5.7% 2.4% 100% 18879 Table 6.1-6, place o frst presentation by housebound status.

20



6.2 GP consultations

Concerns have been expressed about the number o times patients consult with symptoms o cancer beorebeing reerred or specialist assessment.10 Participating practices were asked to count all consultationsrelating to the presenting problem that was associated with the patient’s cancer. Most patients (66%)included in the audit consulted their GP one or two times beore reerral. However 4% consulted fve ormore times, and 9.5% did not consult at all. Those cancer sites where more than 20% o patients had threeor more consultations included lung (including mesothelioma), lymphoma, myeloma, ovary, pancreas andstomach. This was also the case or males aged 25-29.

6.2.1 By cancer type

Cancer type 0 1 2 3 4 5+ Not known Total n

Bladder 9.0% 47.0% 22.6% 6.8% 2.1% 3.6% 8.9% 100% 920

Brain 14.1% 38.5% 16.2% 7.3% 3.8% 5.6% 14.5% 100% 234

Breast 11.7% 72.2% 5.3% 1.4% 0.6% 0.5% 8.4% 100% 3046Cervical 5.9% 52.6% 17.8% 9.2% 3.3% 4.6% 6.6% 100% 152

Colorectal 9.1% 42.4% 22.5% 9.7% 3.7% 4.8% 7.8% 100% 2566

Endometrial 9.0% 61.8% 15.2% 6.0% 0.9% 1.4% 5.7% 100% 435

Gallbladder 7.1% 30.0% 22.9% 10.0% 4.3% 4.3% 21.4% 100% 70

Laryngeal 8.5% 41.9% 23.3% 12.4% 1.6% 3.9% 8.5% 100% 129

Leukaemia 9.8% 42.7% 20.0% 7.1% 3.7% 3.3% 13.4% 100% 574

Liver 13.1% 33.8% 19.2% 6.9% 4.6% 4.6% 17.7% 100% 130

Lung 11.3% 28.9% 24.1% 11.0% 6.2% 7.3% 11.1% 100% 2014

Lymphoma 8.4% 40.0% 21.2% 9.6% 4.2% 8.0% 8.6% 100% 760

Melanoma 7.9% 68.5% 13.1% 2.8% 0.7% 1.4% 5.7% 100% 878

Mesothelioma 10.1% 32.9% 26.6% 15.2% 2.5% 7.6% 5.1% 100% 79

Myeloma 6.7% 24.6% 20.2% 8.7% 9.9% 14.3% 15.5% 100% 252

Oesophageal 7.2% 44.6% 23.5% 10.9% 5.2% 3.2% 5.4% 100% 596

Oropharyngeal 8.7% 43.2% 20.5% 11.8% 2.6% 3.1% 10.0% 100% 229

Ovarian 9.7% 37.0% 22.5% 11.8% 4.7% 5.7% 8.5% 100% 422

Pancreatic 8.5% 32.6% 24.6% 10.5% 6.4% 9.2% 8.2% 100% 390

Prostate 6.8% 40.5% 30.6% 7.7% 2.7% 2.5% 9.1% 100% 2912

Renal 11.8% 35.2% 21.9% 8.3% 3.3% 5.3% 14.3% 100% 398

Sarcoma 9.2% 37.0% 23.5% 11.8% 4.2% 4.2% 10.1% 100% 119

Small Intestine 10.5% 36.8% 28.1% 7.0% 8.8% 3.5% 5.3% 100% 57

Stomach 8.8% 34.2% 19.1% 11.3% 6.3% 8.2% 12.2% 100% 319

Testicular 8.4% 60.8% 18.1% 3.6% 1.2% 0.0% 7.8% 100% 166

Thyroid 7.1% 43.7% 26.2% 5.6% 2.4% 0.8% 14.3% 100% 126

Vulval 7.9% 57.9% 15.8% 1.3% 1.3% 2.6% 13.2% 100% 76

Other 12.0% 43.4% 17.8% 7.6% 3.2% 3.7% 12.3% 100% 567

Unknown Primary 11.1% 31.2% 14.3% 13.2% 6.3% 13.2% 10.6% 100% 189

No Information 5.4% 8.1% 13.5% 2.7% 1.4% 1.4% 67.6% 100% 74

Total 9.4% 46.3% 20.0% 7.5% 3.2% 4.0% 9.5% 100% 18879

Sex 0 1 2 3 4 5+ Not known Total n

Male 9.2% 41.8% 23.9% 8.2% 3.3% 4.1% 9.5% 100% 9759

Female 9.7% 51.2% 15.7% 6.8% 3.2% 3.9% 9.4% 100% 9066

Not Known 9.3% 42.6% 13.0% 0.0% 1.9% 5.6% 27.8% 100% 54

Total 9.4% 46.3% 20.0% 7.5% 3.2% 4.0% 9.5% 100% 18879 Table 6.2-2, number o attendances at GP by sex.

Table 6.2-1, number o attendances at GP by cancer type.

6.2.2 Association with demographics

21



Males, by ageband 0 1 2 3 4 5+ Not known Total n

0-24 6.5% 50.9% 21.3% 5.6% 2.8% 3.7% 9.3% 100% 108

25 3.2% 52.4% 9.5% 12.7% 6.3% 3.2% 12.7% 100% 63

30 6.4% 46.8% 25.5% 8.5% 0.0% 1.1% 11.7% 100% 94

35 5.4% 49.6% 23.3% 7.8% 3.1% 3.1% 7.8% 100% 129

40 9.6% 48.7% 19.8% 8.1% 2.0% 1.5% 10.2% 100% 197

45 9.6% 45.6% 21.0% 7.7% 3.7% 4.4% 8.1% 100% 272

50 10.1% 39.6% 24.8% 9.2% 2.2% 4.0% 10.1% 100% 455

55 8.4% 43.7% 25.5% 7.9% 2.0% 3.9% 8.7% 100% 749

60 9.5% 42.5% 23.9% 8.7% 3.6% 3.6% 8.3% 100% 1256

65 8.6% 39.8% 26.3% 9.1% 3.6% 3.7% 8.9% 100% 1367

70 8.0% 41.3% 26.2% 7.5% 3.7% 4.4% 8.9% 100% 1534

75 8.7% 42.6% 21.6% 8.1% 3.4% 5.2% 10.4% 100% 1419

80 11.5% 38.6% 24.6% 7.1% 3.5% 4.5% 10.1% 100% 1135

85+ 10.2% 41.1% 19.9% 10.1% 3.2% 3.9% 11.6% 100% 793

All males 9.1% 41.8% 23.9% 8.3% 3.3% 4.1% 9.5% 100% 9571 Table 6.2-3, number o attendances at GP by age band, or males.

Females, by ageband 0 1 2 3 4 5+ Not known Total n

0-24 7.8% 36.7% 26.7% 11.1% 3.3% 4.4% 10.0% 100% 90

25 6.2% 52.3% 16.9% 6.2% 1.5% 7.7% 9.2% 100% 65

30 8.3% 51.4% 19.3% 8.3% 0.9% 2.8% 9.2% 100% 109

35 5.8% 58.8% 15.6% 6.2% 2.5% 5.3% 5.8% 100% 243

40 7.8% 61.3% 13.9% 5.2% 2.4% 2.4% 7.1% 100% 424

45 7.8% 61.4% 12.5% 6.9% 2.7% 2.4% 6.2% 100% 625

50 9.7% 56.5% 13.3% 4.4% 3.6% 3.4% 9.1% 100% 616

55 9.4% 54.2% 16.3% 6.1% 2.0% 3.5% 8.4% 100% 789

60 10.9% 50.3% 15.7% 6.3% 3.5% 4.5% 8.8% 100% 947

65 10.1% 49.4% 15.6% 6.9% 4.5% 4.7% 8.7% 100% 953

70 10.0% 47.2% 19.5% 6.8% 3.1% 4.1% 9.3% 100% 1037

75 8.7% 47.0% 17.5% 8.1% 4.5% 4.3% 9.9% 100% 1096

80 11.3% 51.7% 14.3% 6.7% 3.0% 3.9% 9.1% 100% 940

85+ 11.8% 45.3% 13.2% 7.7% 2.6% 3.8% 15.5% 100% 955

All females 9.8% 51.3% 15.7% 6.8% 3.2% 3.9% 9.4% 100% 8889 Table 6.2-4, number o attendances at GP by age band, or emales.

Communication difficulty 0 1 2 3 4 5+ Not known Total n

None 9.3% 47.1% 20.2% 7.4% 3.3% 3.9% 8.8% 100% 17252

Communication difficulty 11.9% 40.5% 18.0% 8.0% 3.1% 4.9% 13.6% 100% 1142

Not known 9.7% 33.6% 14.6% 9.3% 3.3% 4.3% 25.2% 100% 485

Total 9.4% 46.3% 20.0% 7.5% 3.2% 4.0% 9.5% 100% 18879 Table 6.2-5, number o attendances at GP by presence o communication difculty.

Table 6.2-6, number o attendances at GP by housebound status.

Ethnic category 0 1 2 3 4 5+ Not known Total n

White British 9.1% 46.4% 20.1% 7.6% 3.3% 4.1% 9.3% 100% 14644

White other 11.7% 47.0% 20.0% 5.6% 3.0% 3.8% 9.0% 100% 837

Nonwhite 9.5% 46.2% 18.6% 8.7% 3.0% 3.9% 10.1% 100% 1159

Not Known 10.5% 45.9% 19.5% 6.8% 3.0% 3.5% 10.7% 100% 2239

Total 9.4% 46.3% 20.0% 7.5% 3.2% 4.0% 9.5% 100% 18879 Table 6.2-7, number o attendances at GP by ethnic category.

Housebound? 0 1 2 3 4 5+ Not known Total n

No 9.0% 47.7% 20.4% 7.5% 3.3% 3.9% 8.3% 100% 16876

Yes 13.6% 37.0% 15.6% 7.4% 3.2% 4.9% 18.4% 100% 1298

Not Known 12.1% 31.8% 16.6% 9.1% 3.0% 5.0% 22.6% 100% 705

Total 9.4% 46.3% 20.0% 7.5% 3.2% 4.0% 9.5% 100% 18879

22



6.3 Presenting symptom

Participants were asked to record the primary symptom with which the patient presented. The ollowingtables contain data on the requency o symptoms or the our most common cancers. Some inconsistenciesexist in the completion o this feld; or example, the meaning o ‘asymptomatic’ probably mean that thecancer was an incidental fnding but a raised PSA implies some pre-existing symptom that prompted this testto be done.

Breast cancer

Symptom % n

asymptomatic 5.0% 152

breast abscess 0.3% 8

breast pain 4.4% 134

change to breast appearance 3.7% 114change to nipple appearance 2.9% 87

fatigue 0.3% 8

lump in breast 74.0% 2254

neck pain 0.1% 2

nipple discharge 2.1% 63

not known 3.3% 100

other 3.6% 109

shortness of breath 0.3% 8

weight loss 0.2% 7

Total 100.0% 3046

Colorectal cancer

Table 6.3-1, raction o presentations by symptom group, or breast cancer.

Symptom % n

abdominal pain 14.8% 381

anaemia 9.0% 232


bowel obstruction 1.5% 38change in bowel habit 26.4% 678

epigastric pain 0.4% 10

fatigue 4.6% 118

nausea 0.5% 13

not known 2.2% 56

other 6.6% 170

rectal hemorrhage 24.6% 632

rectal pain 1.2% 30


weight loss 3.3% 84

Total 100.0% 2566 Table 6.3-2, raction o presentations by symptom group, or colorectal cancer.

23



Lung cancer

Symptom % n

abdominal pain 1.5% 30


chest infection 5.2% 104

chest pain 6.6% 132

chronic bronchitis, emphysema 2.0% 40

cough 25.2% 507

fatigue 6.5% 130

haemoptysis 7.4% 149

hoarse voice 1.3% 27

lymphadenopathy 1.3% 27

musculoskeletal pain 5.1% 102

not known 3.3% 67

other 8.7% 176


weight loss 4.7% 94

Total 100.0% 2014 Table 6.3-3, raction o presentations by symptom group, or lung cancer.

Prostate cancer

Symptom % n


blood in the semen 0.5% 14

blood in the urine 5.5% 160

bone pain 1.4% 40

change in bowel habit 0.9% 26

enlargement of the prostate 8.4% 246

erectile dysfunction 1.7% 50

fatigue 1.6% 46genitourinary tract pain 1.8% 51

incontinence 0.6% 18

lower urinary tract symptoms 32.0% 931

not known 3.1% 89

other 10.6% 309

painful urination 2.0% 59

raised psa 17.4% 508

urine retention 4.2% 121

weight loss 1.5% 44

Total 100.0% 2912 Table 6.3-4, raction o presentations by symptom group, or prostate cancer.

24



6.4 Use of Investigations

GPs oten use diagnostic services to investigate suspected cancer. In some cases this is advocated as a frststep by NICE guidance, as or some lung symptoms. In others they allow the risk o cancer as the underlyingcause o symptoms to be clarifed. Access to investigations varies widely by PCT and Improving Outcomes:a Strategy for Cancer (2011) contains a commitment to improve access to chest X-ray, non-obstetricultrasound, GI endoscopy and brain MRI. In this audit we ound that blood tests, chest X-ray and ultrasoundexamination were the most commonly used diagnostic tests. As might be expected, these varied accordingto cancer site, but also according to presenting symptom.

Rapid access to investigations would have altered the GP’s management o the patient in 6% o cases.Some cancer patients, however, were more likely to have benefted rom better access to diagnostics. Theseincluded patients with brain, ovary, pancreas, liver and kidney cancer.

6.4.1 Tumour type

All Breast Colorectal Lung Prostate Haematology Other

Blood Test 33.1% 2.0% 41.5% 24.6% 74.0% 52.3% 24.4%

CT 1.1% 0.2% 0.8% 4.0% 0.2% 0.7% 1.2%

CXR 10.3% 1.7% 2.5% 61.0% 3.0% 14.8% 4.1%

Endoscopy 1.1% 0.0% 3.5% 0.4% 0.1% 0.5% 1.4%

MRI 0.2% 0.1% 0.0% 0.3% 0.2% 0.6% 0.3%

USS 6.7% 0.5% 5.4% 2.2% 3.2% 6.1% 12.9% Table 6.4-1, raction o cases o specifed cancer type with an investigation ordered by the GP, by investigation type (i.e.,74.0% o prostate cancer patients have a blood test). Multiple investigations o dierent types in a single patient will becounted more than once.

6.4.2 Association with presenting symptom

Breast cancer

Symptom Chest X-ray Ultrasound MRI Blood test CT Endoscopy n

asymptomatic 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 152

breast abscess 0.0% 0.0% 0.0% 12.5% 0.0% 0.0% 8

breast pain 0.7% 0.0% 0.0% 2.2% 0.0% 0.0% 134

change to breast appearance 0.0% 1.8% 0.0% 3.5% 0.0% 0.0% 114

change to nipple appearance 1.1% 1.1% 0.0% 0.0% 0.0% 0.0% 87

fatigue 0.0% 0.0% 0.0% 25.0% 0.0% 0.0% 8lump in breast 0.2% 0.1% 0.0% 0.6% 0.0% 0.0% 2254

neck pain 0.0% 0.0% 50.0% 0.0% 0.0% 0.0% 2

nipple discharge 0.0% 0.0% 0.0% 3.2% 0.0% 0.0% 63

not known 0.0% 0.0% 0.0% 2.0% 0.0% 0.0% 100

other 35.8% 8.3% 2.8% 27.5% 2.8% 0.0% 109

shortness of breath 50.0% 0.0% 0.0% 12.5% 12.5% 0.0% 8

weight loss 28.6% 14.3% 0.0% 42.9% 0.0% 0.0% 7

Total 1.7% 0.5% 0.1% 2.0% 0.2% 0.0% 3046 Table 6.4-2, percentage o cases presenting with symptom groups by type o investigation undertaken, or breast cancer.

25



Colorectal cancer


abdominal pain 2.1% 16.3% 0.0% 39.9% 1.3% 2.4% 381

anaemia 1.3% 2.2% 0.0% 64.2% 0.9% 4.7% 232asymptomatic 1.3% 2.6% 0.0% 33.8% 1.3% 3.9% 77

bowel obstruction 2.6% 0.0% 0.0% 5.3% 0.0% 2.6% 38

change in bowel habit 1.3% 1.8% 0.0% 42.3% 1.0% 3.5% 678

epigastric pain 10.0% 20.0% 0.0% 60.0% 0.0% 10.0% 10

fatigue 5.1% 9.3% 0.0% 82.2% 0.8% 2.5% 118

nausea 7.7% 38.5% 0.0% 76.9% 0.0% 0.0% 13

not known 0.0% 0.0% 0.0% 8.9% 0.0% 1.8% 56

other 10.6% 12.4% 0.0% 43.5% 1.8% 2.9% 170

rectal hemorrhage 0.3% 0.9% 0.2% 26.4% 0.0% 4.7% 632

rectal pain 0.0% 6.7% 0.0% 20.0% 0.0% 0.0% 30


weight loss 7.1% 10.7% 0.0% 57.1% 2.4% 1.2% 84

Total 2.5% 5.4% 0.0% 41.6% 0.8% 3.5% 2566 Table 6.4-3, percentage o cases presenting with symptom groups by type o investigation undertaken, or colorectal cancer.

Lung cancer


abdominal pain 30.0% 23.3% 0.0% 50.0% 3.3% 0.0% 30

asymptomatic 14.3% 0.8% 0.0% 9.5% 0.8% 0.0% 126

chest infection 58.7% 1.0% 0.0% 12.5% 5.8% 0.0% 104

chest pain 60.6% 2.3% 1.5% 24.2% 6.1% 0.0% 132

chronic bronchitis, emphysema 40.0% 0.0% 0.0% 10.0% 2.5% 0.0% 40

cough 85.2% 0.2% 0.2% 21.1% 4.3% 0.4% 507

fatigue 32.3% 0.8% 0.8% 46.2% 3.1% 0.8% 130

haemoptysis 78.5% 0.0% 0.0% 11.4% 3.4% 0.0% 149

hoarse voice 48.1% 0.0% 0.0% 14.8% 0.0% 0.0% 27

lymphadenopathy 51.9% 14.8% 0.0% 55.6% 0.0% 0.0% 27

musculoskeletal pain 61.8% 4.9% 2.0% 34.3% 2.9% 1.0% 102

not known 13.4% 3.0% 0.0% 3.0% 0.0% 0.0% 67

other 30.1% 4.0% 0.0% 24.4% 5.7% 0.6% 176


weight loss 69.1% 7.4% 0.0% 57.4% 4.3% 2.1% 94

Total 58.4% 2.1% 0.3% 23.4% 3.9% 0.4% 2014 Table 6.4-4, percentage o cases presenting with symptom groups by type o investigation undertaken, or lung cancer.

Prostate cancer


asymptomatic 0.5% 1.0% 0.0% 73.5% 0.0% 0.5% 200

blood in the semen 0.0% 7.1% 0.0% 71.4% 0.0% 0.0% 14

blood in the urine 0.0% 6.3% 0.0% 50.0% 0.0% 0.6% 160

bone pain 45.0% 0.0% 0.0% 67.5% 0.0% 0.0% 40

change in bowel habit 3.8% 7.7% 0.0% 88.5% 0.0% 0.0% 26

enlargement of the prostate glan 0.8% 3.3% 0.0% 87.4% 0.0% 0.0% 246

erectile dysfunction 0.0% 0.0% 0.0% 86.0% 0.0% 0.0% 50

fatigue 6.5% 4.3% 0.0% 76.1% 0.0% 0.0% 46

genitourinary tract pain 11.8% 17.6% 3.9% 78.4% 0.0% 0.0% 51

incontinence 0.0% 0.0% 0.0% 72.2% 0.0% 0.0% 18

lower urinary tract symptoms 0.4% 2.6% 0.0% 87.9% 0.0% 0.0% 931

not known 0.0% 0.0% 0.0% 22.5% 0.0% 0.0% 89

other 12.0% 5.5% 0.6% 74.1% 1.0% 0.3% 309

painful urination 0.0% 1.7% 0.0% 81.4% 0.0% 0.0% 59

raised psa 1.0% 2.2% 0.2% 66.9% 0.4% 0.0% 508urine retention 0.0% 1.7% 0.0% 23.1% 0.0% 0.0% 121

weight loss 22.7% 9.1% 0.0% 90.9% 0.0% 0.0% 44

Total 3.0% 3.2% 0.2% 74.0% 0.2% 0.1% 2912 Table 6.4-5, percentage o cases presenting with symptom groups by type o investigation undertaken, or prostate cancer.26



6.4.3 Change in management

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

F r a c t i o n o

f a l l c a s e s

Figure 6.4-1, percentage o cases in which access to investigation would have changed GP management, by cancer type. 95%confdence intervals are shown.

27



Cancer type Blood tests CT Endoscopy MRI USS XRay Not Known Total

Bladder 1 5 11 2 14 0 8 41

Brain 0 22 0 23 0 1 1 47

Breast 1 7 0 6 25 12 15 66Cervical 0 1 1 0 4 0 2 8

Colorectal 11 45 128 3 21 8 13 229

Endometrial 0 2 1 1 26 0 1 31

Gallbladder 0 5 3 0 3 0 0 11

Laryngeal 0 1 4 0 1 0 0 6

Leukaemia 6 3 0 0 2 0 5 16

Liver 0 11 1 1 5 0 0 18

Lung 3 64 2 10 3 45 9 136

Lymphoma 2 29 2 9 15 1 4 62

Melanoma 0 0 1 2 2 0 11 16

Mesothelioma 0 1 0 0 0 1 0 2

Myeloma 3 1 0 8 0 0 1 13

Oesophageal 3 4 42 1 1 2 2 55

Oropharyngeal 0 2 0 0 4 1 2 9

Ovarian 1 19 1 2 33 0 1 57

Pancreatic 0 30 3 1 17 0 0 51

Prostate 36 4 2 9 19 1 12 83

Renal 1 18 2 7 18 1 2 49

Sarcoma 0 1 0 2 7 0 1 11

Small Intestine 1 0 1 0 1 0 0 3

Stomach 0 4 29 1 4 0 1 39

Testicular 0 1 0 0 18 0 0 19

Thyroid 0 1 0 0 12 0 1 14

Vulval 0 0 0 0 0 0 2 2

Other 4 12 3 7 18 1 3 48

Unknown Primary 0 7 1 2 3 0 1 14

No Information 0 1 0 1 0 0 0 2

Total 73 301 238 98 276 74 98 1158

Investigation type for cases which would have changed management

Table 6.4-6, investigation type or cases in which access to investigation would have changed management, by cancer type.

All Breast Colorectal Lung Prostate Haemo Other Brain

Blood tests 0.4% 0.0% 0.4% 0.1% 1.2% 0.7% 0.2% 0.0%

CT 1.7% 0.2% 1.7% 3.2% 0.1% 2.1% 2.2% 9.4%

X-Ray 1.3% 0.0% 5.0% 0.1% 0.1% 0.1% 1.6% 0.4%

Endoscopy 0.5% 0.2% 0.1% 0.5% 0.3% 1.1% 0.8% 0.0%

MRI 1.6% 0.8% 0.8% 0.1% 0.7% 1.1% 2.9% 9.8%USS 0.4% 0.4% 0.3% 2.3% 0.0% 0.1% 0.1% 0.0%

Unknown 0.5% 0.5% 0.5% 0.4% 0.4% 0.6% 0.6% 0.4%

Total 6.4% 2.2% 8.9% 6.9% 2.9% 5.7% 8.4% 20.1% Table 6.4-7, the investigations which would have changed management. The fgures are the number o investigations orwhich management would have been changed with a denominator all cancers o that type by all cases, by cancer type.

6.5 Routes to diagnosis

An urgent reerral pathway or suspected cancer has now been in operation since 2000, with supportingcriteria or reerral being provided by NICE. Nevertheless, patients enter the secondary care system in

other ways as well. Those being reerred as an emergency are a particular concern because o the pooreroutcomes that are associated with this route to diagnosis.11

28



Overall, over hal o all cases were reerred through the two week urgent reerral pathway, while 12.9%were reerred as an emergency. A proportion o these will have entered secondary care as an emergencywithout having been in contact with primary care. These are likely to also be patients with zero visits to theGP (Table 6.2.1). Emergency presentations were particularly high in the 0-24 age group, and or brain, leu-kaemia, liver, myeloma and pancreas. Two week reerrals less likely or some cancers, notably being less than40% o the total or brain, leukaemia, liver, and myeloma.

6.5.1 Demographic features

Sex Emergency 2 week Routine PrivateNot referred by

practiceNot known Total n

Male 13.1% 50.8% 17.1% 4.9% 7.3% 6.8% 100% 9759

Female 12.7% 57.3% 12.2% 5.0% 6.7% 6.1% 100% 9066

Not Known 13.0% 48.1% 14.8% 0.0% 1.9% 22.2% 100% 54

Total 12.9% 53.9% 14.8% 4.9% 7.0% 6.5% 100% 18879 Table 6.5-1, type o reerral, by sex o patient.

Males, by ageband Emergency 2 week Routine PrivateNot referred by


0-24 39.8% 25.0% 11.1% 2.8% 10.2% 11.1% 100% 108

25 12.7% 49.2% 17.5% 6.3% 6.3% 7.9% 100% 63

30 20.2% 42.6% 14.9% 4.3% 11.7% 6.4% 100% 94

35 15.5% 50.4% 18.6% 4.7% 3.9% 7.0% 100% 129

40 15.2% 48.2% 13.7% 7.1% 8.6% 7.1% 100% 197

45 16.5% 46.7% 19.1% 5.1% 7.4% 5.1% 100% 272

50 11.4% 48.4% 18.7% 7.3% 7.0% 7.3% 100% 455

55 12.3% 49.7% 16.8% 7.7% 7.3% 6.1% 100% 749

60 11.2% 51.4% 18.2% 6.1% 7.2% 5.9% 100% 1256

65 10.3% 52.4% 19.4% 6.1% 5.9% 6.0% 100% 1367

70 11.5% 54.0% 18.2% 3.6% 6.8% 5.9% 100% 1534

75 11.6% 54.1% 16.3% 3.8% 7.5% 6.7% 100% 141980 15.8% 47.9% 15.7% 3.3% 8.5% 8.8% 100% 1135

85+ 18.5% 47.3% 13.7% 3.7% 8.6% 8.2% 100% 793

All males 13.1% 50.7% 17.2% 4.9% 7.3% 6.7% 100% 9571 Table 6.5-2, type o reerral, by age band o patient, or males.

Females, by ageband Emergency 2 week Routine PrivateNot referred by


0-24 45.6% 24.4% 14.4% 5.6% 4.4% 5.6% 100% 90

25 7.7% 50.8% 20.0% 1.5% 10.8% 9.2% 100% 65

30 10.1% 49.5% 24.8% 4.6% 3.7% 7.3% 100% 109

35 9.9% 53.1% 18.1% 7.4% 5.3% 6.2% 100% 243

40 7.3% 59.4% 11.8% 10.4% 6.1% 5.0% 100% 424

45 10.1% 62.6% 14.2% 6.4% 2.6% 4.2% 100% 625

50 9.6% 55.4% 15.1% 6.0% 7.0% 7.0% 100% 616

55 9.9% 59.8% 12.7% 6.2% 5.8% 5.6% 100% 789

60 12.5% 57.3% 11.0% 6.5% 7.0% 5.7% 100% 947

65 12.3% 57.6% 12.9% 5.1% 5.7% 6.4% 100% 953

70 12.2% 60.1% 12.2% 3.3% 6.9% 5.4% 100% 1037

75 13.0% 60.1% 10.7% 3.0% 7.7% 5.5% 100% 1096

80 15.9% 56.1% 9.5% 3.5% 8.7% 6.4% 100% 940

85+ 17.1% 53.0% 10.5% 3.5% 7.7% 8.3% 100% 955

All females 12.7% 57.4% 12.2% 5.0% 6.6% 6.1% 100% 8889 Table 6.5-3, type o reerral, by age band o patient, or emales.

Communi cati on di ff icul ty Emergency 2 week Routi ne Pri vateNot referred by


None 12.6% 54.5% 14.9% 5.1% 6.8% 6.0% 100% 17252Communication difficulty 17.1% 48.7% 13.3% 2.4% 9.6% 8.9% 100% 1142

Not known 11.5% 44.5% 12.2% 3.9% 7.2% 20.6% 100% 485

Total 12.9% 53.9% 14.8% 4.9% 7.0% 6.5% 100% 18879 Table 6.5-4, type o reerral, by presence o communication difculty. 29



Housebound? Emergency 2 week Routine PrivateNot referred by


No 12.0% 55.4% 15.2% 5.2% 6.5% 5.7% 100% 16876

Yes 22.9% 41.3% 10.2% 2.4% 12.2% 10.9% 100% 1298

Not Known 15.6% 40.7% 13.6% 3.5% 8.5% 18.0% 100% 705

Total 12.9% 53.9% 14.8% 4.9% 7.0% 6.5% 100% 18879 Table 6.5-5, type o reerral, by housebound status.

6.5.2 Tumour type

Cancer type Emergency 2 week Routine PrivateNot referred by


Bladder 7.8% 58.8% 15.8% 5.7% 6.2% 5.8% 100% 920

Brain 39.3% 12.8% 17.5% 4.7% 15.0% 10.7% 100% 234

Breast 3.7% 75.9% 5.8% 4.9% 5.0% 4.7% 100% 3046

Cervical 15.1% 49.3% 19.7% 2.0% 8.6% 5.3% 100% 152

Colorectal 14.8% 51.4% 16.4% 5.1% 6.5% 5.7% 100% 2566

Endometrial 6.0% 64.6% 15.9% 6.4% 3.9% 3.2% 100% 435Gallbladder 20.0% 34.3% 18.6% 5.7% 12.9% 8.6% 100% 70

Laryngeal 7.8% 59.7% 21.7% 1.6% 7.8% 1.6% 100% 129

Leukaemia 30.7% 22.1% 24.9% 2.8% 10.5% 9.1% 100% 574

Liver 27.7% 34.6% 11.5% 3.8% 13.1% 9.2% 100% 130

Lung 20.3% 49.0% 8.2% 2.2% 11.4% 8.9% 100% 2014

Lymphoma 17.8% 41.4% 18.8% 6.4% 8.2% 7.4% 100% 760

Melanoma 4.7% 66.5% 16.4% 5.5% 4.0% 3.0% 100% 878

Mesothelioma 29.1% 48.1% 10.1% 3.8% 7.6% 1.3% 100% 79

Myeloma 28.2% 33.3% 17.9% 2.8% 8.3% 9.5% 100% 252

Oesophageal 9.9% 58.2% 17.3% 3.7% 3.2% 7.7% 100% 596

Oropharyngeal 7.4% 58.5% 12.2% 5.7% 9.2% 7.0% 100% 229

Ovarian 23.0% 47.4% 8.1% 8.5% 6.9% 6.2% 100% 422

Pancreatic 29.0% 40.8% 12.3% 5.6% 7.2% 5.1% 100% 390

Prostate 6.6% 55.5% 21.5% 5.5% 5.1% 5.8% 100% 2912

Renal 13.1% 49.0% 12.8% 5.8% 11.8% 7.5% 100% 398

Sarcoma 14.3% 41.2% 17.6% 8.4% 8.4% 10.1% 100% 119

Small Intestine 19.3% 29.8% 14.0% 14.0% 10.5% 12.3% 100% 57

Stomach 21.0% 40.4% 17.6% 4.4% 7.8% 8.8% 100% 319

Testicular 10.2% 56.6% 7.8% 9.6% 10.8% 4.8% 100% 166

Thyroid 7.9% 42.1% 27.8% 9.5% 7.9% 4.8% 100% 126

Vulval 5.3% 65.8% 18.4% 1.3% 5.3% 3.9% 100% 76

Other 15.9% 38.1% 23.3% 6.2% 8.1% 8.5% 100% 567

Unknown Primary 30.2% 36.0% 14.8% 2.6% 10.6% 5.8% 100% 189

No Information 10.8% 12.2% 5.4% 0.0% 1.4% 70.3% 100% 74

Total 12.9% 53.9% 14.8% 4.9% 7.0% 6.5% 100% 18879 Table 6.5-6, type o reerral, by cancer type.

Ethnic category Emergency 2 week Routine PrivateNot referred by


White British 12.8% 54.7% 15.1% 4.9% 6.7% 5.9% 100% 14644

White other 15.2% 47.3% 13.9% 5.7% 9.8% 8.1% 100% 837

Nonwhite 15.5% 50.9% 14.8% 3.5% 7.7% 7.6% 100% 1159

Not Known 11.3% 52.8% 13.3% 5.5% 7.5% 9.6% 100% 2239

Total 12.9% 53.9% 14.8% 4.9% 7.0% 6.5% 100% 18879 Table 6.5-7, type o reerral, by ethnic category.

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6.5.3 Presenting symptom

Breast cancer

Symptom Emergency 2 week Routine PrivateNot referred by


asymptomatic 10.5% 23.7% 2.6% 1.3% 44.1% 17.8% 100% 152

breast abscess 12.5% 75.0% 0.0% 12.5% 0.0% 0.0% 100% 8

breast pain 4.5% 69.4% 17.9% 4.5% 0.7% 3.0% 100% 134

change to breast appearance 4.4% 72.8% 10.5% 1.8% 7.0% 3.5% 100% 114

change to nipple appearance 3.4% 82.8% 8.0% 2.3% 2.3% 1.1% 100% 87

fatigue 62.5% 12.5% 25.0% 0.0% 0.0% 0.0% 100% 8

lump in breast 1.9% 84.3% 4.7% 5.2% 1.8% 2.2% 100% 2254

neck pain 50.0% 50.0% 0.0% 0.0% 0.0% 0.0% 100% 2

nipple discharge 3.2% 66.7% 12.7% 9.5% 4.8% 3.2% 100% 63

not known 5.0% 19.0% 0.0% 3.0% 23.0% 50.0% 100% 100

other 21.1% 48.6% 14.7% 8.3% 4.6% 2.8% 100% 109

shortness of breath 37.5% 37.5% 0.0% 0.0% 12.5% 12.5% 100% 8

weight loss 0.0% 57.1% 0.0% 0.0% 14.3% 28.6% 100% 7

Total 3.7% 75.9% 5.8% 4.9% 5.0% 4.7% 100% 3046 Table 6.5-8, type o reerral with symptom groups by type o investigation, or breast cancer.

Colorectal cancer



abdominal pain 27.8% 37.8% 14.2% 6.3% 7.9% 6.0% 100% 381

anaemia 13.4% 51.3% 17.2% 3.4% 9.5% 5.2% 100% 232

asymptomatic 3.9% 37.7% 6.5% 1.3% 29.9% 20.8% 100% 77

bowel obstruction 50.0% 23.7% 0.0% 0.0% 15.8% 10.5% 100% 38

change in bowel habit 9.1% 63.3% 15.8% 5.6% 3.4% 2.8% 100% 678

epigastric pain 30.0% 10.0% 40.0% 10.0% 0.0% 10.0% 100% 10

fatigue 17.8% 50.0% 16.1% 6.8% 5.1% 4.2% 100% 118

nausea 23.1% 46.2% 15.4% 0.0% 7.7% 7.7% 100% 13

not known 7.1% 17.9% 5.4% 0.0% 23.2% 46.4% 100% 56

other 19.4% 51.2% 11.8% 3.5% 7.1% 7.1% 100% 170

rectal hemorrhage 9.8% 52.4% 23.3% 6.8% 4.0% 3.8% 100% 632

rectal pain 23.3% 50.0% 16.7% 0.0% 6.7% 3.3% 100% 30


weight loss 9.5% 72.6% 10.7% 1.2% 3.6% 2.4% 100% 84

Total 14.8% 51.4% 16.4% 5.1% 6.5% 5.7% 100% 2566 Table 6.5-9, type o reerral with symptom groups by type o investigation, or colorectal cancer.

Lung cancer



abdominal pain 20.0% 46.7% 16.7% 6.7% 10.0% 0.0% 100% 30

asymptomatic 4.8% 27.8% 6.3% 1.6% 41.3% 18.3% 100% 126

chest infection 32.7% 36.5% 6.7% 2.9% 16.3% 4.8% 100% 104

chest pain 25.0% 50.8% 6.1% 3.0% 8.3% 6.8% 100% 132

chronic bronchitis, emphysema 17.5% 40.0% 10.0% 2.5% 17.5% 12.5% 100% 40

cough 14.4% 66.7% 7.1% 1.6% 5.7% 4.5% 100% 507

fatigue 35.4% 26.9% 8.5% 3.8% 12.3% 13.1% 100% 130

haemoptysis 12.1% 68.5% 6.7% 2.0% 6.7% 4.0% 100% 149

hoarse voice 7.4% 66.7% 14.8% 0.0% 3.7% 7.4% 100% 27

lymphadenopathy 14.8% 70.4% 7.4% 0.0% 0.0% 7.4% 100% 27

musculoskeletal pain 19.6% 44.1% 14.7% 2.0% 14.7% 4.9% 100% 102

not known 11.9% 14.9% 4.5% 1.5% 16.4% 50.7% 100% 67

other 26.7% 37.5% 12.5% 4.0% 13.6% 5.7% 100% 176


weight loss 18.1% 63.8% 6.4% 1.1% 3.2% 7.4% 100% 94

Total 20.3% 49.0% 8.2% 2.2% 11.4% 8.9% 100% 2014 Table 6.5-10, type o reerral with symptom groups by type o investigation, or lung cancer.

31



Prostate cancer



asymptomatic 4.0% 47.0% 26.5% 9.0% 8.5% 5.0% 100% 200blood in the semen 0.0% 57.1% 42.9% 0.0% 0.0% 0.0% 100% 14

blood in the urine 6.3% 70.6% 11.9% 7.5% 1.3% 2.5% 100% 160

bone pain 10.0% 67.5% 5.0% 5.0% 5.0% 7.5% 100% 40

change in bowel habit 3.8% 65.4% 15.4% 15.4% 0.0% 0.0% 100% 26

enlargement of the prostate glan 3.3% 60.2% 26.4% 3.7% 2.8% 3.7% 100% 246

erectile dysfunction 2.0% 60.0% 30.0% 6.0% 0.0% 2.0% 100% 50

fatigue 8.7% 65.2% 13.0% 0.0% 6.5% 6.5% 100% 46

genitourinary tract pain 2.0% 68.6% 17.6% 7.8% 3.9% 0.0% 100% 51

incontinence 22.2% 55.6% 11.1% 0.0% 5.6% 5.6% 100% 18

lower urinary tract symptoms 3.9% 61.7% 24.5% 5.0% 1.6% 3.3% 100% 931

not known 2.2% 20.2% 11.2% 2.2% 19.1% 44.9% 100% 89

other 13.9% 58.3% 15.5% 3.9% 4.9% 3.6% 100% 309

painful urination 3.4% 61.0% 25.4% 5.1% 0.0% 5.1% 100% 59

raised psa 2.4% 50.0% 24.0% 7.9% 8.3% 7.5% 100% 508

urine retention 42.1% 11.6% 14.0% 1.7% 19.8% 10.7% 100% 121

weight loss 13.6% 65.9% 11.4% 4.5% 2.3% 2.3% 100% 44

Total 6.6% 55.5% 21.5% 5.5% 5.1% 5.8% 100% 2912 Table 6.5-11, type o reerral with symptom groups by type o investigation, or prostate cancer.

6.6 Commentary

The place o frst presentation varies signifcantly by cancer site. For some, it reects the act that thepresenting symptom can be a medical or surgical emergency. An example is an uncontrolled ft due tobrain cancer, haematemesis (vomiting blood) due to stomach cancer or bowel obstruction due to colorectalcancer. Nevertheless, a proportion o those presenting as an emergency may have delayed seeking medicalhelp rom the GP or may have experienced difculties with access. It is notable that emergency presentation

is more likely in those who are housebound or aged >80 years.

Predictably, those cancers with very specifc presenting symptoms (breast, melanoma) usually only requiredone consultation beore reerral and two thirds o all cases required one or two. The number o consultationsis sometimes taken as a measure o the alacrity with which a diagnosis is reached. However, this measureshould take account o the nature o general practice consultations. These are relatively short, are morecommonly initiated by the patient, make use o interval reassessment, with the results o any diagnostictests ordered only being available ater several days. Nevertheless, it is apparent rom this audit that orsome cancers, typically those with non-specifc and relatively common symptoms, a greater number oconsultations occur beore reerral.

In nearly 10% o cases there were zero consultations. These are likely to be patients who went directlyto A&E or whose cancer was an incidental fnding whilst under specialist care or a co-morbid condition.Patients with communication difculties and those who were housebound were more likely to record zeroconsultations.

The most common presenting symptoms or each o the our main cancers concurred with the NICE criteriaor urgent reerral. It is notable that, o those recorded, haemoptysis was the presenting symptom or lessthan 10% o all cases o lung cancer.

The data on use o investigations and expressed need or better access to diagnostics broadly bears out theimprovements in access proposed in Improving Outcomes: a strategy or cancer. There is one exception,

however, in that or lung cancer this study indicates that only in 0.1% o cases would better access to X-rayhave changed management.

32



Two other reports provide data that can be compared with the fndings o this audit. The National CancerPatient Experience Survey 201012 obtained direct eedback rom 67000 cancer patients who were admittedto hospital in the frst quarter o 2010. It ound that o those patients who saw their GP beore going tohospital, 16% did so three or our times and 9% saw their GP fve or more times. These fndings are broadlysimilar to the audit apart rom the greater proportion consulting fve times or more.

The NCIN Data Briefng on Routes to Diagnosis analysed the route by which patients entered the secondarycare system. It utilised a combination o data rom the National Cancer Data Repository, Cancer WaitingTimes and Hospital Episode Statistics. It ound that 25% o cases were reerred through the two week waitpathway and 23% presented as emergencies. This contrasts with the fndings o this audit that 53.9% werereerred by the two week wait pathway and that 12.9% presented as emergencies. The dierences in thesefndings may be explained by dierences in the patient cohort, dierences in defnitions (two week waitreerral compared to two week wait diagnosis or example), case ascertainment and the exclusion o screen-detected cases. A recent analysis comparing case ascertainment using the National Cancer Data Repositoryand Cancer Waiting Times data has shown that the latter, which might be expected to more closely mirror

those cases that come back to general practice care, similarly underestimates the proportion o emergencypresentations (NCIN personal communication). Nevertheless, these signifcant dierences require urtherdetailed analysis so that uture cancer audits using dierent source data can be reconciled.

33



7.1 Patient interval

Participating practices were asked to estimate rom the clinical records the date when the patient frstdeveloped their presenting symptom. This is not a reliable or consistent method o ascertaining the patientinterval and the data that ollows should be interpreted with considerable caution. For example, in 20% ocases the duration o symptoms was zero days, while or a urther 30% the duration was unknown. Theollowing tables relate the duration o patient delay to demographic eatures, tumour type, reerral routeand presenting symptom (or the our common cancers only).


Sex 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

Male 20.0% 16.7% 10.7% 7.3% 7.4% 4.8% 33.0% 100.0% 9759

Female 19.3% 22.7% 11.3% 7.5% 7.4% 4.6% 27.2% 100.0% 9066

Not known 31.5% 11.1% 5.6% 1.9% 3.7% 7.4% 38.9% 100.0% 54

Total 19.7% 19.6% 11.0% 7.4% 7.4% 4.7% 30.2% 100.0% 18879 Table 7.1-1, patient interval, by sex o patient.

Males , by ageband 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

0-24 24.1% 29.6% 13.9% 3.7% 2.8% 5.6% 20.4% 100.0% 108

25 25.4% 20.6% 11.1% 4.8% 9.5% 7.9% 20.6% 100.0% 63

30 16.0% 26.6% 7.4% 5.3% 12.8% 7.4% 24.5% 100.0% 94

35 15.5% 19.4% 14.0% 7.0% 7.8% 11.6% 24.8% 100.0% 129

40 18.8% 18.8% 11.7% 10.7% 8.6% 7.6% 23.9% 100.0% 197

45 17.3% 19.9% 14.7% 9.2% 8.1% 5.1% 25.7% 100.0% 272

50 16.0% 17.4% 13.0% 9.7% 9.7% 5.7% 28.6% 100.0% 455

55 19.5% 16.8% 10.9% 7.9% 8.8% 5.7% 30.3% 100.0% 749

60 20.1% 16.8% 10.9% 7.9% 7.8% 5.3% 31.2% 100.0% 1256

65 18.9% 16.0% 11.1% 8.0% 7.7% 4.3% 33.9% 100.0% 1367

70 19.8% 16.8% 10.2% 7.0% 7.9% 5.1% 33.2% 100.0% 1534

75 20.4% 15.9% 10.4% 6.6% 6.3% 4.5% 36.0% 100.0% 1419

80 21.4% 15.5% 9.7% 6.0% 6.1% 3.5% 37.8% 100.0% 1135

85+ 23.7% 15.8% 9.6% 5.8% 6.2% 2.9% 36.1% 100.0% 793

All males 20.0% 16.8% 10.8% 7.2% 7.4% 4.8% 33.0% 100.0% 9571 Table 7.1-2, patient interval, by age band o patient, or males.

Females, by ageband 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

0-24 26.7% 28.9% 6.7% 3.3% 8.9% 4.4% 21.1% 100.0% 90

25 18.5% 21.5% 7.7% 7.7% 10.8% 3.1% 30.8% 100.0% 65

30 22.9% 28.4% 10.1% 4.6% 3.7% 10.1% 20.2% 100.0% 109

35 14.8% 31.3% 9.5% 5.3% 9.1% 4.9% 25.1% 100.0% 243

40 12.7% 26.7% 16.5% 10.6% 6.4% 5.7% 21.5% 100.0% 424

45 16.2% 28.5% 11.4% 8.6% 8.8% 6.9% 19.7% 100.0% 625

50 20.5% 21.1% 12.7% 7.0% 8.9% 4.2% 25.6% 100.0% 616

55 19.6% 22.8% 12.7% 8.2% 8.9% 4.4% 23.3% 100.0% 789

60 19.0% 22.5% 10.6% 8.8% 7.8% 3.3% 28.1% 100.0% 947

65 19.5% 22.9% 11.6% 6.9% 8.7% 4.6% 25.7% 100.0% 953

70 18.1% 20.3% 12.3% 7.5% 8.6% 4.5% 28.5% 100.0% 1037

75 21.2% 22.1% 11.2% 7.9% 6.3% 3.1% 28.2% 100.0% 1096

80 21.0% 21.2% 10.5% 7.0% 5.9% 4.6% 29.9% 100.0% 940

85+ 19.9% 20.1% 9.0% 5.5% 4.7% 5.0% 35.7% 100.0% 955

All females 19.2% 22.8% 11.4% 7.5% 7.5% 4.5% 27.2% 100.0% 8889 Table 7.1-3, patient interval, by age band o patient, or emales.

34



Communication difficulty 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

None 19.7% 20.0% 11.1% 7.5% 7.6% 4.8% 29.4% 100.0% 17252

Communication difficulty 21.5% 15.5% 10.2% 6.3% 5.9% 4.2% 36.4% 100.0% 1142

Not known 15.9% 15.1% 9.7% 6.0% 5.6% 3.3% 44.5% 100.0% 485

Total 19.7% 19.6% 11.0% 7.4% 7.4% 4.7% 30.2% 100.0% 18879 Table 7.1-4, patient interval, by presence o communication difculty.

House bound? 0 days 1-14 days 15- 31 days 32-62 days 63-182 days 183+ days Not known Total n

No 19.4% 20.0% 11.3% 7.7% 7.7% 4.8% 29.0% 100.0% 16876

Yes 24.8% 15.6% 8.2% 4.7% 4.5% 4.1% 38.1% 100.0% 1298

Not Known 16.5% 16.2% 8.1% 5.0% 6.4% 2.8% 45.1% 100.0% 705

Total 19.7% 19.6% 11.0% 7.4% 7.4% 4.7% 30.2% 100.0% 18879 Table 7.1-5, patient interval, by housebound status.

Ethni c category 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

White British 19.4% 20.2% 11.2% 7.4% 7.4% 4.6% 29.9% 100.0% 14644

White other 18.8% 18.6% 9.9% 8.1% 8.7% 5.3% 30.6% 100.0% 837

Nonwhite 23.1% 17.7% 10.5% 6.7% 6.8% 5.1% 30.0% 100.0% 1159

Not Known 20.5% 17.0% 10.5% 7.1% 7.4% 4.9% 32.6% 100.0% 2239

Total 19.7% 19.6% 11.0% 7.4% 7.4% 4.7% 30.2% 100.0% 18879 Table 7.1-6, patient interval, by ethnic category.

7.1.2 Tumour type

Cancer type 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

Bladder 29.0% 27.7% 7.4% 3.9% 4.6% 3.5% 23.9% 100.0% 920Brain 21.8% 31.6% 9.8% 5.6% 7.3% 2.6% 21.4% 100.0% 234

Breast 17.2% 32.2% 11.5% 5.9% 5.9% 4.0% 23.3% 100.0% 3046

Cervical 19.7% 15.1% 9.2% 8.6% 12.5% 11.2% 23.7% 100.0% 152

Colorectal 19.2% 16.5% 12.0% 10.8% 11.4% 5.3% 24.8% 100.0% 2566

Endometrial 20.2% 23.9% 10.6% 9.4% 10.1% 6.4% 19.3% 100.0% 435

Gallbladder 25.7% 25.7% 7.1% 2.9% 2.9% 4.3% 31.4% 100.0% 70

Laryngeal 10.1% 12.4% 12.4% 20.9% 13.2% 10.1% 20.9% 100.0% 129

Leukaemia 19.0% 15.9% 8.2% 4.7% 4.2% 3.0% 45.1% 100.0% 574

Liver 18.5% 11.5% 10.8% 7.7% 3.1% 2.3% 46.2% 100.0% 130

Lung 19.3% 19.6% 12.7% 8.2% 6.5% 2.5% 31.2% 100.0% 2014

Lymphoma 16.8% 21.1% 13.8% 9.9% 7.8% 4.9% 25.8% 100.0% 760

Melanoma 17.7% 9.2% 9.5% 7.7% 7.6% 9.6% 38.7% 100.0% 878

Mesothelioma 16.5% 20.3% 22.8% 8.9% 6.3% 5.1% 20.3% 100.0% 79

Myeloma 19.4% 14.7% 11.1% 4.4% 7.1% 3.6% 39.7% 100.0% 252

Oesophageal 15.9% 16.3% 21.8% 11.7% 11.2% 3.0% 20.0% 100.0% 596

Oropharyngeal 13.5% 14.4% 15.3% 14.4% 14.0% 7.0% 21.4% 100.0% 229

Ovarian 16.6% 23.0% 11.6% 8.8% 10.0% 3.3% 26.8% 100.0% 422

Pancreatic 20.3% 26.9% 13.3% 9.0% 8.2% 1.5% 20.8% 100.0% 390

Prostate 22.2% 10.4% 6.7% 5.0% 5.8% 5.3% 44.6% 100.0% 2912

Renal 27.1% 18.6% 8.5% 4.3% 3.8% 3.0% 34.7% 100.0% 398

Sarcoma 22.7% 21.0% 13.4% 6.7% 9.2% 8.4% 18.5% 100.0% 119

Small Intestine 26.3% 19.3% 8.8% 5.3% 17.5% 3.5% 19.3% 100.0% 57

Stomach 23.2% 14.4% 13.5% 6.9% 5.3% 5.0% 31.7% 100.0% 319

Testicular 15.1% 30.7% 10.2% 3.0% 10.8% 9.0% 21.1% 100.0% 166

Thyroid 16.7% 21.4% 13.5% 10.3% 5.6% 9.5% 23.0% 100.0% 126

Vulval 14.5% 19.7% 14.5% 9.2% 10.5% 10.5% 21.1% 100.0% 76

Other 18.9% 14.8% 11.1% 5.1% 7.2% 6.5% 36.3% 100.0% 567

Unknown Primary 28.0% 19.6% 13.8% 4.8% 5.8% 1.6% 26.5% 100.0% 189

No Information 6.8% 4.1% 2.7% 2.7% 2.7% 5.4% 75.7% 100.0% 74

Total 19.7% 19.6% 11.0% 7.4% 7.4% 4.7% 30.2% 100.0% 18879 Table 7.1-7, patient interval, by cancer type.

35



7.1.3 Presenting symptoms

Breast cancer

Symptom 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

asymptomatic 24.3% 5.9% 0.0% 0.0% 0.7% 0.7% 68.4% 100% 152

breast abscess 57.1% 28.6% 0.0% 0.0% 14.3% 0.0% 12.5% 100% 8

breast pain 21.1% 34.2% 17.5% 14.0% 10.5% 2.6% 14.9% 100% 134

change to breast appearance 34.1% 25.9% 16.5% 5.9% 5.9% 11.8% 25.4% 100% 114

change to nipple appearance 19.4% 13.4% 14.9% 14.9% 20.9% 16.4% 23.0% 100% 87

fatigue 33.3% 16.7% 0.0% 16.7% 16.7% 16.7% 25.0% 100% 8

lump in breast 20.3% 45.6% 15.0% 7.2% 7.4% 4.6% 17.7% 100% 2254

neck pain 50.0% 0.0% 0.0% 0.0% 0.0% 50.0% 0.0% 100% 2

nipple discharge 17.3% 40.4% 19.2% 7.7% 3.8% 11.5% 17.5% 100% 63

not known 29.4% 41.2% 11.8% 5.9% 5.9% 5.9% 83.0% 100% 100

other 30.3% 30.3% 19.7% 7.9% 7.9% 3.9% 30.3% 100% 109

shortness of breath 40.0% 20.0% 0.0% 20.0% 0.0% 20.0% 37.5% 100% 8

weight loss 0.0% 0.0% 0.0% 100.0% 0.0% 0.0% 71.4% 100% 7

Total 17.2% 32.2% 11.5% 5.9% 5.9% 4.0% 23.3% 100% 3046 Table 7.1-8, patient interval, by symptom group, or breast cancer.

Colorectal cancer


abdominal pain 20.2% 25.5% 13.9% 8.7% 8.4% 2.4% 21.0% 100% 381

anaemia 24.1% 6.9% 9.1% 4.3% 4.3% 1.7% 49.6% 100% 232

asymptomatic 14.3% 1.3% 0.0% 0.0% 0.0% 1.3% 83.1% 100% 77

bowel obstruction 23.7% 39.5% 2.6% 10.5% 2.6% 0.0% 21.1% 100% 38

change in bowel habit 16.4% 14.5% 15.6% 13.4% 17.3% 8.6% 14.3% 100% 678

epigastric pain 30.0% 30.0% 0.0% 20.0% 0.0% 0.0% 20.0% 100% 10

fatigue 22.9% 11.9% 14.4% 13.6% 6.8% 3.4% 27.1% 100% 118

nausea 15.4% 15.4% 30.8% 15.4% 0.0% 7.7% 15.4% 100% 13

not known 3.6% 1.8% 0.0% 1.8% 5.4% 0.0% 87.5% 100% 56

other 25.9% 17.1% 8.8% 5.3% 10.6% 1.8% 30.6% 100% 170

rectal hemorrhage 18.8% 19.6% 11.9% 13.9% 13.1% 7.0% 15.7% 100% 632

rectal pain 26.7% 13.3% 6.7% 13.3% 10.0% 6.7% 23.3% 100% 30


weight loss 17.9% 10.7% 10.7% 17.9% 14.3% 9.5% 19.0% 100% 84

Total 19.2% 16.5% 12.0% 10.8% 11.4% 5.3% 24.8% 100% 2566 Table 7.1-9, patient interval, by symptom group, or colorectal cancer.

Lung cancer


abdominal pain 16.7% 10.0% 16.7% 6.7% 10.0% 0.0% 40.0% 100% 30asymptomatic 11.1% 1.6% 4.0% 0.0% 0.8% 0.8% 81.7% 100% 126

chest infection 19.2% 26.0% 11.5% 6.7% 1.0% 1.9% 33.7% 100% 104

chest pain 19.7% 32.6% 9.1% 8.3% 3.0% 0.8% 26.5% 100% 132

chronic bronchitis, emphysema 15.0% 12.5% 7.5% 2.5% 0.0% 2.5% 60.0% 100% 40

cough 19.1% 21.7% 15.4% 12.2% 11.4% 4.1% 16.0% 100% 507

fatigue 18.5% 17.7% 12.3% 6.9% 3.1% 3.1% 38.5% 100% 130

haemoptysis 26.2% 34.2% 13.4% 7.4% 4.0% 2.7% 12.1% 100% 149

hoarse voice 14.8% 22.2% 25.9% 22.2% 3.7% 0.0% 11.1% 100% 27

lymphadenopathy 33.3% 25.9% 11.1% 0.0% 11.1% 3.7% 14.8% 100% 27

musculoskeletal pain 18.6% 26.5% 20.6% 7.8% 3.9% 2.0% 20.6% 100% 102

not known 10.4% 6.0% 4.5% 0.0% 3.0% 0.0% 76.1% 100% 67

other 19.3% 15.9% 9.7% 8.0% 6.3% 1.7% 39.2% 100% 176


weight loss 16.0% 5.3% 11.7% 16.0% 8.5% 5.3% 37.2% 100% 94

Total 19.3% 19.6% 12.7% 8.2% 6.5% 2.5% 31.2% 100% 2014 Table 7.1-10, patient interval, by symptom group, or lung cancer.

36



Prostate cancer


asymptomatic 17.5% 1.0% 0.5% 1.0% 1.5% 0.5% 78.0% 100% 200

blood in the semen 21.4% 28.6% 14.3% 21.4% 0.0% 0.0% 14.3% 100% 14

blood in the urine 31.3% 35.0% 4.4% 3.1% 0.6% 3.8% 21.9% 100% 160

bone pain 12.5% 7.5% 7.5% 12.5% 17.5% 2.5% 40.0% 100% 40


enlargement of the prostate 17.1% 8.5% 4.9% 9.3% 7.3% 9.3% 43.5% 100% 246

erectile dysfunction 18.0% 0.0% 2.0% 8.0% 8.0% 26.0% 38.0% 100% 50

fatigue 28.3% 13.0% 13.0% 6.5% 6.5% 2.2% 30.4% 100% 46

genitourinary tract pain 25.5% 19.6% 17.6% 11.8% 3.9% 2.0% 19.6% 100% 51

incontinence 16.7% 0.0% 16.7% 5.6% 5.6% 16.7% 38.9% 100% 18

lower urinary tract symptoms 20.4% 8.3% 8.7% 5.9% 9.7% 8.3% 38.8% 100% 931

not known 6.7% 5.6% 0.0% 1.1% 0.0% 0.0% 86.5% 100% 89

other 19.7% 17.5% 10.7% 6.5% 5.8% 4.2% 35.6% 100% 309

painful urination 25.4% 20.3% 15.3% 8.5% 10.2% 1.7% 18.6% 100% 59

raised psa 28.1% 5.9% 3.1% 0.6% 1.2% 2.0% 59.1% 100% 508

urine retention 35.5% 9.9% 5.0% 5.0% 0.8% 2.5% 41.3% 100% 121

weight loss 20.5% 11.4% 9.1% 6.8% 20.5% 4.5% 27.3% 100% 44

Total 22.2% 10.4% 6.7% 5.0% 5.8% 5.3% 44.6% 100% 2912 Table 7.1-11, patient interval, by symptom group, or prostate cancer.

7.1.4 Referral route

0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

Emergency 28.6% 25.0% 9.9% 5.6% 4.9% 2.5% 23.6% 100% 2432

2 week 18.9% 22.5% 12.9% 9.1% 8.8% 5.2% 22.6% 100% 10175

Routine 18.8% 13.4% 10.1% 6.6% 8.5% 7.3% 35.2% 100% 2789

Private 21.5% 22.4% 12.8% 7.2% 8.7% 5.6% 21.8% 100% 931

Not referred by practice 16.9% 9.2% 4.2% 2.7% 2.6% 1.5% 62.7% 100% 1323

Not known 12.5% 7.2% 5.5% 3.3% 2.8% 2.0% 66.7% 100% 1229

Total 19.7% 19.6% 11.0% 7.4% 7.4% 4.7% 30.2% 100% 18879 Table 7.1-12, patient interval, by reerral route.

7.2 Primary care interval

The primary care interval was defned as the time between frst presentation and date o reerral. Firstpresentation was defned as frst notifcation to any health care proessional working within the Primary HealthCare Team about a symptom or sign which was probably due to the cancer. Date o reerral was defned as thedate that the reerral letter was sent, or i not available the date the proorma was completed or letter written.The ollowing tables relate the duration o the primary care interval to demographic eatures, tumour type,

reerral route and presenting symptom (or the our common cancers only).



Male 24.7% 27.0% 12.5% 7.9% 6.7% 3.2% 18.0% 100.0% 9759

Female 38.8% 22.5% 8.4% 6.9% 5.9% 2.4% 15.0% 100.0% 9066

Not Known 33.3% 7.4% 5.6% 5.6% 9.3% 3.7% 35.2% 100.0% 54

Total 31.5% 24.8% 10.6% 7.4% 6.3% 2.9% 16.6% 100.0% 18879 Table 7.2-1, primary care interval, by sex o patient.

37



Males, by ageband 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

0-24 31.5% 28.7% 9.3% 8.3% 4.6% 0.9% 16.7% 100.0% 108

25 30.2% 27.0% 7.9% 4.8% 9.5% 6.3% 14.3% 100.0% 63

30 29.8% 28.7% 12.8% 5.3% 6.4% 0.0% 17.0% 100.0% 94

35 30.2% 28.7% 7.8% 8.5% 6.2% 4.7% 14.0% 100.0% 129

40 26.4% 27.4% 13.2% 7.6% 6.6% 2.0% 16.8% 100.0% 197

45 30.1% 24.3% 12.5% 7.4% 8.5% 4.0% 13.2% 100.0% 272

50 28.6% 25.5% 11.2% 9.5% 5.3% 3.5% 16.5% 100.0% 455

55 26.2% 27.1% 14.0% 7.5% 6.8% 3.3% 15.1% 100.0% 749

60 26.9% 25.0% 12.9% 8.1% 6.8% 3.9% 16.3% 100.0% 1256

65 21.1% 30.2% 13.6% 8.6% 7.0% 2.9% 16.5% 100.0% 1367

70 21.8% 29.4% 14.0% 7.8% 6.5% 2.5% 17.9% 100.0% 1534

75 24.1% 25.4% 12.5% 8.1% 7.1% 3.5% 19.3% 100.0% 1419

80 23.3% 25.4% 11.5% 7.7% 6.7% 3.4% 21.9% 100.0% 1135

85+ 26.7% 27.0% 9.3% 6.6% 6.3% 3.7% 20.4% 100.0% 793

All males 24.7% 27.1% 12.5% 7.9% 6.7% 3.3% 17.8% 100.0% 9571 Table 7.2-2, primary care interval, by age band o patient, or males.


0-24 20.0% 38.9% 7.8% 13.3% 6.7% 3.3% 10.0% 100.0% 90

25 44.6% 16.9% 4.6% 4.6% 7.7% 6.2% 15.4% 100.0% 65

30 40.4% 14.7% 8.3% 12.8% 10.1% 5.5% 8.3% 100.0% 109

35 41.2% 21.4% 11.5% 9.9% 5.3% 2.9% 7.8% 100.0% 243

40 48.6% 21.0% 7.5% 5.4% 5.9% 2.4% 9.2% 100.0% 424

45 48.2% 22.2% 6.9% 6.4% 5.3% 2.1% 9.0% 100.0% 625

50 43.5% 22.1% 5.4% 6.8% 3.9% 1.8% 16.6% 100.0% 616

55 40.9% 22.1% 8.1% 8.1% 5.2% 2.5% 13.1% 100.0% 789

60 39.5% 22.0% 8.1% 7.1% 6.1% 1.6% 15.6% 100.0% 947

65 36.6% 22.9% 8.0% 7.3% 8.2% 3.4% 13.6% 100.0% 953

70 36.4% 22.1% 10.0% 6.4% 6.5% 2.8% 15.9% 100.0% 1037

75 35.1% 23.8% 11.0% 6.8% 5.4% 2.6% 15.3% 100.0% 1096

80 36.6% 22.0% 8.8% 6.3% 5.4% 2.6% 18.3% 100.0% 940

85+ 36.0% 22.8% 7.4% 5.7% 6.0% 1.8% 20.3% 100.0% 955

All females 38.9% 22.4% 8.4% 6.9% 5.9% 2.5% 14.9% 100.0% 8889 Table 7.2-3, primary care interval, by age band o patient, or emales.

Communication difficulty 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

None 31.8% 25.1% 10.6% 7.4% 6.3% 2.9% 15.8% 100.0% 17252


Not known 24.1% 19.6% 9.3% 7.0% 5.6% 2.3% 32.2% 100.0% 485

Total 31.5% 24.8% 10.6% 7.4% 6.3% 2.9% 16.6% 100.0% 18879 Table 7.2-4, primary care interval, by presence o communication difculty.

House bound? 0 days 1-14 days 15- 31 days 32-62 days 63-182 day s 183+ days Not known Total nNo 32.2% 25.3% 10.7% 7.5% 6.4% 2.8% 15.1% 100.0% 16876

Yes 27.7% 21.2% 8.3% 7.1% 5.2% 2.9% 27.7% 100.0% 1298

Not Known 22.6% 19.1% 10.4% 6.0% 6.1% 3.5% 32.3% 100.0% 705

Total 31.5% 24.8% 10.6% 7.4% 6.3% 2.9% 16.6% 100.0% 18879 Table 7.2-5, primary care interval, by housebound status.

Ethni c category 0 days 1-14 days 15- 31 days 32-62 days 63-182 day s 183+ days Not known Total n

White British 31.4% 25.1% 10.8% 7.3% 6.4% 2.8% 16.1% 100.0% 14644

White other 33.8% 24.3% 7.0% 8.2% 4.7% 2.6% 19.4% 100.0% 837

Nonwhite 31.5% 22.8% 11.1% 7.9% 7.9% 2.1% 16.7% 100.0% 1159

Not Known 31.0% 24.0% 9.6% 7.3% 5.9% 3.5% 18.5% 100.0% 2239

Total 31.5% 24.8% 10.6% 7.4% 6.3% 2.9% 16.6% 100.0% 18879 Table 7.2-6, primary care interval, by ethnic category.

38



7.2.2 Tumour type


Bladder 31.1% 31.1% 10.1% 5.7% 4.3% 3.2% 14.6% 100.0% 920

Brain 33.3% 24.4% 7.3% 4.3% 5.1% 2.6% 23.1% 100.0% 234

Breast 65.2% 17.1% 2.7% 1.6% 1.4% 0.9% 11.1% 100.0% 3046

Cervical 36.8% 22.4% 10.5% 7.2% 9.9% 2.0% 11.2% 100.0% 152

Colorectal 29.2% 23.3% 11.5% 8.3% 8.5% 4.1% 15.2% 100.0% 2566

Endometrial 44.1% 24.1% 7.4% 9.4% 3.9% 2.5% 8.5% 100.0% 435

Gallbladder 5.7% 24.3% 15.7% 12.9% 10.0% 5.7% 25.7% 100.0% 70

Laryngeal 33.3% 23.3% 12.4% 9.3% 5.4% 3.9% 12.4% 100.0% 129

Leukaemia 19.9% 27.9% 10.1% 6.3% 5.1% 1.6% 29.3% 100.0% 574

Liver 16.9% 19.2% 10.8% 6.9% 8.5% 3.1% 34.6% 100.0% 130

Lung 11.8% 28.8% 13.1% 11.3% 8.7% 2.7% 23.6% 100.0% 2014

Lymphoma 23.0% 27.6% 12.6% 8.8% 8.0% 4.1% 15.8% 100.0% 760

Melanoma 50.7% 22.4% 5.8% 7.2% 3.5% 2.4% 8.0% 100.0% 878

Mesothelioma 20.3% 31.6% 16.5% 6.3% 12.7% 0.0% 12.7% 100.0% 79

Myeloma 10.3% 20.2% 13.9% 13.1% 13.1% 4.8% 24.6% 100.0% 252

Oesophageal 34.7% 20.5% 12.2% 11.2% 8.9% 2.2% 10.2% 100.0% 596

Oropharyngeal 34.5% 18.8% 15.3% 8.3% 7.0% 2.6% 13.5% 100.0% 229Ovarian 22.7% 32.7% 10.0% 11.6% 5.5% 0.9% 16.6% 100.0% 422

Pancreatic 22.6% 31.3% 10.0% 10.0% 9.0% 2.8% 14.4% 100.0% 390

Prostate 17.3% 31.0% 15.7% 7.6% 7.0% 3.8% 17.5% 100.0% 2912

Renal 20.4% 22.4% 12.6% 10.1% 6.5% 3.3% 24.9% 100.0% 398

Sarcoma 26.9% 21.0% 10.1% 11.8% 9.2% 5.9% 15.1% 100.0% 119

Small Intestine 19.3% 28.1% 8.8% 10.5% 8.8% 1.8% 22.8% 100.0% 57

Stomach 24.5% 18.2% 12.2% 6.9% 14.4% 4.7% 19.1% 100.0% 319

Testicular 37.3% 25.3% 12.7% 4.2% 3.0% 2.4% 15.1% 100.0% 166

Thyroid 20.6% 24.6% 22.2% 7.1% 4.8% 4.0% 16.7% 100.0% 126

Vulval 47.4% 26.3% 6.6% 5.3% 3.9% 3.9% 6.6% 100.0% 76

Other 28.0% 22.9% 11.3% 6.7% 6.7% 3.0% 21.3% 100.0% 567

Unknown Primary 24.3% 18.5% 15.3% 12.7% 7.4% 4.2% 17.5% 100.0% 189

No Information 12.2% 5.4% 4.1% 4.1% 1.4% 1.4% 71.6% 100.0% 74

Total 31.5% 24.8% 10.6% 7.4% 6.3% 2.9% 16.6% 100.0% 18879 Table 7.2-7, primary care interval, by cancer type.


Breast cancer


asymptomatic 18.4% 4.6% 2.6% 0.7% 0.0% 0.0% 73.7% 100% 152

breast abscess 50.0% 37.5% 0.0% 12.5% 0.0% 0.0% 0.0% 100% 8

breast pain 56.0% 20.9% 6.0% 7.5% 4.5% 1.5% 3.7% 100% 134


change to nipple appearance 71.3% 14.9% 2.3% 4.6% 2.3% 1.1% 3.4% 100% 87fatigue 37.5% 12.5% 12.5% 12.5% 12.5% 0.0% 12.5% 100% 8

lump in breast 73.8% 17.6% 2.1% 0.7% 0.6% 0.9% 4.3% 100% 2254

neck pain 50.0% 0.0% 0.0% 0.0% 50.0% 0.0% 0.0% 100% 2


not known 10.0% 3.0% 1.0% 3.0% 0.0% 0.0% 83.0% 100% 100

other 24.8% 22.9% 10.1% 10.1% 11.9% 3.7% 16.5% 100% 109


weight loss 0.0% 28.6% 28.6% 28.6% 0.0% 0.0% 14.3% 100% 7

Total 65.2% 17.1% 2.7% 1.6% 1.4% 0.9% 11.1% 100% 3046 Table 7.2-8, primary care interval, by symptom, or breast cancer.

39



Colorectal cancer


abdominal pain 21.3% 22.6% 13.1% 11.5% 10.0% 5.2% 16.3% 100% 381

anaemia 17.2% 26.7% 12.1% 4.7% 6.9% 7.8% 24.6% 100% 232

asymptomatic 9.1% 15.6% 2.6% 7.8% 3.9% 2.6% 58.4% 100% 77



epigastric pain 20.0% 20.0% 10.0% 20.0% 10.0% 10.0% 10.0% 100% 10

fatigue 16.1% 28.0% 17.8% 11.9% 8.5% 3.4% 14.4% 100% 118

nausea 0.0% 53.8% 15.4% 23.1% 7.7% 0.0% 0.0% 100% 13

not known 7.1% 1.8% 1.8% 1.8% 1.8% 0.0% 85.7% 100% 56

other 20.0% 21.8% 18.2% 6.5% 10.0% 2.4% 21.2% 100% 170


rectal pain 16.7% 33.3% 6.7% 20.0% 10.0% 3.3% 10.0% 100% 30


weight loss 36.9% 21.4% 13.1% 6.0% 13.1% 2.4% 7.1% 100% 84

Total 29.2% 23.3% 11.5% 8.3% 8.5% 4.1% 15.2% 100% 2566 Table 7.2-9, primary care interval, by symptom, or colorectal cancer.

Lung cancer


abdominal pain 13.3% 13.3% 26.7% 13.3% 10.0% 0.0% 23.3% 100% 30

asymptomatic 7.1% 9.5% 1.6% 1.6% 1.6% 2.4% 76.2% 100% 126

chest infection 10.6% 18.3% 19.2% 13.5% 8.7% 1.9% 27.9% 100% 104

chest pain 10.6% 34.1% 12.1% 14.4% 9.1% 1.5% 18.2% 100% 132


cough 5.9% 33.9% 16.6% 16.8% 14.0% 3.4% 9.5% 100% 507

fatigue 15.4% 23.8% 14.6% 9.2% 6.2% 1.5% 29.2% 100% 130

haemoptysis 18.1% 43.6% 13.4% 5.4% 6.0% 2.7% 10.7% 100% 149

hoarse voice 25.9% 37.0% 11.1% 14.8% 0.0% 0.0% 11.1% 100% 27



not known 7.5% 7.5% 3.0% 4.5% 3.0% 1.5% 73.1% 100% 67

other 21.0% 26.1% 9.1% 10.8% 4.5% 3.4% 25.0% 100% 176


weight loss 9.6% 37.2% 13.8% 10.6% 10.6% 3.2% 14.9% 100% 94

Total 11.8% 28.8% 13.1% 11.3% 8.7% 2.7% 23.6% 100% 2014 Table 7.2-10, primary care interval, by symptom, or lung cancer.

Prostate cancer


asymptomatic 17.5% 16.0% 7.5% 6.0% 3.0% 3.5% 46.5% 100% 200

blood in the semen 28.6% 21.4% 7.1% 21.4% 7.1% 7.1% 7.1% 100% 14

blood in the urine 34.4% 33.8% 13.8% 5.6% 4.4% 2.5% 5.6% 100% 160

bone pain 2.5% 22.5% 22.5% 15.0% 12.5% 2.5% 22.5% 100% 40




fatigue 10.9% 37.0% 15.2% 10.9% 8.7% 2.2% 15.2% 100% 46


incontinence 22.2% 44.4% 22.2% 5.6% 0.0% 0.0% 5.6% 100% 18


not known 10.1% 5.6% 4.5% 1.1% 1.1% 0.0% 77.5% 100% 89

other 11.0% 35.6% 18.4% 9.4% 11.7% 2.6% 11.3% 100% 309


raised psa 24.4% 22.6% 12.0% 3.7% 6.5% 3.7% 27.0% 100% 508

urine retention 38.8% 14.0% 5.8% 0.8% 2.5% 0.0% 38.0% 100% 121

weight loss 9.1% 52.3% 11.4% 11.4% 6.8% 4.5% 4.5% 100% 44Total 17.3% 31.0% 15.7% 7.6% 7.0% 3.8% 17.5% 100% 2912 Table 7.2-11, primary care interval, by symptom, or prostate cancer.

40





Emergency 34.3% 27.3% 9.3% 6.5% 6.1% 2.9% 13.7% 100% 2432

2 week 38.9% 28.0% 11.7% 8.1% 6.1% 2.5% 4.7% 100% 10175

Routine 21.2% 25.7% 14.5% 10.3% 11.2% 5.8% 11.3% 100% 2789

Private 33.6% 31.0% 9.5% 7.3% 6.8% 4.0% 7.8% 100% 931


Not known 8.6% 7.5% 3.9% 2.7% 2.5% 0.9% 73.9% 100% 1229

Total 31.5% 24.8% 10.6% 7.4% 6.3% 2.9% 16.6% 100% 18879 7.3 Referral interval

Reerral interval was defned as the period between reerral and the date the patient frst attended insecondary care, either or assessment in the outpatient clinic, admission or investigation. The ollowingtables relate the reerral interval to demographic eatures, tumour type, reerral route and presenting

symptom. Because o sample and cell size, this has been done or the our common cancers only.



Male 9.1% 45.0% 17.1% 10.4% 3.9% 1.4% 13.2% 100.0% 9759

Female 8.8% 51.7% 16.1% 7.8% 2.3% 1.1% 12.2% 100.0% 9066

Not Known 9.3% 27.8% 11.1% 11.1% 5.6% 0.0% 35.2% 100.0% 54

Total 8.9% 48.2% 16.6% 9.1% 3.1% 1.3% 12.7% 100.0% 18879

Table 7.2-12, primary care interval, by reerral route.

Table 7.3-1, reerral interval, by sex o patient.

Males , by ageband 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

0-24 29.6% 32.4% 9.3% 7.4% 3.7% 0.9% 16.7% 100.0% 10825 6.3% 54.0% 14.3% 9.5% 4.8% 0.0% 11.1% 100.0% 63

30 12.8% 44.7% 10.6% 8.5% 4.3% 2.1% 17.0% 100.0% 94

35 5.4% 46.5% 20.2% 9.3% 4.7% 1.6% 12.4% 100.0% 129

40 9.6% 44.7% 15.7% 10.7% 2.5% 1.5% 15.2% 100.0% 197

45 9.2% 46.0% 16.5% 11.8% 4.0% 0.4% 12.1% 100.0% 272

50 8.1% 42.2% 18.5% 10.5% 4.6% 1.1% 14.9% 100.0% 455

55 8.1% 48.7% 16.6% 10.1% 3.6% 1.7% 11.1% 100.0% 749

60 7.6% 47.2% 18.0% 10.4% 4.2% 1.7% 11.0% 100.0% 1256

65 7.6% 45.0% 17.0% 12.8% 4.1% 2.0% 11.5% 100.0% 1367

70 8.3% 45.8% 18.0% 10.6% 3.7% 1.3% 12.3% 100.0% 1534

75 8.1% 45.2% 18.7% 9.7% 3.4% 1.5% 13.3% 100.0% 1419

80 11.8% 42.5% 15.8% 9.1% 4.1% 0.8% 16.0% 100.0% 1135

85+ 12.6% 41.0% 15.8% 9.0% 3.9% 1.8% 16.0% 100.0% 793

All males 9.1% 44.9% 17.2% 10.4% 3.9% 1.5% 13.1% 100.0% 9571 Table 7.3-2, reerral interval, by age band o patient, or males.


0-24 34.4% 33.3% 11.1% 7.8% 2.2% 1.1% 10.0% 100.0% 90

25 6.2% 36.9% 20.0% 15.4% 4.6% 4.6% 12.3% 100.0% 65

30 6.4% 43.1% 22.0% 15.6% 4.6% 0.9% 7.3% 100.0% 109

35 7.0% 55.1% 15.2% 10.7% 3.7% 0.0% 8.2% 100.0% 243

40 5.2% 56.8% 17.9% 6.8% 1.9% 1.2% 10.1% 100.0% 424

45 5.6% 59.2% 15.8% 7.8% 2.9% 0.3% 8.3% 100.0% 625

50 7.0% 49.0% 19.8% 7.8% 2.4% 1.5% 12.5% 100.0% 616

55 5.6% 57.5% 15.5% 7.2% 2.9% 0.8% 10.5% 100.0% 789

60 7.7% 52.7% 15.5% 7.5% 2.7% 1.5% 12.4% 100.0% 947

65 8.6% 52.5% 15.3% 8.6% 2.4% 0.7% 11.9% 100.0% 953

70 8.9% 53.3% 14.6% 7.7% 2.0% 1.2% 12.3% 100.0% 1037

75 8.7% 52.6% 16.1% 7.9% 1.7% 1.4% 11.5% 100.0% 109680 11.1% 46.9% 17.3% 7.0% 1.7% 1.6% 14.4% 100.0% 940

85+ 13.3% 46.6% 15.1% 6.4% 1.9% 0.7% 16.0% 100.0% 955

All females 8.7% 51.9% 16.1% 7.8% 2.3% 1.1% 12.1% 100.0% 8889 Table 7.3-3, reerral interval, by age band o patient, or emales.

41



Communicat ion difficulty 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

None 8.7% 49.0% 16.8% 9.2% 3.1% 1.3% 12.0% 100.0% 17252


Not known 7.6% 39.6% 14.6% 6.0% 3.7% 0.4% 28.0% 100.0% 485

Total 8.9% 48.2% 16.6% 9.1% 3.1% 1.3% 12.7% 100.0% 18879 Table 7.3-4, reerral interval, by presence o communication difculty.

House bound? 0 days 1-14 days 15-31 days 32- 62 days 63-182 day s 183+ days Not known Total n

No 8.4% 49.5% 17.0% 9.4% 3.1% 1.3% 11.3% 100.0% 16876

Yes 16.1% 37.3% 13.8% 6.5% 2.9% 1.0% 22.4% 100.0% 1298

Not Known 9.2% 37.2% 13.0% 7.5% 3.3% 0.9% 28.9% 100.0% 705

Total 8.9% 48.2% 16.6% 9.1% 3.1% 1.3% 12.7% 100.0% 18879 Table 7.3-5, reerral interval, by housebound status.

Ethni c category 0 days 1-14 days 15-31 days 32-62 days 63-182 days 183+ days Not known Total n

White British 8.9% 48.9% 16.8% 9.0% 3.1% 1.3% 12.1% 100.0% 14644

White other 9.6% 41.8% 16.6% 10.6% 3.6% 1.0% 16.8% 100.0% 837Nonwhite 9.1% 43.2% 17.8% 11.7% 3.5% 1.4% 13.3% 100.0% 1159

Not Known 8.4% 48.8% 15.0% 8.3% 3.2% 1.4% 15.0% 100.0% 2239

Total 8.9% 48.2% 16.6% 9.1% 3.1% 1.3% 12.7% 100.0% 18879 Table 7.3-6, reerral interval, by ethnic category.

7.3.2 Tumour type


Bladder 5.3% 45.3% 23.2% 9.5% 3.5% 2.0% 11.3% 100.0% 920

Brain 26.9% 28.2% 12.0% 7.3% 3.0% 0.9% 21.8% 100.0% 234

Breast 2.7% 66.1% 16.2% 4.4% 0.8% 0.6% 9.2% 100.0% 3046

Cervical 7.9% 46.7% 21.1% 11.8% 2.0% 0.0% 10.5% 100.0% 152

Colorectal 10.9% 44.3% 16.0% 11.8% 3.9% 1.0% 12.1% 100.0% 2566

Endometrial 3.0% 55.2% 20.9% 7.8% 4.4% 1.1% 7.6% 100.0% 435

Gallbladder 14.3% 34.3% 12.9% 8.6% 2.9% 2.9% 24.3% 100.0% 70

Laryngeal 3.9% 48.8% 20.9% 7.0% 7.0% 0.8% 11.6% 100.0% 129

Leukaemia 22.8% 27.0% 13.8% 15.7% 2.6% 1.6% 16.6% 100.0% 574

Liver 15.4% 38.5% 12.3% 9.2% 0.0% 3.1% 21.5% 100.0% 130

Lung 15.6% 43.9% 13.9% 5.0% 1.2% 1.2% 19.0% 100.0% 2014

Lymphoma 13.0% 44.1% 17.5% 8.9% 3.0% 1.6% 11.8% 100.0% 760

Melanoma 2.1% 54.8% 17.7% 11.3% 5.7% 1.6% 6.9% 100.0% 878

Mesothelioma 21.5% 46.8% 13.9% 7.6% 1.3% 0.0% 8.9% 100.0% 79

Myeloma 14.3% 40.9% 17.1% 8.3% 4.8% 0.4% 14.3% 100.0% 252

Oesophageal 6.0% 49.5% 19.6% 10.7% 2.2% 1.7% 10.2% 100.0% 596

Oropharyngeal 5.2% 56.8% 15.3% 7.4% 2.2% 0.9% 12.2% 100.0% 229

Ovarian 17.1% 51.7% 12.6% 3.6% 0.9% 0.5% 13.7% 100.0% 422

Pancreatic 20.5% 45.1% 12.8% 5.6% 0.8% 1.8% 13.3% 100.0% 390

Prostate 4.1% 45.9% 19.5% 12.7% 5.3% 1.8% 10.7% 100.0% 2912

Renal 9.0% 45.2% 14.3% 8.8% 2.5% 1.5% 18.6% 100.0% 398

Sarcoma 5.9% 51.3% 11.8% 10.9% 5.9% 0.8% 13.4% 100.0% 119

Small Intestine 15.8% 40.4% 12.3% 10.5% 1.8% 0.0% 19.3% 100.0% 57

Stomach 13.8% 36.1% 16.9% 10.7% 4.1% 2.2% 16.3% 100.0% 319

Testicular 5.4% 56.0% 15.1% 5.4% 1.8% 0.6% 15.7% 100.0% 166

Thyroid 3.2% 38.1% 19.8% 19.8% 7.9% 0.8% 10.3% 100.0% 126

Vulval 2.6% 52.6% 19.7% 13.2% 2.6% 2.6% 6.6% 100.0% 76

Other 10.4% 38.3% 12.9% 14.3% 6.9% 1.8% 15.5% 100.0% 567

Unknown Primary 23.3% 40.7% 9.5% 5.8% 1.6% 1.6% 17.5% 100.0% 189

No Information 4.1% 12.2% 6.8% 6.8% 1.4% 0.0% 68.9% 100.0% 74

Total 8.9% 48.2% 16.6% 9.1% 3.1% 1.3% 12.7% 100.0% 18879 Table 7.3-7, reerral interval, by cancer type.

42



Breast cancer



asymptomatic 12.5% 30.9% 7.2% 2.0% 0.0% 0.7% 46.7% 100% 152

breast abscess 12.5% 50.0% 25.0% 12.5% 0.0% 0.0% 0.0% 100% 8

breast pain 1.5% 59.7% 24.6% 8.2% 0.7% 1.5% 3.7% 100% 134


change to nipple appearance 0.0% 64.4% 24.1% 5.7% 2.3% 2.3% 1.1% 100% 87

fatigue 37.5% 37.5% 25.0% 0.0% 0.0% 0.0% 0.0% 100% 8

lump in breast 1.5% 72.7% 16.2% 3.9% 0.6% 0.5% 4.5% 100% 2254

neck pain 50.0% 50.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100% 2


not known 2.0% 24.0% 3.0% 1.0% 0.0% 0.0% 70.0% 100% 100

other 14.7% 45.0% 17.4% 11.0% 1.8% 0.9% 9.2% 100% 109


weight loss 0.0% 28.6% 28.6% 0.0% 14.3% 14.3% 14.3% 100% 7

Total 2.7% 66.1% 16.2% 4.4% 0.8% 0.6% 9.2% 100% 3046 Table 7.3-8, reerral interval by symptom, or breast cancer.

Colorectal cancer


abdominal pain 21.3% 35.7% 15.7% 6.8% 4.7% 0.8% 15.0% 100% 381

anaemia 9.5% 40.1% 15.5% 17.2% 4.3% 1.3% 12.1% 100% 232

asymptomatic 3.9% 27.3% 11.7% 11.7% 1.3% 2.6% 41.6% 100% 77



epigastric pain 20.0% 20.0% 10.0% 30.0% 10.0% 0.0% 10.0% 100% 10

fatigue 14.4% 43.2% 17.8% 8.5% 1.7% 1.7% 12.7% 100% 118

nausea 23.1% 46.2% 15.4% 15.4% 0.0% 0.0% 0.0% 100% 13

not known 1.8% 12.5% 5.4% 5.4% 0.0% 0.0% 75.0% 100% 56

other 14.7% 45.3% 12.9% 7.6% 2.4% 0.6% 16.5% 100% 170


rectal pain 16.7% 40.0% 20.0% 6.7% 3.3% 0.0% 13.3% 100% 30


weight loss 4.8% 54.8% 19.0% 7.1% 6.0% 1.2% 7.1% 100% 84

Total 10.9% 44.3% 16.0% 11.8% 3.9% 1.0% 12.1% 100% 2566 Table 7.3-9, reerral interval by symptom, or colorectal cancer.

Lung cancer


abdominal pain 16.7% 40.0% 13.3% 3.3% 0.0% 13.3% 13.3% 100% 30asymptomatic 4.8% 19.0% 15.1% 7.1% 0.8% 1.6% 51.6% 100% 126

chest infection 25.0% 33.7% 9.6% 5.8% 0.0% 2.9% 23.1% 100% 104

chest pain 18.2% 43.2% 14.4% 6.1% 0.8% 0.8% 16.7% 100% 132


cough 10.1% 54.8% 18.5% 4.9% 1.4% 0.8% 9.5% 100% 507

fatigue 24.6% 30.0% 13.8% 5.4% 0.8% 0.8% 24.6% 100% 130

haemoptysis 9.4% 65.8% 11.4% 2.7% 1.3% 0.0% 9.4% 100% 149

hoarse voice 7.4% 55.6% 11.1% 3.7% 0.0% 11.1% 11.1% 100% 27



not known 4.5% 13.4% 3.0% 7.5% 1.5% 0.0% 70.1% 100% 67

other 22.2% 38.6% 10.8% 6.3% 2.3% 1.7% 18.2% 100% 176


weight loss 14.9% 53.2% 13.8% 6.4% 1.1% 1.1% 9.6% 100% 94

Total 15.6% 43.9% 13.9% 5.0% 1.2% 1.2% 19.0% 100% 2014 Table 7.3-10, reerral interval by symptom, or lung cancer.

43



Prostate cancer


asymptomatic 2.0% 43.0% 19.0% 14.0% 5.0% 0.5% 16.5% 100% 200

blood in the semen 0.0% 57.1% 14.3% 21.4% 7.1% 0.0% 0.0% 100% 14blood in the urine 2.5% 55.6% 18.8% 11.9% 3.1% 2.5% 5.6% 100% 160

bone pain 2.5% 55.0% 25.0% 2.5% 0.0% 2.5% 12.5% 100% 40




fatigue 6.5% 54.3% 13.0% 10.9% 2.2% 2.2% 10.9% 100% 46


incontinence 16.7% 55.6% 11.1% 11.1% 0.0% 0.0% 5.6% 100% 18


not known 2.2% 11.2% 7.9% 4.5% 5.6% 1.1% 67.4% 100% 89

other 9.4% 50.8% 16.8% 9.1% 3.2% 1.6% 9.1% 100% 309


raised psa 1.6% 40.6% 20.9% 15.4% 6.1% 2.6% 13.0% 100% 508

urine retention 28.9% 9.9% 9.9% 10.7% 6.6% 1.7% 32.2% 100% 121

weight loss 4.5% 63.6% 11.4% 11.4% 2.3% 2.3% 4.5% 100% 44

Total 4.1% 45.9% 19.5% 12.7% 5.3% 1.8% 10.7% 100% 2912 Table 7.3-11, reerral interval by symptom, or prostate cancer.



Emergency 53.4% 20.8% 7.6% 5.7% 1.8% 0.7% 10.0% 100% 2432

2 week 1.0% 72.8% 17.8% 3.7% 0.8% 1.3% 2.6% 100% 10175

Routine 1.0% 11.8% 28.4% 37.4% 14.5% 2.3% 4.7% 100% 2789

Private 6.0% 64.3% 16.6% 5.9% 1.3% 1.2% 4.6% 100% 931


Not known 3.7% 9.0% 9.0% 4.5% 1.8% 0.9% 71.3% 100% 1229

Total 8.9% 48.2% 16.6% 9.1% 3.1% 1.3% 12.7% 100% 18879 Table 7.3-12, reerral interval by reerral route.

7.4 Commentary

The data on patient delay should be interpreted with considerable caution, or the reasons previously stated,namely that inormation on duration o symptoms is not always recorded in the clinical record. When it is,the inormation may not have been elicited in a systematic way and reects the doctor’s interpretation o thepatient’s statements. Overall, 12% o patients were recorded as having symptoms or two months or moreprior to frst presentation. There were some surprising patient delays relating to alarm symptoms – 12% othose with breast lump, 26% o those with change in bowel habit and 20% o those with rectal bleeding

delayed or more than two months beore consulting. This underlines the importance o communicatingmessages to the public on the importance o seeking medical advice promptly.

There was little impact on the primary care interval relating to housebound status, communication difcultyor ethnicity. The duration o this interval was shorter or women, related to the high proportion o two weekwait reerrals or breast cancer. Some symptoms were associated with delays o two months or more, over15% o cases o colorectal cancer presenting with anaemia, and o lung cancer presenting with cough ormusculoskeletal pain.

For the reerral period, the ractions with zero and one - 14 day duration correlate well with emergencyand two week wait reerrals. Similarly, the larger raction o patients who are housebound or have

communication difculties that have short reerral delay is likely to represent their greater likelihood to bereerred as emergencies.

44



Stage at diagnosis was determined by the practice ollowing review o the available clinical records andhospital correspondence, and was assigned to categories that equate to the grouped staging described bySEER. O all the cancers included in this audit, 46% were identifed as confned to the organ, 25% withlocal (regional) spread and 18% with metastatic disease. For 11% the stage was unknown. Solid tumourscomprised 91% o the total. O these, 52% were confned to the organ. There was a large variation in theraction o tumours diagnosed with organ confned disease. I tumours with unknown stage had the samedistribution as those recorded then these fgures ranged rom Brain (80%), Melanoma (78%) and Testicular(74%) down to Pancreatic (22%), Ovarian (28%) and Lung (28%). The ollowing tables relate stage atdiagnosis to demographic eatures, tumour type, reerral route and presenting symptom (or the ourcommon cancers only).

8.1 Demographic factors

Sex Organ Local spread Distant mets Not known Total n

Male 46.9% 22.5% 19.0% 11.5% 100.0% 9,759Female 44.2% 27.9% 17.0% 10.9% 100.0% 9,066

Not Known 24.1% 20.4% 14.8% 40.7% 100.0% 54

All persons 45.5% 25.1% 18.0% 11.3% 100.0% 18,879 Table 8.1-1, stage, by sex o patient.

Males, by ageband Organ Local spread Distant mets Not known Total n

0-24 48.1% 21.3% 12.0% 18.5% 100.0% 108

25 57.1% 17.5% 12.7% 12.7% 100.0% 63

30 62.8% 18.1% 11.7% 7.4% 100.0% 94

35 50.4% 20.9% 14.7% 14.0% 100.0% 129

40 39.6% 31.5% 16.8% 12.2% 100.0% 197

45 50.0% 24.3% 15.1% 10.7% 100.0% 272

50 47.5% 23.5% 16.5% 12.5% 100.0% 455

55 44.9% 24.7% 20.4% 10.0% 100.0% 749

60 50.1% 21.3% 17.4% 11.1% 100.0% 1,256

65 50.8% 21.9% 17.6% 9.7% 100.0% 1,367

70 45.6% 24.6% 20.3% 9.5% 100.0% 1,534

75 46.4% 21.3% 19.8% 12.5% 100.0% 1,419

80 44.2% 22.1% 20.3% 13.4% 100.0% 1,135

85+ 41.5% 21.7% 22.4% 14.4% 100.0% 793

All males 46.9% 22.6% 18.9% 11.5% 100.0% 9,571 Table 8.1-2, stage, by age band o patient, or males.

45



Females, by ageband Organ Local spread Distant mets Not known Total n

0-24 42.2% 22.2% 12.2% 23.3% 100.0% 90

25 50.8% 24.6% 12.3% 12.3% 100.0% 65

30 56.9% 23.9% 11.0% 8.3% 100.0% 10935 50.6% 28.8% 10.7% 9.9% 100.0% 243

40 50.2% 32.5% 7.3% 9.9% 100.0% 424

45 49.4% 30.6% 13.4% 6.6% 100.0% 625

50 48.1% 29.7% 11.0% 11.2% 100.0% 616

55 44.2% 30.5% 16.2% 9.0% 100.0% 789

60 42.6% 27.3% 19.2% 10.9% 100.0% 947

65 42.1% 27.8% 19.3% 10.8% 100.0% 953

70 42.5% 27.3% 21.1% 9.1% 100.0% 1,037

75 45.6% 24.7% 18.2% 11.5% 100.0% 1,096

80 39.3% 29.4% 19.0% 12.3% 100.0% 940

85+ 40.3% 25.1% 18.7% 15.8% 100.0% 955

All females 44.1% 27.9% 17.0% 11.0% 100.0% 8,889 Table 8.1-3, stage, by age band o patient, or emales.

Communication dif fi cul ty Organ Local spread Distant mets Not known Total n

None 46.6% 25.3% 17.6% 10.5% 100.0% 17,252

Communication difficulty 36.7% 27.6% 22.1% 13.7% 100.0% 1,142

Not known 29.5% 13.8% 22.7% 34.0% 100.0% 485

Total 45.5% 25.1% 18.0% 11.3% 100.0% 18,879 Table 8.1-4, stage, by presence o communication difculty.

Housebound? Organ Local spread Distant mets Not known Total n

No 47% 25% 17% 10% 100.0% 16,876

Yes 31% 26% 27% 16% 100.0% 1,298

Not Known 27% 19% 27% 28% 100.0% 705

Total 46% 25% 18% 11% 100.0% 18,879

Ethnic category Organ Local spread Distant mets Not known Total n

White British 46.0% 25.1% 18.4% 10.6% 100.0% 14,644White other 42.4% 28.6% 17.1% 11.9% 100.0% 837

Nonwhite 43.7% 28.2% 16.1% 12.0% 100.0% 1,159

Not Known 44.8% 22.7% 17.1% 15.3% 100.0% 2,239

Total 45.5% 25.1% 18.0% 11.3% 100.0% 18,879 Table 8.1-6, stage, by ethnic category.

46

Table 8.1-5, stage by housebound status.



8.2 Tumour type

Cancer type Organ Local spread Distant mets Not known Total n

Bladder 67.6% 18.5% 4.9% 9.0% 100.0% 920

Brain 72.2% 13.7% 5.1% 9.0% 100.0% 234

Breast 48.2% 33.8% 8.7% 9.3% 100.0% 3,046

Cervical 30.9% 43.4% 13.2% 12.5% 100.0% 152

Colorectal 39.9% 30.9% 21.9% 7.2% 100.0% 2,566

Endometrial 62.5% 23.7% 5.5% 8.3% 100.0% 435

Gallbladder 30.0% 27.1% 35.7% 7.1% 100.0% 70

Laryngeal 58.1% 33.3% 2.3% 6.2% 100.0% 129

Leukaemia 46.2% 6.4% 4.2% 43.2% 100.0% 574

Liver 39.2% 14.6% 33.1% 13.1% 100.0% 130

Lung 24.7% 29.5% 35.6% 10.2% 100.0% 2,014

Lymphoma 34.6% 23.3% 19.6% 22.5% 100.0% 760Melanoma 70.7% 14.8% 5.5% 9.0% 100.0% 878

Mesothelioma 35.4% 39.2% 6.3% 19.0% 100.0% 79

Myeloma 36.5% 8.7% 22.2% 32.5% 100.0% 252

Oesophageal 31.5% 32.9% 24.3% 11.2% 100.0% 596

Oropharyngeal 40.2% 46.7% 7.9% 5.2% 100.0% 229

Ovarian 24.4% 32.2% 36.0% 7.3% 100.0% 422

Pancreatic 19.7% 29.2% 41.8% 9.2% 100.0% 390

Prostate 61.4% 15.6% 14.0% 9.0% 100.0% 2,912

Renal 50.0% 15.3% 28.1% 6.5% 100.0% 398

Sarcoma 47.1% 28.6% 17.6% 6.7% 100.0% 119

Small Intestine 40.4% 26.3% 21.1% 12.3% 100.0% 57

Stomach 28.5% 35.7% 28.8% 6.9% 100.0% 319

Testicular 70.5% 16.3% 8.4% 4.8% 100.0% 166

Thyroid 51.6% 25.4% 11.1% 11.9% 100.0% 126

Vulval 50.0% 35.5% 3.9% 10.5% 100.0% 76

Other 41.1% 25.9% 14.3% 18.7% 100.0% 567

Unknown Primary 1.6% 4.8% 87.3% 6.3% 100.0% 189

No Information 10.8% 6.8% 6.8% 75.7% 100.0% 74

Total 45.5% 25.1% 18.0% 11.3% 100.0% 18,879 Table 8.2-1, stage, by cancer type.

47



Symptom Organ Local spread Distant mets Not known Total n

asymptomatic 61.8% 23.0% 7.2% 7.9% 100% 152

breast abscess 37.5% 25.0% 25.0% 12.5% 100% 8

breast pain 50.7% 30.6% 9.7% 9.0% 100% 134

change to breast appearance 35.1% 45.6% 12.3% 7.0% 100% 114

change to nipple appearance 52.9% 39.1% 3.4% 4.6% 100% 87

fatigue 25.0% 37.5% 37.5% 0.0% 100% 8

lump in breast 49.0% 35.8% 6.2% 9.0% 100% 2254

neck pain 0.0% 0.0% 100.0% 0.0% 100% 2

nipple discharge 73.0% 15.9% 4.8% 6.3% 100% 63

not known 42.0% 20.0% 5.0% 33.0% 100% 100

other 16.5% 21.1% 56.9% 5.5% 100% 109

shortness of breath 12.5% 12.5% 75.0% 0.0% 100% 8

weight loss 28.6% 14.3% 42.9% 14.3% 100% 7

Total 48.2% 33.8% 8.7% 9.3% 100% 3046

8.3 Presenting symptom

Breast cancer

Table 8.3-1, stage by symptom, or breast cancer.

Colorectal cancer


abdominal pain 29.4% 31.0% 32.8% 6.8% 100% 381

anaemia 45.3% 33.6% 13.4% 7.8% 100% 232

asymptomatic 58.4% 14.3% 19.5% 7.8% 100% 77

bowel obstruction 42.1% 28.9% 21.1% 7.9% 100% 38

change in bowel habit 40.3% 33.9% 19.5% 6.3% 100% 678

epigastric pain 10.0% 30.0% 60.0% 0.0% 100% 10

fatigue 32.2% 33.1% 25.4% 9.3% 100% 118

nausea 23.1% 30.8% 46.2% 0.0% 100% 13

not known 32.1% 19.6% 14.3% 33.9% 100% 56

other 32.4% 24.7% 35.3% 7.6% 100% 170

rectal hemorrhage 49.4% 29.3% 15.2% 6.2% 100% 632

rectal pain 26.7% 53.3% 13.3% 6.7% 100% 30

shortness of breath 34.0% 38.3% 25.5% 2.1% 100% 47

weight loss 27.4% 31.0% 35.7% 6.0% 100% 84

Total 39.9% 30.9% 21.9% 7.2% 100% 2566 Table 8.3-2, stage by symptom, or colorectal cancer.

48



Lung cancer


abdominal pain 10.0% 23.3% 63.3% 3.3% 100% 30asymptomatic 49.2% 23.8% 19.0% 7.9% 100% 126

chest infection 29.8% 32.7% 26.9% 10.6% 100% 104

chest pain 22.0% 32.6% 35.6% 9.8% 100% 132

chronic bronchitis, emphysema 42.5% 22.5% 20.0% 15.0% 100% 40

cough 24.9% 37.9% 30.2% 7.1% 100% 507

fatigue 16.9% 23.8% 49.2% 10.0% 100% 130

haemoptysis 34.9% 32.9% 24.2% 8.1% 100% 149

hoarse voice 11.1% 33.3% 40.7% 14.8% 100% 27

lymphadenopathy 7.4% 22.2% 70.4% 0.0% 100% 27

musculoskeletal pain 17.6% 18.6% 57.8% 5.9% 100% 102

not known 17.9% 16.4% 35.8% 29.9% 100% 67

other 15.3% 22.2% 53.4% 9.1% 100% 176shortness of breath 25.1% 30.7% 30.4% 13.9% 100% 303

weight loss 18.1% 24.5% 40.4% 17.0% 100% 94

Total 24.7% 29.5% 35.6% 10.2% 100% 2014 Table 8.3-3, stage by symptom, or lung cancer.

Prostate cancer


asymptomatic 75.5% 14.0% 5.0% 5.5% 100% 200

blood in the semen 57.1% 14.3% 14.3% 14.3% 100% 14blood in the urine 63.8% 12.5% 15.6% 8.1% 100% 160

bone pain 35.0% 5.0% 57.5% 2.5% 100% 40

change in bowel habit 50.0% 19.2% 23.1% 7.7% 100% 26

enlargement of the prostate glan 64.6% 16.7% 9.8% 8.9% 100% 246

erectile dysfunction 70.0% 20.0% 2.0% 8.0% 100% 50

fatigue 39.1% 17.4% 43.5% 0.0% 100% 46

genitourinary tract pain 54.9% 19.6% 15.7% 9.8% 100% 51

incontinence 66.7% 11.1% 16.7% 5.6% 100% 18

lower urinary tract symptoms 63.1% 17.8% 9.7% 9.5% 100% 931

not known 44.9% 13.5% 10.1% 31.5% 100% 89

other 48.5% 9.1% 32.7% 9.7% 100% 309

painful urination 66.1% 15.3% 11.9% 6.8% 100% 59raised psa 71.9% 16.3% 5.3% 6.5% 100% 508

urine retention 47.1% 15.7% 26.4% 10.7% 100% 121

weight loss 25.0% 22.7% 43.2% 9.1% 100% 44

Total 61.4% 15.6% 14.0% 9.0% 100% 2912 Table 8.3-4, stage by symptom, or prostate cancer.

49



8.4 Presentation route

Organ Local spread Distant mets Not known Total n

Emergency 34.1% 24.8% 28.3% 12.7% 100% 24322 week 47.1% 27.5% 16.5% 8.9% 100% 10175

Routine 54.0% 20.4% 13.7% 11.8% 100% 2789

Private 47.5% 26.4% 17.0% 9.1% 100% 931

Not referred by practice 45.5% 21.4% 20.9% 12.2% 100% 1323

Not known 34.3% 19.9% 18.1% 27.7% 100% 1229

Total 45.5% 25.1% 18.0% 11.3% 100% 18879 Table 8.4-1, stage by route o diagnosis.

8.5 Commentary

This is the most comprehensive description o stage at diagnosis yet to become available. Levels o recordingvary considerably by cancer registry and by cancer site, but even in the best circumstances are in theregion o 75% complete across all cancer types. In this audit we received stage data on 89% o all casesand the proportion is higher i only solid tumours are considered. The data or a small number o sitesshould be interpreted with caution. The staging or myeloma and leukaemia are not compatible with theoptions oered in this audit and thereore the data or these sites are not reliable . Brain cancer very rarelyundergoes distant spread (though it is a site or secondary spread) and the reported 5.1% with distantspread may be unreliable.

When all cancers are considered, there are notable dierences in stage at diagnosis or those with

communication difculty and housebound status. Cancer diagnosis in these population sub-groups meritsurther investigation to determine the underlying reasons. Age >75 yrs was associated with more advancedstage or prostate cancer but with earlier stage or lung cancer.

For emergency presentations, compared to other reerrals, there are about 25% ewer with organ-confneddisease, mirrored by a greater proportion with disseminated disease. Even so, a third o emergencypresentations have disease confned to the organ or origin. We need to know more about the way thatsymptoms develop in these patients in order to understand where interventions to reduce emergencypresentation can be most eectively targeted.

50



This frst national audit o cancer diagnosis in primary care gained the participation o 14% o all thepractices in England, a remarkable level o voluntary participation. It has demonstrated that high quality,reliable inormation on the primary care pathway to cancer diagnosis can be collected through audit utilisingprimary care records. It has provided unique insights into the diagnostic pathway or the rarer cancers, orwhich it obtained data on signifcant numbers in all cases.

There are important potential sources o bias to be acknowledged. Participation was voluntary, and in a ewcases selective. It is possible that those practices most interested in cancer care volunteered to participate,and thereore the fndings represent ‘better’ practice. Against this, one in six o all English general practicesparticipated and the eect is unlikely to be a major bias.

Practices were required to audit all cases occurring in a specifed period. There are 250,000 cases o cancerannually in England. When this fgure is adjusted by the exclusion criteria or the audit and the proportion opractices participating, there is no evidence o signifcant exclusion o cases.

Data was extracted rom clinical records and hospital correspondence. This was done by a range oindividuals, sometimes a clinician and sometimes an administrative assistant. In all cases it was reviewed ata practice meeting and then by a cancer network clinical lead. There is scope or errors o interpretation, orexample in deciding on the date o frst consultation or the stage o disease. Such potential sources o errorapply to most studies o diagnostic intervals and we do not believe that this audit was more susceptible orsome reason. We particularly stress caution in the interpretation o the patient interval, since this is betterdetermined by means other than scrutiny o GP records.

Two other important reports have been published in recent months, the NCIN analysis o Routes to Diagnosisand the Patient Experience survey. In several respects the fndings o this audit bear out the fndings o thosereports. For example, in fnding that two-thirds o patients consult once or twice beore reerral. Where they

dier, or example on the proportion o emergency presentations, it is important to careully analyse thereasons. The valuable understanding o cancer diagnosis that is being built up through these separate pieceso work will be stronger or doing so.

This report provides a descriptive overview o the results o the audit. It oers an opportunity to CancerNetworks and PCTs to benchmark their own local results against a national picture. There remain somesignifcant pieces o work to be undertaken. For example, over 4000 ree text comments were made onreasons or delay in diagnosis and these are currently being analysed using a combination o qualitativeand quantitative methods. The oversight group have put in place a process by which requests or accessto the data by bona fde researchers and NHS organisations or the purpose o additional analysis can beconsidered.

As a result o the experience o conducting this audit, some changes have been made to the felds andexplanatory notes. These continue to be available on www.durham.ac.uk/school.health/erdu/cancer_audit/ .In 2010/11 its use is being encouraged by Cancer Network GP leads as they work with selected practices onthe introduction o practice cancer profles.

Future audit o the part played by general practice in cancer diagnosis may develop in several directions. Thecancer diagnostic pathway spans primary and secondary care. Combining primary and secondary care auditor specifc cancer sites has the potential to oer valuable insights into the sometimes poorly understoodinteraction between two, inorming uture commissioning needs.

51

http://www.durham.ac.uk/school.health/erdu/cancer_audit/

http://www.durham.ac.uk/school.health/erdu/cancer_audit/



1. In the absence o a NICE Quality Standard or NHS Commissioning Board guidance, commissionersmight like to consider the ollowing points when commissioning cancer care in primary care settings.Specifcally, the fndings rom this report could inorm the setting o criteria or good practice in cancerdiagnosis in primary care.

2. The fndings o this report could be used to inorm plans to improve access to diagnostics as outlined inImproving Outcomes: a Strategy for Cancer

3. The Cancer Diagnosis Audit Tool could be a useul tool or practices, Cancer Networks andcommissioners to identiy local areas or improvement and to monitor the impact o serviceimprovements.

4. The systematic use o national level data on the audit o cancer diagnosis could be used in order tomonitor the impact on primary care outcomes o policy in the area o early diagnosis.

5. The Cancer Diagnosis Audit Tool could be used by practices to review their quality o care in the area ocancer diagnosis. Aspects o care that might be examined could include• The number o consultations prior to reerral• The proportion o patients with cancer who present as an emergency

• The quality o care experienced by patients who are disadvantaged by virtue o being housebound,having communication difculties, being old or rom an ethnic minority

• The use o appropriate basic investigations prior to reerral6. Analytical support could be made available or those commissioners and networks that make locality-

wide use o the audit tool.7. Primary care audit could be combined with other data, rom secondary care audit or rom the

Association o Public Health Observatories Practice Profles, or example, to generate more detailedunderstanding o actors inuencing the pathway to diagnosis.

8. The role o co-morbidities should be examined in uture audit.

Acknowledgements

We wish to specifcally acknowledge the contributions o Nicola Cooper and Chris Carrigan at NCIN, as wellas the support o the Cancer Network GP leads at the time o this audit.

52



The Audit steering group comprised:

David WellerPeter RoseIan WatsonKathy ElliottJennier BenjaminImran RafRosie LotusSara HiomCathy BurtonRichard Neal

The sub-group overseeing this national analysis comprised:

David WellerPeter VedstedRosie LotusCathy BurtonKathy ElliottSara HiomImran Raf

53



Data Security and Data Transfer

Summary

This document describes the governance arrangements around the collation and analysis o data rom theNational Audit o Cancer Diagnosis in Primary Care, at a national level. It also describes the steps by whichthis data is anonymised beore being submitted to the National Cancer Action Team. The data submittedwill be held securely at the South West Public Health Observatory (SWPHO) within the custodianship o

the National Cancer Intelligence Network (NCIN). Data security and the governance procedures around therelease o data are also described.

Roles and contact details

Project Lead Professor Greg Rubin

[email protected]

NCAT Sponsor Kathy Elliott

[email protected]

Project Analyst andprimary contact for data exchange

Dr Sean [email protected]

01179 706 474 x364

Address for correspondence

Dr Sean McPhail

South West Public Health Observatory

Grosvenor House

149 Whiteladies Road

Bristol

BS8 2RA

InformationCustodian

Chris Carrigan, Head of NCIN Co-ordinating Team

[email protected]

020 7061 8377

Local CaldicottGuardian

Dr Julia Verne, Director of the South West Public HealthObservatory

[email protected]

01179 706 474

54



Security of data

The data will be held in same system that is currently used to store the cancer registration dataset or theSouth West o England. This is a server which is an integral part o the South West Public Health Observatorylocal area network. The SWPHO network has a hardened CISCO PIX frewall and anti-virus sotware whichare approved to a NHS code o connection standard.

User access is through PC terminals, running Windows XP, physically within the organisation. These arepassword protected and can only be used by members o the organisation. In addition, access to the datais restricted to those who use it as part o their daily work. The building in which the data is held is securewith two independent alarm systems. Daytime access requires both a pin number and a swipe-card to passthrough two locked doors. Servers are located behind urther doors with separate pin coded security locks,accessible only by nominated IT support sta. The SWPHO security policy is ully implemented and complieswith ISO 17799 and 27001.

Data backups are held encrypted on magnetic tapes on site in a locked freproo sae.

Anonymisation

Using the process described below and embodied in the accompanying spreadsheet will pseudo-anonymisethe patients and GP surgeries. Each patient and GP surgery will be assigned a new ID number. Each networkor PCT that submits data will hold the fle which will cross reerence the new ID number to a list o GPsurgeries, meaning that practices are anonymous within the national analysis.

This type o pseudo-anonymisation will allow the NCAT to inorm a submitting network/PCT i analysis othe data reveals issues o clinical signifcance, and or the network/PCT to trace these to their source, all the

while preserving the anonymity o the GP surgeries at a national level.

The pseudo-anonymisation process will also allow data quality issues within the dataset to be investigatedby grouping patients by their GP surgery while anonymising both their identity and that o their GP surgery.Careul data quality work o this nature is necessary to ensure robustness o the resultant analyses.

Use and release of data

The analytical programme or the project will be determined by an Analysis Steering Group chaired byProessor Greg Rubin and the NCIN Lead or Analysis and Inormation. This group will design and overseethe analysis o the national dataset, taking all appropriate steps to ensure that the resultant outputs are

clinically and statistically robust.

Quality assurance o analytical outputs will take place within the NCIN with input rom the Analysis SteeringGroup.

Release o analytical outputs will take place as determined by the Project Lead, NCAT Sponsor, andInormation Custodian.

55



Preparing and sending the data

Preparing the data for anonymisation

The data sheets sent back rom each GP surgery can either be combined by manually cut-and-pasting theminto a single spreadsheet or via the more automated procedure described below and in the accompanyingspreadsheet:

1. Copy all the audit spreadsheets returned by your GPs into a single directory. These should be the rawdata fles submitted by each GP practice beore any data processing is done on them. A quick way odoing this is described below.a. Open windows explorer.b. Navigate to the directory that holds all your spreadsheets (probably in separate sub-directories).c. Right-click on the directory and pick “search” rom the menu.d. Type “xls” or the search text and run the search.

e. This should fnd all the spreadsheets in your directory and its sub-directories.. Press Ctrl-A to select all the spreadsheets.g. Copy them all to a resh directory.h. Check that you haven’t included any spreadsheets that don’t include GP audit data.

2. Save the “National Audit o Cancer Diagnoses - anonymisation v1.2.xls” spreadsheet that you receivedalong with this document into the same directory.

3. Open the “National Audit o Cancer Diagnoses - anonymisation v1.2.xls” spreadsheet.4. Follow the instructions in the “National Audit o Cancer Diagnoses - anonymisation v1.2.xls”

spreadsheet to combine the raw data.

Anonymising the data

Once the data returned by the GP surgeries has been combined it can be anonymised using theaccompanying spreadsheet. Full instructions are included in the spreadsheet itsel.

Sending the data

1. I the anonymisation has been successul two new spreadsheets will have been created in the samedirectory – “RCGP audit data to submit.csv” and “RCGP audit network data.csv”.

2. Check that these spreadsheets contain the number o patients and GP surgeries that you expect themto.

3. Save the “RCGP audit network data.csv” spreadsheet or your records.

4. The spreadsheet named “RCGP audit data to submit.csv” should be emailed as an attachment to [email protected].

Data should only be sent via the national email acility NHS Contact (i.e. email addresses ending with @nhs.net). All data should be accompanied with the Name, Address, and Telephone Number o the sender.Receipt o data will be confrmed within two working days.

I you have any problems with or questions about processing or sending the data please contact SeanMcPhail or assistance ([email protected], 01179 706 474 x364).

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mailto:sean.mcphail%40nhs.net?subject=National%20Audit%20of%20Cancer%20Diagnosis%20in%20Primary%20Care








CANCER PATHWAY NOTES

Template Heading What is wanted Why this is wanted

Patient IDSome way for your practice to identify the patient. Please donot use patient name, DOB or any other identifiable data.

Consider using computer number

To allow the GP practice to identify and differentiatebetween different patients when completing the

template

NHS No. Patient's NHS No.

To allow linkage of this information with Cancer Registry data, e.g. on staging and outcome. If your practice has witheld consent for linkage, this field neednot be completed

DoB Date of birth

Gender Male or Female

Ethnicity Ethnicity of patient

Country of origin Patient's country of origin

Problems communicating Any communication problems the patient has

Housebound Is the patient housebound

To help determine any relationship betweenage/gender/ethnicity/language/communicationproblems/access and the likelihood of urgent referralor diagnosis of cancer

Diagnosis

Enter the diagnosis of the primary cancer Please note that theaudit should only include confirmed malignancies andEXCLUDES non-melanotic carcinomas of the skin. AlsoEXCLUDE CIN, for example of the cervix, or other carcinoma in

situ.

This will allow comparison about the referral processfor different types of cancer

Date patient noted firstsymptoms or signs of cancer

For all date entries please enter date as dd/mm/yy. This willallow a hidden program to calculate the number of daysbetween different dates. If the notes only refer to the month(i.e. diarrhoea since May 2007), put '15th' as the day of themonth (i.e. 15/05/07) If the date is not known, please enter 'NK'

The cancer journey starts when the patient first noticesa symptom or sign that is suggestive of cancer. Theremay be long delays before the patient then presents toPrimary Care. Noting how long the patient waitedbefore presenting may provide useful information

57



Date patient reported symptomor sign to Primary Care

First notification to any health care professional working withinthe Primary Health Care Team about a symptom or sign whichwas probably due to the cancer

about barriers to attending for health care. It may alsohelp inform which cancers need Health Promotioncampaigns to encourage earlier attendance.

Date of Decision to Refer

Date that a Primary Health Care professional decided to refer

the patient to secondary care for further investigation or management of the symptoms or signs suggestive of cancer

To identify if there is any delay in actioning referral incertain cancers.

Date Referral SentDate that the referral letter was sent from Primary Care. If thisis not available, please use the date that the referral letter or proforma was completed.

To identify if delays in practice systems significantlyaffect overall waits for treatment from firstpresentation.

Type of referralThe urgency with which a patient was referred for further investigation or management

To allow GPs to review the urgency with which theyreferred their patient

Date first seen by specialistDate the patient first had contact with secondary care followingthe referral, whether for an investigation or an out patientappointment

Delays in informing practiceDo you think that there were avoidable delays in the practicebeing informed?

This information (if available) will help give informationabout any delays around diagnosis or communication

Were there avoidable delays tothis patient's journey

Reflect on the referral process and consider what things mayhave improved the diagnostic journey for the patient, and howthings may have been improved

Powerful learning tool and opportunity to makesuggestions about how the referral process could beimproved.

58



Cancer Network Participating PCTs /

localities

No of

participating

% uptake

practices

Greater

Manchester and

Cheshire

11 PCTs 59 Limited to

10% of all

practices

Merseyside and

Cheshire

7 PCTs 33 79% (funding

was available

for 42

practices)

North Trent Barnsley

Doncaster

Bassetlaw

Rotherham

Sheffield

Chesterfield –North

Chesterfield - South

9

9

3

12

13

20

9

21%

20%

27%

29%

14%

36%

16%

East Midlands Leicestershire County

Rutland

Leicester City

Northamptonshire

47

40

52

57%

60%

63%

Mount Vernon Hertfordshire 31 27%

North West

London

7 (out of 8) PCTs Not available Not available

North London Islington

Barnet

Camden

West Essex

Enfield

Haringey

24

37

20

19

16

5

63%

53%

50%

47%

26%

9%

North East

London

Not available Not available Not available

South East

London

Lambeth

Bromley

Greenwich

Southwark

32

26

21

8

62%

Not available

Not available

Not available

South West

London

5 PCTS 39 Not available

Peninsula Plymouth 31 Not available

Dorset Not recorded Not available Not available

59



Avon, Somerset,

Wiltshire

Banes

Bristol

N Somerset

8

15

9

30%

26%

35%

Somerset

S Gloucestershire

Wiltshire

6

6

11

8%

21%

18%

Three Counties Not recorded 73 Not available

Surrey, West

Sussex

Hampshire

Adur and West Crawley

localities

Spellthorne and Woking

localities

Surrey PCT

22

28

100%

100%

Kent andMedway

Medway 21 Not available

Anglia 6 PCTs 124 33%

Greater Midlands 8 PCTs 161 42.8%

Lancashire and S

Cumbria

North Lancashire PCT 16 Not available

60



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http://info.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@hea/documents/generalcontent/cr_046646.pdf






http://www.dur.ac.uk/school.health/erdu/cancer_audit/cancerdiagnosisaudittool/



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The Royal College o General Practitioners is a network o over 42,000 amily doctors working to improvecare or patients. We work to encourage and maintain the highest standards o general medical practiceand act as the voice o GPs on education, training, research and clinical standards.



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Royal College of General Practitioners

Documents

National Audit of Cancer Diagnosis in Primary-Care