Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer.

NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68-0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67-0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21-0.35 p < 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.

Delays in referral from primary care worsen survival for patients with colorectal cancer: a retrospective cohort study.

BACKGROUND: Delays in referral for patients with colorectal cancer may occur if the presenting symptom is falsely attributed to a benign condition. AIM: To investigate whether delays in referral from primary care are associated with a later stage of cancer at diagnosis and worse prognosis. DESIGN AND SETTING: A national retrospective cohort study in England including adult patients with colorectal cancer identified from the cancer registry with linkage to Clinical Practice Research Datalink, who had been referred following presentation to their GP with a 'red flag' or 'non-specific' symptom. METHOD: The hazard ratios (HR) of death were calculated for delays in referral of between 2 weeks and 3 months, and >3 months, compared with referrals within 2 weeks. RESULTS: A total of 4527 (63.5%) patients with colon cancer and 2603 (36.5%) patients with rectal cancer were included in the study. The percentage of patients presenting with red-flag symptoms who experienced a delay of >3 months before referral was 16.9% of those with colon cancer and 13.5% of those with rectal cancer, compared with 35.7% of patients with colon cancer and 42.9% of patients with rectal cancer who presented with non-specific symptoms. Patients referred after 3 months with red-flag symptoms demonstrated a significantly worse prognosis than patients who were referred within 2 weeks (colon cancer: HR 1.53; 95% confidence interval [CI] = 1.29 to 1.81; rectal cancer: HR 1.30; 95% CI = 1.06 to 1.60). This association was not seen for patients presenting with non-specific symptoms. Delays in referral were associated with a significantly higher proportion of late-stage cancers. CONCLUSION: The first presentation to the GP provides a referral opportunity to identify the underlying cancer, which, if missed, is associated with a later stage in diagnosis and worse survival.

Comparison of cancer diagnosis recording between the Clinical Practice Research Datalink, Cancer Registry and Hospital Episodes Statistics.

INTRODUCTION: The Clinical Practice Research Datalink (CPRD) is a large electronic dataset of primary care medical records. For the purpose of epidemiological studies, it is necessary to ensure accuracy and completeness of cancer diagnoses in CPRD. METHOD: Cases included had a colorectal, oesophagogastric (OG), breast, prostate or lung cancer diagnosis recorded in a least one of CPRD, Cancer Registry (CR) or Hospital Episodes Statistics(HES) between 2000 and 2013. Agreement in diagnosis between the datasets, difference in dates, survival at one and five-years, and whether patient characteristics differed according to the dataset or the timing of diagnosis were investigated. RESULTS: 116,769 patients were included. For each cancer, approximately 10% of cases identified from CPRD or HES were not confirmed in the CR. 25.5% colorectal, 26.0% OG, 8.9% breast, 32.0% lung and 18.6% prostate cases identified from the CR were missing in CPRD. The diagnosis date was recorded later in CPRD compared with CR for each cancer, ranging from 81.1% for prostate to 59.6% for colorectal, especially if the diagnosis was an emergency. Compared with the CR and HES, the adjusted risk of a missing diagnosis in CPRD was significantly higher if the patient was older, had more co-morbidities or was diagnosed as an emergency. Survival at one and five-years was highest for CPRD. CONCLUSION: Patient demographics and the route of diagnosis impact the accuracy of cancer diagnosis in CPRD. Although CPRD provides invaluable primary care data, patients should ideally be identified from the CR to reduce bias.