This site is intended for health professionals only

Six in ten red flag cancer symptoms not referred through two-week wait, finds study

Six in ten red flag cancer symptoms not referred through two-week wait, finds study

Six in ten patients with key red flag cancer symptoms are not given an urgent referral when they present to their GP, a study of practice data shows.

Analysis of GP data from 2014/15 found that of those who did not receive a referral through the 14-day urgent pathway, 3.6% were diagnosed with cancer within the next year.

The researchers noted that of those who did receive a two-week wait referral almost 10% went on to be diagnosed with cancer within the next 12 months.

Overall of the 48,715 patients who presented with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time, 40% received a two-week wait referral.

But there were large differences depending on the symptom with 68% of breast lumps referred urgently compared with 17% of patients with dysphagia.

Rates of referral also varied substantially both among clinicians and among practices, the researchers from the University of Exeter reported in BMJ Quality and Safety.

Younger patients and those with a higher number of coexisting conditions were less likely to be given an urgent referral, they reported.

And although there was no overall link with deprivation across all symptoms, there was evidence that patients living in more deprived neighbourhoods were more likely to be referred urgently if they presented with haematuria, post-menopausal bleeding, or rectal bleeding, but less likely to be referred urgently with a breast lump.

The percentage of patients diagnosed with cancer of a specific site within a year who had not been referred urgently was low for most cancers, with the exception of bowel cancer for patients with iron deficiency anaemia (5.5%), breast cancer for those with a breast lump (3.5%), and womb cancer for patients with postmenopausal bleeding (3%).

It is important to note that as an observational study, the research can not establish cause and could also not assess the potential impact of any referral on cancer progression. 

In a health and social care committee hearing last week, RCGP chair Professor Martin Marshall told MPs that GPs need to shift their mindset to have a lower threshold for referral for potential cancer symptoms.

Recent research published in the British Journal of General Practice found that urgent 14-day referrals have more than doubled over the past ten years.

Speaking with Pulse, study author Professor Willie Hamilton, professor of primary care diagnostics at the University of Exeter, said there were several possible explanations for why a referral was not made despite it being recommended in the guidelines.

These include an emergency admission, an out-of-hours consultation, or prior referral for another condition, which would not have shown up in the study.

Overall the team concluded that ‘stricter adherence to the guidelines and increased awareness of patient groups especially at risk of long diagnostic timelines may help improve early diagnosis and ultimately cancer survival rates’. 

But efforts to do this must focus on the whole diagnostic pathway, they added.

Being able to easily access two-week wait pathways or variation in local referral guidance may partly explain the findings, Professor Hamilton said, explaining that two-week wait referrals are rising by about 10% every year.

‘We also need to remember that there is often a clear explanation for the symptom and that the GP is “right” in non-referral. However, they’re not always “right” when you see the cancer percentages in the non-referred.’

He added: ‘It’s a tricky finding – and far too easy to interpret as GPs not offering patients what they need. But GPs don’t work in isolation – we know secondary care are really under pressure in providing diagnostic services and [we] try not to make unnecessary referrals.

‘What this study shows is that the selection process works (the cancer rate in the referred was much higher than in the non-referred) but does it work enough? That’s the area we need to think over.’

Responding to the study, RCGP’s Professor Marshall pointed out that the study looks at data from 2014/15 and that since then, new cancer guidance [NG12] has been published and ‘referrals via the urgent two-week referral pathway increased by nearly 44% up to 2019/20’.

‘Additionally, the percentage of cancer diagnoses made through this urgent pathway has increased from 48.4% in 2014/15 to 54% in 2019/20.

‘This is against a backdrop of increasing workload and falling GP numbers over the same period,’ he said.

Adding: ‘What the research does show is the importance of clinical judgement in making a decision to refer. GPs follow clinical guidance to ensure that referrals are appropriate and are sensitive to the risks of over-referring patients because this would risk overloading specialist services and would not be helpful to patients or the NHS.

‘GPs find themselves in a position where they are criticised for referring both too much and too little: what would help is better access to diagnostic tools in the community and additional training to use them and interpret the results, so that better informed referrals can be made.

‘GPs and our teams are currently working under intense workload and workforce pressures but referring patients they suspect of having cancer is something they take incredibly seriously.’

Meanwhile, improved artificial intelligence (AI) and training of receptionists would also aid GPs in improving rates of early cancer diagnosis, RCGP clinical adviser Dr Richard Roope suggested to MPs last month.

Click to complete relevant cancer CPD modules on Pulse Learning.


Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.


Please note, only GPs are permitted to add comments to articles

Mark Essop 5 October, 2021 10:45 am

Why on earth use such old data?

Douglas Callow 5 October, 2021 11:34 am

pointless article
AI and digital solutions no issues finding money
expanding medical workforce in primary care apart from ARRS on the way to difficult step !
go figure

Christopher Castle 5 October, 2021 12:51 pm

This study misses the point the red flags are a terrible tool for screening cancer- they found tgat 96.4% of patients with ted flags did not develop cancer.

The study should be concluding that red flags are useless and a better screening process is required. Until then experienced GPs are the best that we have.

David OHagan 5 October, 2021 1:04 pm

This is simply a restatement of last weeks headline about lowering the threshold for referral to a lower risk of cancer level.
This is a proposed strategy which is not supported by the available infrastructure.
GPs, as we have to work in the real world, know that if we refer too many people with ever lower risk of cancer we will further overload an already sunken ship.

Patrufini Duffy 5 October, 2021 1:14 pm

The cancer anxiety epidemic. What is this country dodging?… mortality? That’s one long struggle.

James Cuthbertson 5 October, 2021 1:36 pm

Unfortunately a lot of the work of a good GP- balancing risk, watching and waiting, preventing inappropriate prescribing and referrals, is a thankless task. If you refer every patient and detect a couple of extra cancers early over your career you’re a hero, no matter how much collateral damage is caused.

Patrufini Duffy 5 October, 2021 3:07 pm

Also more than 6 in 10 with a red flag don’t have cancer. Go figure.

Kevlar Cardie 5 October, 2021 4:23 pm

36.74 % of statistics are made up on the spot.

David Ansell 11 October, 2021 1:13 pm

The study states that for haematuria they only checked to see if the 2 most common drugs (nitrofurantoin, trimethprim) to treat a uti were used otherwise classed it as missed cancer. This was just lazy and this study shows poor research process rather than poor GP practice.
Also local hospital referral acceptance criteria for 2ww for rectal bleed varies by age group. Some insisting on fbc and anaemia and prior to acceptance of a 2ww referral. None of this was taken into account in the study analysis.
Iron deficiency anaemia occurs in chronic disease such as rheumatoid arthritis, chronic kidney disease, ulcerative colitis. Some guidelines insist on a +ve Fit test before acceptance for 2ww.

This was a poorly designed study and lacked any proper clinical thought or pathway process.
At outset it was predestined to falsely indicate poor GP practice.