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Background A two-phase ‘respiratory symptoms’ mass media campaign was conducted in 2016 and 2017 in England raising awareness of cough and worsening shortness of breath as symptoms warranting a general practitioner (GP) visit. Method A prospectively planned pre–post evaluation was done using routinely collected data on 15 metrics, including GP attendance, GP referral, emergency presentations, cancers diagnosed (five metrics), cancer stage, investigations (two metrics), outpatient attendances, inpatient admissions, major lung resections and 1-year survival. The primary analysis compared 2015 with 2017. Trends in metrics over the whole period were also considered. The effects of the campaign on awareness of lung cancer symptoms were evaluated using bespoke surveys. Results There were small favourable statistically significant and clinically important changes over 2 years in 11 of the 15 metrics measured, including a 2.11% (95% confidence interval 1.02–3.20, p Conclusion There were small positive changes in most metrics relating to lung cancer diagnosis after this campaign. However, the pattern over time challenges whether the improvements are wholly attributable to the campaign. Given the importance of education on cancer in its own right, raising awareness of symptoms should remain important. However further research is needed to maximise the effect on health outcomes.

Background Emergency diagnosis of cancer is associated with poorer short-term survival and may reflect delayed help-seeking. Optimal targeting of interventions to raise awareness of cancer symptoms is therefore needed. Methods We examined the risk of emergency presentation of lung and colorectal cancer (diagnosed in 2016 in England). By cancer site, we used logistic regression (outcome emergency/non-emergency presentation) adjusting for patient-level variables (age, sex, deprivation and ethnicity) with/without adjustment for geodemographic segmentation (Mosaic) group. Results Analysis included 36 194 and 32 984 patients with lung and colorectal cancer. Greater levels of deprivation were strongly associated with greater odds of emergency presentation, even after adjustment for Mosaic group, which nonetheless attenuated associations (odds ratio [OR] most/least deprived group = 1.67 adjusted [model excluding Mosaic], 1.28 adjusted [model including Mosaic], P Conclusion Variation in risk of emergency presentation in cancer patients can be explained by geodemography, additional to deprivation group and age. The findings support proof of concept for public health interventions targeting all the examined attributes, including geodemography.

Objective: To assess the impact of the fourth Be Clear on Cancer (BCoC) ‘Blood in Pee’ (BiP) campaign (July to September 2018) on bladder and kidney cancer symptom awareness and outcomes in England. Methods: In this uncontrolled before and after study, symptom awareness and reported barriers to GP attendance were assessed using panel and one-to-one interviews. The Health Improvement Network (THIN), National Cancer Registration and Analysis Service (NCRAS) and NHS Cancer Waiting Times (CWT) data were analysed to assess the impact on GP attendances, urgent cancer referrals, cancer diagnoses and 1-year survival. Analyses used Poisson, negative binomial and Cox regression. Results: Symptom awareness and intention to consult a GP after one episode of haematuria increased following the campaign. GP attendance with haematuria (rate ratio (RR) 1.17, 95% confidence interval (CI): 1.07–1.28) and urgent cancer referrals (RR 1.18 95% CI: 1.08–1.28) increased following the campaign. Early-stage diagnoses increased for bladder cancer (difference in percentage 2.8%, 95% CI: −0.2%–5.8%), but not for kidney cancer (difference −0.6%, 95% CI: −3.2%–2.1%). Conclusions: The fourth BCoC BiP campaign appears to have been effective in increasing bladder cancer symptom awareness and GP attendances, although long-term impacts are unclear.

Objective: A regional ‘Be Clear on Cancer’ (BCoC) campaign developed by Public Health England aimed to promote public awareness of key abdominal cancer symptoms in people aged 50 years and over. Methods: Data were analysed for metrics at different stages in the patient care pathway including public awareness, GP attendance and referrals, to cancer diagnosis. Results: There was significantly higher recognition of the BCoC abdominal campaign in the campaign region compared to the control area (Post Campaign/Control, n = 401/406; 35% vs. 24%, p [less than] 0.05). The campaign significantly improved knowledge of ‘bloating’ as a symptom (p = 0.03) compared to pre-campaign levels. GP attendances for abdominal symptoms increased significantly by 5.8% (p = 0. 03), although the actual increase per practice was small (average 16.8 visits per week in 2016 to 17.7 in 2017). Urgent GP referrals for suspected abdominal cancer increased by 7.6%, compared to a non-significant change (0.05%) in the control area. For specific abdominal cancers, the number diagnosed were similar to or higher than the median in the campaign area but not in the control area in people aged 50 and over: colorectal (additional n = 61 cancers), pancreatic (additional n = 102) and stomach cancers (additional n = 17). Conclusions: This campaign had a modest impact on public awareness of abdominal cancer symptoms, GP attendances and cancers diagnosed.

The Be Clear on Cancer (BCoC) campaigns have run in England since 2010. They aim to raise awareness of possible cancer symptoms, encouraging people to consult a general practice with these symptoms. Our study provides an overview of the impact of 11 national campaigns, for bowel, lung, bladder and kidney, breast and oesophago-gastric cancers. We synthesised existing results for each campaign covering seven clinical metrics across the patient pathway from primary care attendances to one-year net survival. For each metric, "before" and "after" periods were compared to assess change potentially related to the campaign. Results show that primary care attendances for campaign-related symptoms increased for 9 of 10 campaigns and relevant urgent referrals for suspected cancer increased above general trends for 9 of 11 campaigns. Diagnostic tests increased for 6 of 11 campaigns. For 7 of 11 campaigns, there were increases in cancer diagnoses resulting from an urgent referral for suspected cancer. There were sustained periods where more cancers were diagnosed than expected for 8 of 10 campaigns, with higher than expected proportions diagnosed at an early stage for sustained periods for 4 of 10 campaigns. There was no impact on survival. In summary, there is evidence that the BCoC campaigns impact help-seeking by patients and referral patterns by general practitioners, with some impact on diagnosis (incidence and stage). There was no clear evidence of impact on survival.

Background Large variation in measures of diagnostic activity has been described previously between English general practices, but related predictors remain understudied. Objective To examine associations between general practice population and characteristics, with the use of urgent referrals for suspected cancer, and use of endoscopy. Methods Cross-sectional observational study of English general practices. We examined practice-level use (/1000 patients/year) of urgent referrals for suspected cancer, gastroscopy, flexible sigmoidoscopy and colonoscopy. We used mixed-effects Poisson regression to examine associations with the sociodemographic profile of practice populations and other practice attributes, including the average age, sex and country of qualification of practice doctors. Results The sociodemographic characteristics of registered patients explained much of the between-practice variance in use of urgent referrals (32%) and endoscopic investigations (18–25%), all being higher in practices with older and more socioeconomically deprived patients. Practice-level attributes explained a substantial amount of between-practice variance in urgent referral (19%) but little of the variance in endoscopy (3%-4%). Adjusted urgent referral rates were higher in training practices and those with younger GPs. Practices with mean doctor ages of 41 and 57 years (at the 10th/90th centiles of the national distribution) would have urgent referral rates of 24.1 and 19.1/1000 registered patients, P < 0.001. Conclusion Most between-practice variation in use of urgent referrals and endoscopies seems to reflect health need. Some practice characteristics, such as the mean age of GPs, are associated with appreciable variation in use of urgent referrals, though these associations do not seem strong enough to justify targeted interventions.

A retrospective population-based observational study using cancer registration data of women diagnosed with invasive cervical cancer between 2006 and 2010, in England, was carried out to explore how different morphological subtypes affect survival rates. Age-standardised net survival rates by morphological subtype are presented alongside with excess mortality modelling accounting for the impact of demographic, diagnostic and tumour factors. The three main morphological subtypes (squamous cell carcinoma (SCC), adenocarcinoma and adenosquamous carcinoma) have similar one-year net survival rates of approximately 85%. After adjusting for other important determinants of survival, there were no differences at five-years amongst the three main morphological subtypes, with unadjusted survival rates of 55-65%. As expected, women presenting with neuroendocrine tumours had a much poorer outcome than other epithelial cervical malignancies, with 1-year survival of up to 55%, five-year survival of 34% and excess mortality rates compared to SCC varying between 1.9 and 5.9. Impact Statement What is already known on this subject: This is the first study on survival by cervical cancer morphological subtype using national cancer data. What the results of this study add: This study uses excess mortality modelling to investigate the effects of the morphological subtypes whilst adjusting the other factors that affect cervical cancer survival such as stage, age and grade. What the implications are of these findings for clinical practice and/or further research: It is known that cervical neuroendocrine tumours have a poor prognosis and this is confirmed by this study. Squamous cell carcinomas (SCC), adenocarcinomas (AC) and adenosquamous carcinomas (ASC) have the highest net survival and when accounting for other factors there are no differences amongst these morphological subtypes in terms of survival.

BackgroundThere is considerable variation between GP practices in England in their use of urgent referral pathways for suspected cancer.AimTo determine the association between practice use of urgent referral and cancer stage at diagnosis and cancer patient mortality, for all cancers and the most common types of cancer (colorectal, lung, breast, and prostate).Design and settingNational cohort study of 1.4 million patients diagnosed with cancer in England between 2011 and 2015.MethodThe cohort was stratified according to quintiles of urgent referral metrics. Cox proportional hazards regression was used to quantify risk of death, and logistic regression to calculate odds of late-stage (III/IV) versus early-stage (I/II) cancers in relation to referral quintiles and cancer type.ResultsCancer patients from the highest referring practices had a lower hazard of death (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.95 to 0.97), with similar patterns for individual cancers: colorectal (HR = 0.95; CI = 0.93 to 0.97); lung (HR = 0.95; CI = 0.94 to 0.97); breast (HR = 0.96; CI = 0.93 to 0.99); and prostate (HR = 0.88; CI = 0.85 to 0.91). Similarly, for cancer patients from these practices, there were lower odds of late-stage diagnosis for individual cancer types, except for colorectal cancer.ConclusionHigher practice use of referrals for suspected cancer is associated with lower mortality for the four most common types of cancer. A significant proportion of the observed mortality reduction is likely due to earlier stage at diagnosis, except for colorectal cancer. This adds to evidence supporting the lowering of referral thresholds and consequent increased use of urgent referral for suspected cancer.

Objective To quantify trends in 30-day mortality following surgery for endometrial carcinoma in England, and investigate hospital- and geographical-level variations. Design Retrospective population-based observational study using cancer registration and Hospital Episodes Statistics data. Setting England. Population Women diagnosed with endometrial carcinoma (ICD10 C54-C55 excluding sarcomas and malignant mixed Mullerian tumours) between 2000 and 2009 who were treated surgically (n = 38 332). Methods Random effects logistic regression model of postoperative mortality rates, adjusting for patient- and/or tumour-level factors (namely age, income deprivation, year of diagnosis, FIGO stage and grade). Case-mix adjusted postoperative mortality rates for hospitals and cancer networks were derived from the model. Multiple imputation was used to account for missing stage and grade data. Main outcome measures 30-day postoperative mortality rate. Results For 2000–2009, the percentage of women dying within 30 days of surgery for endometrial carcinoma was very low at 0.61% (235 deaths), and decreased from 0.70% in 2000–2001 to 0.48% in 2008–2009. Postoperative mortality rates were lower for laparoscopic surgery, and higher for older women, those with advanced stage disease and high-grade tumours. Crude and case-mix adjusted results indicated that one hospital had a higher postoperative mortality rate than expected. Conclusions The postoperative mortality rate for endometrial carcinoma in England is low and has improved since 2000, with increasing use of laparoscopic surgery. Postoperative mortality rates differed by surgical approach, patient age, disease stage and tumour grade. Only one hospital had a higher postoperative mortality rate than expected after adjusting for patient case-mix. Tweetable abstract More women with endometrial cancer but better 30-day survival after surgery since 2000.

The aim of this study is to evaluate the impact of the 1999 national recommendations for ovarian cancer surgery in England to be performed by specialist surgeons in specialist centres.A retrospective analysis of English cancer registry records, Hospital Episode Statistics (HES) data for all English NHS providers and General Medical Council (GMC) sub-specialty accreditation, to consider changes to the annual proportion of ovarian cancer (ICD10 C56-C57) patients undergoing major gynaecological surgery in gynaecological cancer centres (GCCs) or by specialist gynaecological oncologists (GOs).From 2000 to 2009, 2428 consultants were responsible for surgery on 30,753 patients. There were significant increases in the proportions of patients undergoing surgery at GCCs (43% to 76%, P0.001), by GMC accredited GOs (5% to 36%, P0.001), and by high ovarian cancer caseload (≥18 cases) surgeons (22% to 56%, P0.001).There have been increased centralisation and specialisation of surgery for ovarian cancer patients since the NHS Cancer Plan (2000) and there has also been improved survival. However, by 2009, many ovarian cancer patients were still not receiving specialist surgery; the majority of patients were not operated on by GMC accredited gynaecological oncologists and there was considerable regional variation. Systems of accreditation should be reviewed and trusts should ensure that HES data accurately records clinical activity.

Background: The Cancer Networks Supporting Primary Care programme was a National Health Service (NHS) initiative in England between 2011 and 2013 that aimed to better understand and improve referral practices for suspected cancer. Methods: A mixed methods evaluation using semi-structured interviews with purposefully sampled key stakeholders and an analysis of Cancer Waiting Times and Hospital Episode Statistics data for all 8179 practices in England were undertaken. We compared periods before (2009/10) and at the end (2012/13) of the initiative for practices taking up any one of four specified quality improvement initiatives expected to change referral practice in the short to medium term and those that did not. results: Overall, 38% of general practices were involved in at least one of four quality improvement activities (clinical audit, significant event analysis, use of risk assessment tools and development of practice plans). Against an overall 29% increase in urgent cancer referrals between 2009/10 and 2012/13, these practices had a significantly higher increase in referral rate, with reduced between-practice variation. There were no significant differences between the two groups in conversion, detection or emergency presentation rates. Key features of successful implementation at practice and network level reported by participants included leadership, organisational culture and physician involvement. Concurrent health service reforms created organisational uncertainty and limited the programme’s effectiveness. Conclusions: Specific primary care initiatives promoted by cancer networks had an additional and positive impact on urgent referrals for suspected cancer. Successful engagement with the programmes depended on effective and well-supported leadership by cancer networks and their general practitioner (GP) leads

Recent public reporting initiatives in England highlight general practice variation in indicators of diagnostic activity related to cancer. We aimed to quantify the size and sources of variation and the reliability of practice-level estimates of such indicators, to better inform how this information is interpreted and used for quality improvement purposes.Ecological cross-sectional study.English primary care.All general practices in England with at least 1000 patients.Sixteen diagnostic activity indicators from the Cancer Services Public Health Profiles.Mixed-effects logistic and Poisson regression showed that substantial proportions of the observed variance in practice scores reflected chance, variably so for different indicators (between 7% and 85%). However, after accounting for the role of chance, there remained substantial variation between practices (typically up to twofold variation between the 75th and 25th centiles of practice scores, and up to fourfold variation between the 90th and 10th centiles). The age and sex profile of practice populations explained some of this variation, by different amounts across indicators. Generally, the reliability of diagnostic process indicators relating to broader populations of patients most of whom do not have cancer (eg, rate of endoscopic investigations, or urgent referrals for suspected cancer (also known as 'two week wait referrals')) was high (≥0.80) or very high (≥0.90). In contrast, the reliability of diagnostic outcome indicators relating to incident cancer cases (eg, per cent of all cancer cases detected after an emergency presentation) ranged from 0.24 to 0.54, which is well below recommended thresholds (≥0.70).Use of indicators of diagnostic activity in individual general practices should principally focus on process indicators which have adequate or high reliability and not outcome indicators which are unreliable at practice level.

Introduction: Long-term lung cancer survival in England has improved little in recent years and is worse than many countries. The Department of Health funded a campaign to raise public awareness of persistent cough as a lung cancer symptom and encourage people with the symptom to visit their GP. This was piloted regionally within England before a nationwide rollout. Methods: To evaluate the campaign's impact, data were analysed for various metrics covering public awareness of symptoms and process measures, through to diagnosis, staging, treatment and 1-year survival (available for regional pilot only). Results: Compared with the same time in the previous year, there were significant increases in metrics including: public awareness of persistent cough as a lung cancer symptom; urgent GP referrals for suspected lung cancer; and lung cancers diagnosed. Most encouragingly, there was a 3.1 percentage point increase (P

BackgroundThe Cancer Services profiles report indicators of cancer diagnostic activity for all English general practices. A recent study reported that several indicators were dominated by chance, with some practice-level variation explained by the practice’s age-sex profile.AimTo assess the variation explained by patient-level case-mix and whether the practice age-sex profile adequately adjusts for this.MethodFive indicators from Cancer Waiting Times (2016/17, 6050 practices) or Routes to Diagnosis (2015, 6355 practices) data were considered: Two Week Wait (TWW) conversion and detection rates, and emergency-, referred- and other-diagnosis proportions. Mixed-effect logistic regression adjusted for patient-level case-mix, using national cancer registration data on age, sex, deprivation, referral/cancer-type and, where possible, ethnicity and stage at diagnosis, with and without practice-level age-sex profile.ResultsChance explained 60–85% of practice-level variation, with the combination of chance and patient-level case-mix explaining 75% (TWW conversion rate) to 89% (emergency diagnosis proportion). For TWW conversion rate, there was considerable overlap in the variance explained by practice- and patient-level factors. For the other indicators, practice- or patient-level factors were largely independent.ConclusionChance is not synonymous with case-mix and is the dominant source of variation in single-year practice indicators. Therefore, we recommend the continued aggregation of data over multiple years. For most studied indicators, adjustment for the age-sex profile of the whole practice population is not a substitute for case-mix of individual cancer patients and so should not be used. Patient-level case-mix adjustment leads to a modest reordering of practices and so may not be a priority.

BackgroundThe ‘Be Clear on Cancer’ awareness campaigns aim to raise awareness of cancer symptoms and encourage people with these symptoms to ‘tell their doctor’. GP attendances are therefore a key metric for evaluating the impact of a campaign. We considered the impact on GP attendances of several campaigns since 2013, including the 2015 national oesophagogastric cancer campaign, the 2016 national respiratory symptoms campaign and campaigns for lung cancer, ‘blood in pee’, and breast cancer in women aged >70 years.AimTo consider the impact on GP attendances of several campaigns since 2013, including the 2015 national oesophagogastric cancer campaign, the 2016 national respiratory symptoms campaign and others.MethodData on the weekly numbers of GP attendances and practices were extracted from The Health Improvement Network (THIN) database. For patients reporting campaign symptoms or a control symptom (back pain), the average number of GP attendances per practice per week was calculated. Analysis considered the trend in GP attendances, calculated the change in attendances for the campaign period compared to the same period in an earlier year, and assessed this change using a χ2 test.ResultsThe 2015 oesophagogastric cancer campaign, resulted in a statistically significant 29% increase (PConclusionThe THIN database has provided primary care data which can be used to assess the impact of awareness campaigns on primary care activity. Results demonstrate increases in GP attendances following some of the campaigns, suggesting that some patients responded to the campaigns’ call to action.

For some cancers, late presentation is associated with poor survival. In England, less than half of patients are diagnosed following a general practitioner-initiated urgent referral. We explore whether particular practice or practitioner characteristics are associated with use of the urgent referral system.The study sample was 603/614 practices in the East Midlands. Logistic regression models were fitted to investigate relationships between cancer detection rate, how easy it is to book appointments quickly, in advance or with a preferred doctor, and whether patients have confidence and trust in the doctor.The percentage of patients who definitely have confidence and trust in the doctor was positively associated with the cancer detection rate [odds ratio = 1.08 (95% confidence interval (CI) 1.01, 1.15) per 10 percentage points]. When all four survey variables were modelled together, the percentage of patients who were able to see a preferred doctor was negatively associated with the cancer detection rate [odds ratio = 0.93 (95% CI 0.88, 0.98) per 10 percentage points].Our analyses suggest that in the UK National Health Service, confidence and trust in the doctor may be more important in cancer detection than the ease of access or whether there is choice of doctor.

Objective To explore the trends and age characteristics of vulval cancer incidence, mortality, survival and stage of disease. Design Retrospective population-based observational study based on cancer registry and Office for National Statistics data. Setting England. Population All women diagnosed with vulval cancer, defined by the site of the tumour (ICD-10 code C51). Methods Including all C51 cases, Poisson regression was used to test for trends in incidence and mortality rates, and generalised linear modelling was used to test for trends in relative survival. Excluding women with melanomas, basal cell carcinomas and Paget disease, stage was investigated as a percentage of staged data by age. Main outcome measures Age-standardised incidence and mortality rates, relative survival rates and stage of disease at diagnosis. Results From 1990, there was a statistically significant increase in overall incidence (P = 0.018) and decrease in mortality (P

ObjectiveThis study aimed to investigate differences in the treatment of cervical cancer by tumor morphology after accounting for demographic, diagnostic, and tumor factors.MethodsRetrospective population-based observational study using linked cancer registration and treatment data from administrative data sources of women diagnosed with cervical cancer (International Classification of Diseases, Tenth Edition C53, malignant behavior) during 2009 and 2010 in England. Descriptive analyses and multinomial regression modeling have been used to consider differences in treatment by morphological subtype. For each morphological subtype, number and percentage of cases are presented by demographic, diagnostic, and tumor factors and treatment modality. Relative risk ratios are provided for each treatment modality by morphological subtype and other specified factors.ResultsForty-three percent of women were treated surgically; 36% by clinical oncology and only 8% by combination of surgery and clinical oncology. Compared with squamous cell carcinomas, both adenocarcinomas and adenosquamous carcinomas were more likely to be treated by trachelectomy, hysterectomy, radiotherapy with hysterectomy, or chemoradiotherapy with hysterectomy than by chemoradiotherapy without hysterectomy. These differences were explained mainly by a different stage distribution, but some difference remained after adjustment for other factors including stage. As clinically recommended, neuroendocrine tumors were not treated surgically. Further treatment differences were found by age, route to diagnosis, stage, and grade. Deprivation was not generally associated with treatment differences, with 1 exception that those from more deprived areas were less likely to be treated by trachelectomy.ConclusionsImportant treatment differences according to tumor morphology remain after adjusting for relevant patient demographic, diagnostic, and tumor factors. In particular, the difference between the treatment of squamous cell carcinoma and adenocarcinoma is notable.

ObjectiveInternational studies show lower survival rates in the United Kingdom than other countries with comparable health care systems. We report on factors associated with excess mortality in the first year after diagnosis of primary invasive epithelial ovarian, tubal, and primary peritoneal cancer.MethodsRoutinely collected national data were used for patients diagnosed in England in 2008 to 2010. A multivariate Poisson model was used to model excess mortality in 3 periods covering the first year after diagnosis, adjusting for various factors including age at diagnosis, route to diagnosis, tumor stage, tumor morphology, and treatment received.ResultsOf 14,827 women diagnosed as having ovarian cancer, 5296 (36%) died in the first year, with 1673 deaths in the first month after diagnosis. Age older than 70 years, diagnosis after an emergency presentation or by an unknown route, and unspecified or unclassified epithelial morphologies were strongly and independently associated with excess mortality in the first year after diagnosis. Of the 2100 (14%) women who fulfilled all 3 criteria, 1553 (74%) did not receive any treatment and 1774 (85%) died in the first year after diagnosis. In contrast, only 193 (4%) of the 4414 women without any of these characteristics did not receive any treatment, and only 427 (9%) died in the first year after diagnosis.ConclusionsAlthough our results are based on data from England, they are likely to have implications for cancer care pathways worldwide because most of the identified factors are not specific to the UK health care system. Our results suggest the need to increase symptom awareness, promote timely general practitioner referral, and optimize diagnostic and early treatment pathways within secondary care to increase access to treatment for women with advanced-stage invasive epithelial ovarian, tubal, and primary peritoneal cancer. This process should be pursued alongside continued efforts to develop primary prevention and screening strategies.

Denne artikel undersøger sammenhængen mellem engelske lægers brug af pakkehenvisning og kræftpatienters overlevelse. Pakkehenvisninger for kræftsymptomer (two-week-wait referrals) blev indført i England i 2000. Det engelske system med to ugers ventetid svarer til det danske kræftpakkeforløb og går ud på at sende patienten gennem et velstruktureret og effektivt undersøgelsesforløb, så man hurtigt kan få en kræftdiagnose og komme i gang med behandlingen. Sammenhængen mellem stadiefordeling og overlevelse er ikke tidligere undersøgt, men det nye studie giver for første gang et indblik i konsekvenserne af indførelsen af kræftpakkeforløbene. Resultaterne viser, at dødeligheden falder markant, hvis den praktiserende læge hurtigt sender patienten afsted til undersøgelse for kræft. Undersøgelsen slår fast, at forskellen i kræftoverlevelsen er op til 12 procentpoint, afhængig af hvor hurtigt og effektivt man får sin diagnose og begynder behandlingen. Studiet er lavet i tæt samarbejde mellem danske og engelske forskere, og englænderne skeler til den danske strategi for tidlig diagnose med kræftpakkeforløb og diagnostiske centre. Den omtalte engelske undersøgelse viser, at det er en god investering for Danmark, at almen praksis har fået adgang til kræftpakker, fordi det har en positiv betydning for patienternes prognose. OBJECTIVE: To assess the overall effect of the English urgent referral pathway on cancer survival.SETTING: 8049 general practices in England.DESIGN: Cohort study. Linked information from the national Cancer Waiting Times database, NHS Exeter database, and National Cancer Register was used to estimate mortality in patients in relation to the propensity of their general practice to use the urgent referral pathway.PARTICIPANTS: 215 284 patients with cancer, diagnosed or first treated in England in 2009 and followed up to 2013.OUTCOME MEASURE: Hazard ratios for death from any cause, as estimated from a Cox proportional hazards regression.RESULTS: During four years of follow-up, 91 620 deaths occurred, of which 51 606 (56%) occurred within the first year after diagnosis. Two measures of the propensity to use urgent referral, the standardised referral ratio and the detection rate, were associated with reduced mortality. The hazard ratio for the combination of high referral ratio and high detection rate was 0.96 (95% confidence interval 0.94 to 0.99), applying to 16% (n=34 758) of the study population. Patients with cancer who were registered with general practices with the lowest use of urgent referral had an excess mortality (hazard ratio 1.07 (95% confidence interval 1.05 to 1.08); 37% (n=79 416) of the study population). The comparator group for these two hazard ratios was the remaining 47% (n=101 110) of the study population. This result in mortality was consistent for different types of cancer (apart from breast cancer) and with other stratifications of the dataset, and was not sensitive to adjustment for potential confounders and other details of the statistical model.CONCLUSIONS: Use of the urgent referral pathway could be efficacious. General practices that consistently have a low propensity to use urgent referrals could consider increasing the use of this pathway to improve the survival of their patients with cancer.

Background: A 2-Week Wait (2WW) referral pathway for earlier diagnosis of suspected cancer was introduced in England in 2000. Nevertheless, a significant proportion of patients with cancer are diagnosed by other routes (detection rate), only a small proportion of 2WW referrals have cancer (conversion rate) and there is considerable between-practice variation. Aim: This study examined use by practices of the 2WW referral in relation to all cancer diagnoses. Design and setting: A cross-sectional analysis of data extracted from the Cancer Waiting Times Database for all 2WW referrals in 2009 and for all patients receiving a first definitive treatment in the same year. Method: The age standardised referral ratio, conversion rate, and detection rate were calculated for all practices in England and the correlation coefficient for each pair of measures. The median detection rate was calculated for each decile of practices ranked by conversion rate and vice versa, performing nonparametric tests for trend in each case. Results: Data for 8049 practices, 865 494 referrals, and 224 984 cancers were analysed. There were significant correlations between referral ratio and conversion rate (inverse) and detection rate (direct). There was also a direct correlation between conversion and detection rates. There was a significant trend in conversion rate for deciles of detection rate, and vice versa, with a marked difference between the lowest and higher deciles. Conclusion: There is a consistent relationship between 2WW referral conversion rate and detection rate that can be interpreted as representing quality of clinical practice. The 2WW referral rate should not be a measure of quality of clinical care.