Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study

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.