National Audit of Cancer Diagnosis in Primary Care

Clinical Innovation and Research Centre 2011

National Audit of Cancer Diagnosis in Primary Care

This report was prepared by:
Royal College of General Practitioners: Greg Rubin, Professor of General Practice and Primary Care
National Cancer Intelligence Network: Sean McPhail, Senior Analyst
National Cancer Action Team: Kathy Elliott, National Lead for prevention, early diagnosis and inequalities
Please note that the views expressed within this report are the authors own and do not necessarily reflect
the view of the Department of Health or its policies in this area.
Department of Health Gateway approval: 16345

Acknowledgements
The introduction of a National Audit of Cancer Diagnosis in Primary Care was a vision shared by Professor
Sir Mike Richards, Director of Cancer Services, and Professor Mayur Lakhani, Chairman of the Royal College
of General Practitioners (RCGP) at the time of the publication of the Cancer Reform Strategy. It could not
have been realised without the support of the RCGP and the National Cancer Action Team (NCAT). The
Department of Health Cancer Policy Team and the National Cancer Intelligence Network (NCIN) have played
critical roles in enabling this national report to be produced. Our thanks go to the many Cancer Networks
that participated, for supporting practices as they completed the audit and collating data for the NCIN.
Lastly, this audit would not have happened without the enthusiastic participation of the English general
practice community. Together their efforts have produced a result that few thought could be achieved.

ii

Acknowledgements ii
Foreword 5

Executive summary 6
1. Introduction 7
1.1 Background 7
1.1.1 Diagnosis of cancer in primary care
7
1.1.2 Audit of cancer diagnosis in primary care
7
1.1.3 Previous audits of cancer care
7
1.2 Aims of the audit 8

2 Audit methods 9
2.1 Design of the audit 9
2.2 Conduct of the audit in 2009/10
9
2.2.1 Ethics and Information Governance
9
2.2.2 Local and national analysis
10
2.3 Data collection, cleaning and categorisation
10
2.3.1 Stage 10
2.3.2 Number of times patient attended surgery
10
2.3.3 Investigations Ordered 10
2.3.4 Symptoms at presentation
10
2.3.5 Intervals along the patient pathway
11
2.4 Statistical Methods of Analysis 11
2.4.1 Tools 11
3 Participation and case ascertainment 12
3.1 Participation 12
3.2 Case ascertainment 12

4 Data Quality 13
4.1 Data completeness 13
4.2 Comparison to other data 14
4.2.1 By cancer type 14
4.2.2 By age and sex 14
4.3 Commentary 15
5 Patient characteristics 16
5.1 Demographic features 16
5.2 Cancer site 18
5.3 Commentary 18
6 Diagnostic pathway 19
6.1 Place of presentation 19
6.1.1 By cancer site 19
6.1.2 Association with demographics
19
6.2 GP consultations 21
6.2.1 By cancer type 21
6.2.2 Association with demographics
21

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6.3 Presenting symptom 23

6.4 Use of Investigations 25
6.4.1 Tumour type 25
6.4.2 Association with presenting symptom
25
6.4.3 Change in management
27
6.5 Routes to diagnosis 28
6.5.1 Demographic features 29
6.5.2 Tumour type 30
6.5.3 Presenting symptom 31
6.6 Commentary 32
7 Intervals in the diagnostic pathway 34
7.1 Patient interval 34
7.1.1 Demographic features 34
7.1.2 Tumour type 35
7.1.3 Presenting symptoms 36
7.1.4 Referral route 37
7.2 Primary care interval 37
7.2.1 Demographic features 37
7.2.2 Tumour type 39
7.2.3 Presenting symptom 39
7.2.4 Referral route 41
7.3 Referral interval 41
7.3.1 Demographic features 41
7.3.2 Tumour type 42
7.3.3 Presenting symptom 43
7.3.4 Referral route 44
7.4 Commentary 44
8 Cancer stage at diagnosis 45
8.1 Demographic factors 45
8.2 Tumour type 47
8.3 Presenting symptom 48
8.4 Presentation route 50
8.5 Commentary 50
9 Conclusions 51
10 Suggestions for improvement 52

Appendix 1: Audit Steering Group 53
Appendix 2: Data Security and Data Transfer 54
Appendix 3: Notes accompanying audit template 57
Appendix 4: Participation
59

References 61

iv

Foreword
I would like to thank all the General Practitioners and practice teams who
have contributed to the collection of audit data that will help to shape our
thoughts on the primary care diagnosis of cancer.
The success around the methodology of this audit has been dependent
not only on the excellent leadership shown by the project lead, Professor
Greg Rubin and the steering group, but also the cancer network GP leads
who have helped to facilitate the collection of the data presented in this
report .
The data show we do well in General Practice in identifying our patients
who have cancer. There are, of course, groups of patients where we do
have difficulty for various reasons in making a rapid diagnosis of cancer. Sometimes these are patient,
practitioner or system factors.
However, the foundations that will enable us to continue to provide a quality service are the attributes
of quality General Practice - continuity of care; patient centredness and shared decision making; clinical
acumen and sound diagnostic skills.
We must also be prepared to evaluate what we do and this audit is an excellent example of how such
evaluation can provide rich messages for the future care of our patients.
Dr Clare Gerada, Chair of Council, RCGP

The National Awareness and Early Diagnosis Initiative (NAEDI) is intended to better understand and address
the reasons for later diagnosis of cancer in England. An audit of cancer diagnosis in primary care was
undertaken in 2009/10 as part of this initiative.
An audit template was developed and piloted by an expert group of academic and service GPs, utilising
experience in earlier local audits of cancer diagnosis. Information was collected on patient demographics
and the nature of the assessment process in primary care, including the time taken from first presentation
to referral. Participating cancer networks identified GP leads for the initiative, who also validated practice
returns before acceptance. In addition to the local analyses undertaken by these networks, the data were
collated into a single database by the NCIN. The collated data form the basis of this report.
Data were collected on 18879 patients by 1170 practices in 20 cancer networks. Data quality was high with
most categorical fields (including stage) being close to or over 90% complete. Comparison with cancer
registry data demonstrated that the dataset was representative in respect of age, sex and distribution by
cancer site.
The duration of the primary care and referral intervals showed considerable variation by cancer site.
Emergency presentation, usually associated with worse outcomes, occurred in 12.9% of all cases but ranged
from 3.7% (breast) to 39.3% (brain). In 6.0% of cases the GP believed that better access to investigations
would have reduced delay in diagnosis. This also varied considerably by site, being much greater for brain,
ovary, pancreas and kidney.
This is the largest and most comprehensive study to date of the primary care pathway to cancer diagnosis.
It provides detailed insights into current clinical practice that can direct initiatives to reduce the time to
diagnosis for cancer, as well as raising important questions for future research. It has raised awareness
among GPs of their contribution to timely diagnosis of cancer and has stimulated professional and practice
development. Many individual practices have expressed their intention to use the audit tool to regularly
monitor their performance for the future. Networks have used their involvement as a springboard to wider
engagement with primary care, taking advantage of the other quality improvement approaches that have
been developed alongside this audit.
We recommend:
1. That these findings could inform quality improvement initiatives that address the pathway to cancer
diagnosis.
2. That the findings of this report are used to inform plans to improve access to diagnostics as outlined in
Improving Outcomes: a Strategy for Cancer.
3. The Cancer Diagnosis Audit Tool could be a useful tool for practices, Cancer Networks and Clinical
Commissioning Groups to identify local areas for improvement and to monitor the impact of service
improvements.
4. That the audit of cancer diagnosis could be used systematically at a national level in order to monitor the
impact on primary care outcomes of policy in the area of early diagnosis.
5. That primary care audit could be combined with other data, from secondary care audit or from the
Association of Public Health Observatories Practice Profiles, for example, to generate more detailed
understanding of factors influencing the pathway to diagnosis.

1.1 Background
1.1.1 Diagnosis of cancer in primary care
Over 90% of all patient contacts with health care in the UK occur in primary care. It is the setting in which
symptoms are usually first evaluated and where those people who need further evaluation are identified and
referred to specialist care. There are an estimated 300 million consultations in general practice in England
annually,1 and they represent a major challenge in the sifting of often undifferentiated symptoms in order to
identify those patients with significant disease. For those patients with suspected cancer, clinical guidance
for GPs was produced by Department of Health in 2000 and then revised by NICE in 2005. This provided
information on symptoms and signs that merited urgent referral for further assessment. It was supported
by a referral pathway for suspected cancer that would ensure patients were assessed within two weeks of
referral.
The Cancer Reform Strategy (2007) marked a new direction for improving cancer outcomes in England.
A central theme was that of achieving earlier diagnosis, predicated on the belief that delay in the period
leading up to diagnosis and subsequent treatment contributed significantly to the poor outcomes that
were apparent from the EUROCARE studies. This emphasis on the importance of early diagnosis has been
maintained in Improving Outcomes: a Strategy for Cancer (2011).
A programme of activities spanning the cancer pathway from first suspicion of bodily change to
confirmation of cancer diagnosis, the NAEDI, was launched in 2008 to better understand and address
reasons for late diagnosis in England. One strand of the NAEDI work programme was a national audit of
cancer diagnosis in primary care. This was intended to inform decisions about how best to provide more
support to primary care professionals to ensure the earliest possible diagnosis of cancer and was to be
undertaken in collaboration with the RCGP. Lessons from the audit could inform the education and training
of GPs, including through continuous professional development and appraisal. The audit could also assist
in the development of decision aids to support healthcare professionals in assessing symptoms and making
decisions about further investigation or referral.2

1.1.2 Audit of cancer diagnosis in primary care

Audit is the review of clinical care, using objective measures, against explicit criteria for good clinical
practice. There are no specific criteria that currently apply to primary care in respect of cancer diagnosis.
The NICE referral guidelines for suspected cancer contain three suggestions for audit, all of which could
present operational challenges. They relate to the provision of information about the likely diagnosis and the
investigation or referral at first consultation of patients with classical features of cancer. Nevertheless, some
groups have designed audits of cancer diagnosis in primary care.

1.1.3 Previous audits of cancer care

National annual audits are well established for lung, colorectal, head and neck cancer and oesophago-gastric
cancer. These have been managed by the NHS Information Centre. In all cases the audit has focussed on the
secondary care pathway, for many aspects of which, criteria had previously been developed. The objective
in each case has been to obtain data on all patients diagnosed with the cancer in question for a specified
period and from as many participant specialist units as possible. After several rounds, high participation rates
have been achieved. For example, 169/172 Hospital Trusts participated in the 2009 lung cancer audit and
94% of all cases presenting to secondary care were included.3
Large scale audit of cancer diagnosis in primary care has previously been undertaken by the Scottish Primary
Care Cancer Group4 and in three English areas. These audits had primarily focussed on use of the two week

referral pathway but collected additional information about the diagnostic process. In Scotland, where two
rounds of audit were completed, it was possible to discern some consequential changes, notably in relative
use of referral pathways. The experience in these pilot sites provided valuable information about the feasibility of undertaking such an audit, participation and completion rates.

1.2 Aims of the audit

The aim of this audit was to define current practice in primary care cancer diagnosis and to develop criteria
for best practice, in order to improve future cancer outcomes. The objectives were to generate insights
into the diagnostic pathway in general practice that could inform professional and practice development,
as well as the commissioning process for services that support the cancer diagnosis pathway. Within
cancer networks the findings were intended to stimulate clinical and service improvement and to provide a
benchmark.
This audit has important differences from the site-specific audits of secondary care practice that have been
published. We chose to examine current practice for all cancers. To do this in all 8100 practices in England
would have presented very considerable logistical and resource challenges. Instead, the ability of practices to
participate depended on the priorities of Cancer Networks and the resources available to them.

2.1 Design of the audit

The audit has been a collaboration between the following partners:

Department of Health Cancer Policy Team

National Cancer Action Team
National Cancer Intelligence Network
Clinical Innovation and Research Centre at the Royal College of General Practitioners.

An audit development group was established to develop a model audit template, drawing on the experience
of those involved in the Scottish audit and in the pilot audits in SE London, Manchester and Avon, Somerset
and Wiltshire. The group comprised individuals responsible for these earlier audits, academic GPs active in
cancer diagnosis, primary care leads from cancer networks and other stakeholders (Appendix 1). A model
audit template was piloted by members of the development group before being made openly available.5
A number of complementary actions were undertaken concurrently with this audit. These included a study
of the interval from first presentation to diagnosis for 15 cancers, using the General Practice Research
Database, large-scale significant event audit by general practices of their most recent cases of specified
cancers6, and the development of a support structure for this programme of activity within the RCGP.

2.2 Conduct of the audit in 2009/10

In 2009 the Department of 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 develop
local programmes of work which could include bringing together data to assess the needs related to early
diagnosis of cancer; local strategies, governance and business cases; and implementation of evidence based
awareness raising or primary care service change programmes. One option offered to networks as they
formulated their LAEDI proposals was to participate in the Primary Care Cancer Audit. If this option was
chosen, Networks were required to ensure that there was a GP Lead to provide clinical leadership for the
audit.
Participation in primary care cancer audit was included in 20 English Cancer Networks plans for a LAEDI and
approved for funding from the NCAT and the Department of Health.
Participating practices were required to complete the audit template from their practice clinical records
and 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 identified audit leads whose responsibility it would be to support participating practices and to
review their audit data for 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 of the overall initiative was undertaken by ERDU, on behalf of the RCGP.

2.2.1 Ethics and Information Governance

Participating networks were required to gain local approval for this audit. No patient identifiable data were
collected. All data submitted to the National Cancer Intelligence Network (NCIN) for analysis were held on
the same IT system and under the same information governance arrangements as apply to cancer registries.

2.2.2 Local and national analysis

A major purpose of the audit was to contribute to the development of local awareness and early diagnosis
initiatives within the Cancer Networks of England during 2009/10. Participating networks undertook to
analyse and report their local data. The National Cancer Action Team produced an overview report of this
LAEDI programme and on the priorities for sharing learning in 2010/11, which included GP engagement.7
The value of undertaking an analysis of combined data from participating networks was recognised from
the outset, in terms of more robust understandings, particularly of less common pathways and rarer cancers.
It also provides a benchmark against which local findings can be compared as well as an opportunity to set
criteria for clinical care.

2.3 Data collection, cleaning and categorisation

Returns from participating practices were aggregated at network level. With detailed guidance to networks
from NCIN they were then submitted and imported into a single dataset for analysis by NCIN (Appendix 3).

2.3.1 Stage
Stage at diagnosis was simplified. We used a three stage grouping, based on the grouped staging which has
previously been employed by cancer registries and which is described by SEER. Thus, stage was described
as confined to organ, local (regional) spread, or distant (metastatic) spread.8,9 These equate to SEER stages
two to four, carcinoma in situ (stage one) being excluded from the audit. Stage was determined by the
practitioner completing the template, based on information available in the practice records, including
hospital correspondence.

2.3.2 Number of times patient attended surgery

A lookup table was generated and different expressions of frequency of attendance were given a single
numerical value (for example mapping 1, once and one to the numeric value 1). Values which failed
to match were examined and the lookup table refined until for 95.6% of patients a numeric value for the
number of times that the patient attended surgery prior to diagnosis was extracted.

2.3.3 Investigations Ordered

Pattern matching was done within each free text item. For example, it was recorded that the GP ordered
blood tests if any of the patterns bloods, b/t, PSA, or blood test (plus others) were contained in
the data field. The resulting matches were examined without finding any that appeared inappropriately
matched.

2.3.4 Symptoms at presentation

Where multiple symptoms were listed, the first was taken as the primary symptom. Descriptions of
symptoms were aggregated into cognate groups which naturally fitted the responses, by individual cancer
type.
For example breast lump and lump were grouped for breast cancer. These natural groups were then
reviewed by a clinician and further aggregated along clinically relevant lines.

10

2.3.5 Intervals along the patient pathway

The patient interval was defined as the date of onset of symptoms to the first consultation. The primary care
interval was the date of first presentation to the date of referral. The referral interval was defined as the date
of referral to the date the patient first attended for specialist assessment in secondary care.
As well as the actual length of these intervals, they were categorised into those over 31 days, and those of
31 days and less. This cut off was considered to be the generally accepted time period within which GP
assessment and referral should be completed.

2.4 Statistical Methods of Analysis

2.4.1 Tools
Data were imported and analysed within the Stata 11 software package.

11

3.1 Participation
In total 20 Cancer Networks participated in the audit. Two networks invited practices from selected localities
within their area, in both cases on the basis of socio-economic deprivation. In a third network five out of the
seven PCTs exercised a selection process for practices wishing to participate. In the remaining networks all
practices 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 specified time frame
for the selection of cases, which in most cases was 12 months. Participants were required to include all cases
with a date of diagnosis within that period. However, one network applied a quota to the number of cases a
practice was required to submit and in another, the practices were asked to focus on the four most common
cancers (breast, bowel, lung, prostate).
In total 1170 practices from 20 cancer networks participated. This represents 14% of all practices in
England, drawn from nearly three-quarters of the 28 cancer networks.

3.2 Case ascertainment

The audit only included confirmed malignancies. It excluded screen-detected cancers, in-situ carcinomas and
non-melanotic carcinomas of the skin.

12

The completeness of data in the final audit is displayed in table 4.1-1. For categorical fields the percentage
of valid entries is shown, along with the percentage of responses that were Not known (or equivalent),
where this was a possible response. For free text fields where validation is not easily possible the percentage
of cases were the field had at least some text present is given.
Most categorical fields had a completion with a valid response of close to or above 90%. Fields for which
the response is conditional have a lower percentage completion, as might be expected.

4.1 Data completeness

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%
48.4%
If yes, please list investigations ordered
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%
Table 4.1-1, Data completeness by field.

13

4.2 Comparison to other data

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

4.2.1 By cancer type

18%

Audit

16%

Registry

Fraction of cases

14%
12%
10%
8%
6%
4%
2%

Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information

0%

Figure 4.2-1, representation of cancers in the audit by cancer type, compared to those in cancer registry data. Data source:
Office of National Statistics. 95% confidence intervals are shown for the proportion of cancers in the audit dataset.

4.2.2 By age and sex

18%

18%

14%

12%
10%
8%
6%

10%
8%
6%
4%

2%

2%

0%

0%

0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+

4%

Audit

Male

12%

0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+

Fraction of cases

14%

16%

Female

Fraction of cases

16%

Registry

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

14

4.3 Commentary
There was very high data completeness, close to or in excess of 90% for nearly all categorical fields. The
recording of dates in the patient pathway is also close to 90%, except for the date that the patient first
noted signs or symptoms of cancer, which is close to 75%. The fraction of free text fields which were
interpretable is high. For example, it is over 95% for the number of times attending surgery and main
presenting symptom.

15

Patients included in this audit were typically aged over 65 years, men comprised 52% of the total, women
48% and 0.2% were unknown. A communication difficulty was recorded for 6.0% of the total, while 6.9%
of all patients were housebound. 78% of those included were identified as White British. White other was
the second largest identified ethnic group (3.2%) and 12% were unknown. We were not able to identify
socio-economic status at the level of the individual, since this would have necessitated the collection of
patient-identifiable data.

5.1 Demographic features

1800
1600

Number of persons

1400
1200
1000
800
Male
600

Female

400
200
0

Age band
Figure 5.1-1, number of cases in the audit by age and sex.

16,000

Number of persons

14,000

14,644

12,000
10,000
8,000
6,000
4,000
2,000
0

2,239
225

612

45

16

27

100

326

62

Ethnicity

16

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

21

101

197

100

18

47

99

18,000

16,876

16,000

Number of persons

14,000
12,000
10,000
8,000
6,000
4,000
1,298

2,000

705

0
Not housebound

Housebound

Not Known

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

20,000
18,000

17,252

Number of persons

16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0

281

66

251

65

114

44

194

127

485

Figure 5.1-4, number of cases in the audit by the presence of communication difficulties.

17

5.2 Cancer site

3500
3046

2912

3000

Number of persons

2566
2500
2014

2000
1500
1000

920
574

435

500

234

152

878
760

70 129

130

596
79

422390
229

252

567

398

319
166126
119 57
76

189

74

No Information

Unknown Primary

Other

Vulval

Thyroid

Stomach

Testicular

Small Intestine

Renal

Sarcoma

Prostate

Ovarian

Pancreatic

Oropharyngeal

Myeloma

Oesophageal

Melanoma

Mesothelioma

Lung

Lymphoma

Liver

Laryngeal

Leukaemia

Gallbladder

Colorectal

Endometrial

Cervical

Brain

Breast

Bladder

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

5.3 Commentary
Substantial numbers of cases were included for each cancer site, with over 2000 for each of the four main
cancers. 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 information collected is useful for understanding inequalities. The audit development
group believed that some features had a particular potential to impact on the diagnostic process in primary
care and are also commonly evident in the GP record. These included being housebound and having a
communication difficulty. However, it was recognised by the group that these are not customary measures
of inequality, and that those used by the National Cancer Equality Initiative are not all routinely recorded in
GP records. There were over 1000 cases in each of our categories, enabling some conclusions to be drawn
about the quality of care provided to them.

18

6.1 Place of presentation

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

6.1.1 By cancer site

All persons
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

Practice
82.1%
66.7%
87.1%
88.2%
84.6%
90.6%
81.4%
89.9%
78.2%
69.2%
75.7%
82.9%
90.9%
87.3%
75.0%
89.8%
79.5%
84.8%
85.9%
86.3%
71.4%
79.8%
82.5%
79.6%
83.7%
79.4%
88.2%
79.5%
81.5%
29.7%
83.3%

Out patients
4.1%
2.1%
2.7%
2.0%
3.4%
1.4%
5.7%
3.9%
6.3%
12.3%
4.8%
4.6%
3.6%
2.5%
7.1%
2.7%
4.8%
1.4%
2.3%
4.7%
6.5%
4.2%
1.8%
2.2%
2.4%
10.3%
2.6%
4.6%
1.1%
4.1%
3.9%

A&E
4.6%
20.1%
0.6%
1.3%
5.4%
3.2%
8.6%
0.0%
4.5%
5.4%
9.5%
5.0%
0.6%
6.3%
8.3%
4.0%
3.1%
7.8%
6.4%
2.1%
10.1%
3.4%
5.3%
10.7%
3.6%
0.8%
1.3%
4.9%
11.1%
0.0%
4.5%

Walk-in centre
0.7%
0.0%
0.1%
0.7%
0.3%
0.2%
0.0%
0.8%
0.3%
0.8%
0.1%
0.5%
0.0%
0.0%
0.0%
0.0%
0.4%
0.0%
0.5%
0.2%
0.8%
0.8%
0.0%
1.3%
0.0%
0.8%
0.0%
0.2%
0.0%
0.0%
0.3%

Other
6.3%
7.7%
7.4%
5.3%
4.3%
3.0%
4.3%
3.9%
7.3%
8.5%
7.8%
4.5%
3.6%
3.8%
6.0%
2.0%
9.6%
4.7%
3.6%
4.5%
9.3%
9.2%
8.8%
4.1%
7.8%
7.1%
6.6%
7.6%
4.2%
2.7%
5.7%

Not Known
2.3%
3.4%
2.2%
2.6%
1.9%
1.6%
0.0%
1.6%
3.3%
3.8%
2.0%
2.5%
1.3%
0.0%
3.6%
1.5%
2.6%
1.2%
1.3%
2.3%
2.0%
2.5%
1.8%
2.2%
2.4%
1.6%
1.3%
3.2%
2.1%
63.5%
2.4%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
920
234
3046
152
2566
435
70
129
574
130
2014
760
878
79
252
596
229
422
390
2912
398
119
57
319
166
126
76
567
189
74
18879

Table 6.1-1, place of first presentation by cancer type.

6.1.2 Association with demographics

Sex
Male
Female
Not Known
Total

Practice
82.4%
84.3%
59.3%
83.3%

Out patients
4.6%
3.1%
1.9%
3.9%

A&E
4.9%
4.0%
9.3%
4.5%

Walk-in centre
0.3%
0.2%
0.0%
0.3%

Other
5.3%
6.1%
5.6%
5.7%

Not Known
2.3%
2.3%
24.1%
2.4%

Total
100%
100%
100%
100%

n
9759
9066
54
18879

Table 6.1-2, place of first presentation by sex.

19

Males, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All males

Practice
73.1%
85.7%
81.9%
86.8%
81.2%
84.6%
83.7%
84.1%
83.6%
83.9%
84.6%
82.7%
78.5%
77.9%
82.5%

Out patients
2.8%
1.6%
3.2%
1.6%
3.6%
1.5%
2.9%
3.6%
4.8%
5.3%
4.8%
5.6%
5.8%
3.9%
4.6%

A&E
8.3%
1.6%
6.4%
6.2%
7.1%
6.6%
5.9%
3.7%
3.0%
3.8%
4.6%
4.1%
6.6%
7.3%
4.8%

Walk-in centre
1.9%
0.0%
1.1%
0.0%
0.0%
0.4%
0.7%
0.9%
0.4%
0.3%
0.2%
0.2%
0.3%
0.1%
0.3%

Other
9.3%
6.3%
4.3%
3.9%
6.1%
5.5%
4.2%
5.3%
5.8%
5.0%
4.6%
4.4%
5.7%
7.8%
5.3%

Not Known
4.6%
4.8%
3.2%
1.6%
2.0%
1.5%
2.6%
2.3%
2.4%
1.8%
1.3%
3.0%
3.1%
2.9%
2.3%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

Walk-in centre
3.3%
0.0%
0.0%
0.0%
0.0%
0.2%
0.0%
0.5%
0.1%
0.1%
0.1%
0.2%
0.1%
0.1%
0.2%

Other

Walk-in centre
0.2%
0.4%
0.2%
0.3%

Other

1.1%
4.6%
2.8%
5.3%
3.3%
2.7%
7.8%
7.0%
6.7%
7.5%
3.6%
4.6%
8.1%
10.3%
6.2%

Not Known
5.6%
4.6%
0.9%
2.1%
2.4%
1.6%
1.9%
1.0%
2.9%
3.1%
1.8%
2.0%
2.7%
2.4%
2.2%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

Not Known
1.9%
3.5%
15.9%
2.4%

Total
100%
100%
100%
100%

n
17252
1142
485
18879

Not Known
1.9%
3.5%
11.3%
2.4%

Total
100%
100%
100%
100%

n
16876
1298
705
18879

108
63
94
129
197
272
455
749
1256
1367
1534
1419
1135
793
9,571

Table 6.1-3, place of first presentation by age band, for males.

Females, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All females

Practice
82.2%
84.6%
93.6%
88.1%
90.8%
91.4%
83.8%
85.9%
83.9%
83.6%
85.4%
85.2%
79.6%
77.7%
84.3%

Out patients
1.1%
1.5%
1.8%
2.5%
1.2%
2.2%
3.2%
3.3%
3.3%
2.6%
4.1%
3.1%
3.9%
2.8%
3.1%

A&E
6.7%
4.6%
0.9%
2.1%
2.4%
1.9%
3.2%
2.3%
3.2%
3.0%
4.9%
4.9%
5.6%
6.7%
4.0%

n
90
65
109
243
424
625
616
789
947
953
1037
1096
940
955
8889

Table 6.1-4, place of first presentation by age band, for females.

Communication difficulty?
None
Communication difficulty
Not known
Total

Practice
84.3%
74.0%
69.1%
83.3%

Out patients
3.8%
4.8%
4.1%
3.9%

A&E
4.3%
6.9%
4.9%
4.5%

5.4%
10.4%
5.8%
5.7%

Table 6.1-5, place of first presentation by presence of communication difficulty.

Housebound?
No
Yes
Not Known
Total

Practice
84.9%
68.4%
71.5%
83.3%

Out patients
3.9%
3.9%
4.7%
3.9%

A&E
3.9%
10.9%
6.5%
4.5%

Table 6.1-6, place of first presentation by housebound status.

20

Walk-in centre
0.3%
0.2%
0.0%
0.3%

Other
5.1%
13.1%
6.0%
5.7%

6.2 GP consultations
Concerns have been expressed about the number of times patients consult with symptoms of cancer before
being referred for specialist assessment.10 Participating practices were asked to count all consultations
relating to the presenting problem that was associated with the patients cancer. Most patients (66%)
included in the audit consulted their GP one or two times before referral. However 4% consulted five or
more times, and 9.5% did not consult at all. Those cancer sites where more than 20% of patients had three
or more consultations included lung (including mesothelioma), lymphoma, myeloma, ovary, pancreas and
stomach. This was also the case for males aged 25-29.

6.2.1 By cancer type

Cancer type
Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

1
9.0%
14.1%
11.7%
5.9%
9.1%
9.0%
7.1%
8.5%
9.8%
13.1%
11.3%
8.4%
7.9%
10.1%
6.7%
7.2%
8.7%
9.7%
8.5%
6.8%
11.8%
9.2%
10.5%
8.8%
8.4%
7.1%
7.9%
12.0%
11.1%
5.4%
9.4%

2
47.0%
38.5%
72.2%
52.6%
42.4%
61.8%
30.0%
41.9%
42.7%
33.8%
28.9%
40.0%
68.5%
32.9%
24.6%
44.6%
43.2%
37.0%
32.6%
40.5%
35.2%
37.0%
36.8%
34.2%
60.8%
43.7%
57.9%
43.4%
31.2%
8.1%
46.3%

3
22.6%
16.2%
5.3%
17.8%
22.5%
15.2%
22.9%
23.3%
20.0%
19.2%
24.1%
21.2%
13.1%
26.6%
20.2%
23.5%
20.5%
22.5%
24.6%
30.6%
21.9%
23.5%
28.1%
19.1%
18.1%
26.2%
15.8%
17.8%
14.3%
13.5%
20.0%

4
6.8%
7.3%
1.4%
9.2%
9.7%
6.0%
10.0%
12.4%
7.1%
6.9%
11.0%
9.6%
2.8%
15.2%
8.7%
10.9%
11.8%
11.8%
10.5%
7.7%
8.3%
11.8%
7.0%
11.3%
3.6%
5.6%
1.3%
7.6%
13.2%
2.7%
7.5%

5+
2.1%
3.8%
0.6%
3.3%
3.7%
0.9%
4.3%
1.6%
3.7%
4.6%
6.2%
4.2%
0.7%
2.5%
9.9%
5.2%
2.6%
4.7%
6.4%
2.7%
3.3%
4.2%
8.8%
6.3%
1.2%
2.4%
1.3%
3.2%
6.3%
1.4%
3.2%

3.6%
5.6%
0.5%
4.6%
4.8%
1.4%
4.3%
3.9%
3.3%
4.6%
7.3%
8.0%
1.4%
7.6%
14.3%
3.2%
3.1%
5.7%
9.2%
2.5%
5.3%
4.2%
3.5%
8.2%
0.0%
0.8%
2.6%
3.7%
13.2%
1.4%
4.0%

Not known
8.9%
14.5%
8.4%
6.6%
7.8%
5.7%
21.4%
8.5%
13.4%
17.7%
11.1%
8.6%
5.7%
5.1%
15.5%
5.4%
10.0%
8.5%
8.2%
9.1%
14.3%
10.1%
5.3%
12.2%
7.8%
14.3%
13.2%
12.3%
10.6%
67.6%
9.5%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
920
234
3046
152
2566
435
70
129
574
130
2014
760
878
79
252
596
229
422
390
2912
398
119
57
319
166
126
76
567
189
74
18879

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

6.2.2 Association with demographics

Sex
Male
Female
Not Known
Total

1
9.2%
9.7%
9.3%
9.4%

2
41.8%
51.2%
42.6%
46.3%

3
23.9%
15.7%
13.0%
20.0%

4
8.2%
6.8%
0.0%
7.5%

5+
3.3%
3.2%
1.9%
3.2%

4.1%
3.9%
5.6%
4.0%

Not known
9.5%
9.4%
27.8%
9.5%

Total
100%
100%
100%
100%

n
9759
9066
54
18879

Table 6.2-2, number of attendances at GP by sex.

21

Males, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All males

1
6.5%
3.2%
6.4%
5.4%
9.6%
9.6%
10.1%
8.4%
9.5%
8.6%
8.0%
8.7%
11.5%
10.2%
9.1%

2
50.9%
52.4%
46.8%
49.6%
48.7%
45.6%
39.6%
43.7%
42.5%
39.8%
41.3%
42.6%
38.6%
41.1%
41.8%

3
21.3%
9.5%
25.5%
23.3%
19.8%
21.0%
24.8%
25.5%
23.9%
26.3%
26.2%
21.6%
24.6%
19.9%
23.9%

4
5.6%
12.7%
8.5%
7.8%
8.1%
7.7%
9.2%
7.9%
8.7%
9.1%
7.5%
8.1%
7.1%
10.1%
8.3%

5+
2.8%
6.3%
0.0%
3.1%
2.0%
3.7%
2.2%
2.0%
3.6%
3.6%
3.7%
3.4%
3.5%
3.2%
3.3%

Not known
9.3%
12.7%
11.7%
7.8%
10.2%
8.1%
10.1%
8.7%
8.3%
8.9%
8.9%
10.4%
10.1%
11.6%
9.5%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

3.7%
3.2%
1.1%
3.1%
1.5%
4.4%
4.0%
3.9%
3.6%
3.7%
4.4%
5.2%
4.5%
3.9%
4.1%

Not known
10.0%
9.2%
9.2%
5.8%
7.1%
6.2%
9.1%
8.4%
8.8%
8.7%
9.3%
9.9%
9.1%
15.5%
9.4%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

4.4%
7.7%
2.8%
5.3%
2.4%
2.4%
3.4%
3.5%
4.5%
4.7%
4.1%
4.3%
3.9%
3.8%
3.9%

3.9%
4.9%
4.3%
4.0%

Not known
8.8%
13.6%
25.2%
9.5%

Total
100%
100%
100%
100%

n
17252
1142
485
18879

108
63
94
129
197
272
455
749
1256
1367
1534
1419
1135
793
9571

Table 6.2-3, number of attendances at GP by age band, for males.

Females, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All females

1
7.8%
6.2%
8.3%
5.8%
7.8%
7.8%
9.7%
9.4%
10.9%
10.1%
10.0%
8.7%
11.3%
11.8%
9.8%

2
36.7%
52.3%
51.4%
58.8%
61.3%
61.4%
56.5%
54.2%
50.3%
49.4%
47.2%
47.0%
51.7%
45.3%
51.3%

3
26.7%
16.9%
19.3%
15.6%
13.9%
12.5%
13.3%
16.3%
15.7%
15.6%
19.5%
17.5%
14.3%
13.2%
15.7%

4
11.1%
6.2%
8.3%
6.2%
5.2%
6.9%
4.4%
6.1%
6.3%
6.9%
6.8%
8.1%
6.7%
7.7%
6.8%

5+
3.3%
1.5%
0.9%
2.5%
2.4%
2.7%
3.6%
2.0%
3.5%
4.5%
3.1%
4.5%
3.0%
2.6%
3.2%

90
65
109
243
424
625
616
789
947
953
1037
1096
940
955
8889

Table 6.2-4, number of attendances at GP by age band, for females.

Communication difficulty
None
Communication difficulty
Not known
Total

1
9.3%
11.9%
9.7%
9.4%

2
47.1%
40.5%
33.6%
46.3%

3
20.2%
18.0%
14.6%
20.0%

4
7.4%
8.0%
9.3%
7.5%

5+
3.3%
3.1%
3.3%
3.2%

Table 6.2-5, number of attendances at GP by presence of communication difficulty.

Housebound?
No
Yes

Not Known
Total

9.0%
13.6%

1
47.7%
37.0%

2
20.4%
15.6%

3
7.5%
7.4%

4
3.3%
3.2%

5+
3.9%
4.9%

Not known
8.3%
18.4%

Total
100%
100%

n
16876
1298

12.1%
9.4%

31.8%
46.3%

16.6%
20.0%

9.1%
7.5%

3.0%
3.2%

5.0%
4.0%

22.6%
9.5%

100%
100%

705
18879

4.1%
3.8%
3.9%
3.5%
4.0%

Not known
9.3%
9.0%
10.1%
10.7%
9.5%

Total
100%
100%
100%
100%
100%

n
14644
837
1159
2239
18879

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

Ethnic category
White British
White other
Nonwhite
Not Known
Total

1
9.1%
11.7%
9.5%
10.5%
9.4%

2
46.4%
47.0%
46.2%
45.9%
46.3%

3
20.1%
20.0%
18.6%
19.5%
20.0%

Table 6.2-7, number of attendances at GP by ethnic category.

22

4
7.6%
5.6%
8.7%
6.8%
7.5%

5+
3.3%
3.0%
3.0%
3.0%
3.2%

6.3 Presenting symptom

Participants were asked to record the primary symptom with which the patient presented. The following
tables contain data on the frequency of symptoms for the four most common cancers. Some inconsistencies
exist in the completion of this field; for example, the meaning of asymptomatic probably mean that the
cancer was an incidental finding but a raised PSA implies some pre-existing symptom that prompted this test
to be done.

Breast cancer
Symptom
asymptomatic
breast abscess
breast pain
change to breast appearance
change to nipple appearance
fatigue
lump in breast
neck pain
nipple discharge
not known
other
shortness of breath
weight loss
Total

%
5.0%
0.3%
4.4%
3.7%
2.9%
0.3%
74.0%
0.1%
2.1%
3.3%
3.6%
0.3%
0.2%
100.0%

n
152
8
134
114
87
8
2254
2
63
100
109
8
7
3046

Table 6.3-1, fraction of presentations by symptom group, for breast cancer.

Colorectal cancer
Symptom
abdominal pain
anaemia
asymptomatic
bowel obstruction
change in bowel habit
epigastric pain
fatigue
nausea
not known
other
rectal hemorrhage
rectal pain
shortness of breath
weight loss
Total

%
14.8%
9.0%
3.0%
1.5%
26.4%
0.4%
4.6%
0.5%
2.2%
6.6%
24.6%
1.2%
1.8%
3.3%
100.0%

n
381
232
77
38
678
10
118
13
56
170
632
30
47
84
2566

Table 6.3-2, fraction of presentations by symptom group, for colorectal cancer.

23

Lung cancer
Symptom
abdominal pain
asymptomatic
chest infection
chest pain
chronic bronchitis, emphysema
cough
fatigue
haemoptysis
hoarse voice
lymphadenopathy
musculoskeletal pain
not known
other
shortness of breath
weight loss
Total

%
1.5%
6.3%
5.2%
6.6%
2.0%
25.2%
6.5%
7.4%
1.3%
1.3%
5.1%
3.3%
8.7%
15.0%
4.7%
100.0%

n
30
126
104
132
40
507
130
149
27
27
102
67
176
303
94
2014

Table 6.3-3, fraction of presentations by symptom group, for lung cancer.

Prostate cancer
Symptom
asymptomatic
blood in the semen
blood in the urine
bone pain
change in bowel habit
enlargement of the prostate
erectile dysfunction
fatigue
genitourinary tract pain
incontinence
lower urinary tract symptoms
not known
other
painful urination
raised psa
urine retention
weight loss
Total

%
6.9%
0.5%
5.5%
1.4%
0.9%
8.4%
1.7%
1.6%
1.8%
0.6%
32.0%
3.1%
10.6%
2.0%
17.4%
4.2%
1.5%
100.0%

n
200
14
160
40
26
246
50
46
51
18
931
89
309
59
508
121
44
2912

Table 6.3-4, fraction of presentations by symptom group, for prostate cancer.

24

6.4 Use of Investigations

GPs often use diagnostic services to investigate suspected cancer. In some cases this is advocated as a first
step by NICE guidance, as for some lung symptoms. In others they allow the risk of cancer as the underlying
cause of symptoms to be clarified. 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-obstetric
ultrasound, GI endoscopy and brain MRI. In this audit we found that blood tests, chest X-ray and ultrasound
examination were the most commonly used diagnostic tests. As might be expected, these varied according
to cancer site, but also according to presenting symptom.
Rapid access to investigations would have altered the GPs management of the patient in 6% of cases.
Some cancer patients, however, were more likely to have benefited from better access to diagnostics. These
included patients with brain, ovary, pancreas, liver and kidney cancer.

6.4.1 Tumour type

All
Blood Test
CT
CXR
Endoscopy
MRI
USS

Breast
33.1%
1.1%
10.3%
1.1%
0.2%
6.7%

2.0%
0.2%
1.7%
0.0%
0.1%
0.5%

Colorectal
Lung
41.5%
0.8%
2.5%
3.5%
0.0%
5.4%

24.6%
4.0%
61.0%
0.4%
0.3%
2.2%

Prostate
Haematology Other
74.0%
52.3%
24.4%
0.2%
0.7%
1.2%
3.0%
14.8%
4.1%
0.1%
0.5%
1.4%
0.2%
0.6%
0.3%
3.2%
6.1%
12.9%

Table 6.4-1, fraction of cases of specified cancer type with an investigation ordered by the GP, by investigation type (i.e.,
74.0% of prostate cancer patients have a blood test). Multiple investigations of different types in a single patient will be
counted more than once.

6.4.2 Association with presenting symptom

Breast cancer
Symptom
asymptomatic
breast abscess
breast pain
change to breast appearance
change to nipple appearance
fatigue
lump in breast
neck pain
nipple discharge
not known
other
shortness of breath
weight loss
Total

Chest X-ray
0.0%
0.0%
0.7%
0.0%
1.1%
0.0%
0.2%
0.0%
0.0%
0.0%
35.8%
50.0%
28.6%
1.7%

Ultrasound
0.0%
0.0%
0.0%
1.8%
1.1%
0.0%
0.1%
0.0%
0.0%
0.0%
8.3%
0.0%
14.3%
0.5%

MRI
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
50.0%
0.0%
0.0%
2.8%
0.0%
0.0%
0.1%

Blood test
0.0%
12.5%
2.2%
3.5%
0.0%
25.0%
0.6%
0.0%
3.2%
2.0%
27.5%
12.5%
42.9%
2.0%

CT
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
2.8%
12.5%
0.0%
0.2%

Endoscopy
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%

n
152
8
134
114
87
8
2254
2
63
100
109
8
7
3046

Table 6.4-2, percentage of cases presenting with symptom groups by type of investigation undertaken, for breast cancer.

25

Colorectal cancer
Symptom
abdominal pain
anaemia
asymptomatic
bowel obstruction
change in bowel habit
epigastric pain
fatigue
nausea
not known
other
rectal hemorrhage
rectal pain
shortness of breath
weight loss
Total

Chest X-ray
2.1%
1.3%
1.3%
2.6%
1.3%
10.0%
5.1%
7.7%
0.0%
10.6%
0.3%
0.0%
19.1%
7.1%
2.5%

Ultrasound
16.3%
2.2%
2.6%
0.0%
1.8%
20.0%
9.3%
38.5%
0.0%
12.4%
0.9%
6.7%
4.3%
10.7%
5.4%

MRI
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.2%
0.0%
0.0%
0.0%
0.0%

Blood test
39.9%
64.2%
33.8%
5.3%
42.3%
60.0%
82.2%
76.9%
8.9%
43.5%
26.4%
20.0%
80.9%
57.1%
41.6%

CT
1.3%
0.9%
1.3%
0.0%
1.0%
0.0%
0.8%
0.0%
0.0%
1.8%
0.0%
0.0%
0.0%
2.4%
0.8%

Endoscopy
2.4%
4.7%
3.9%
2.6%
3.5%
10.0%
2.5%
0.0%
1.8%
2.9%
4.7%
0.0%
0.0%
1.2%
3.5%

n
381
232
77
38
678
10
118
13
56
170
632
30
47
84
2566

Table 6.4-3, percentage of cases presenting with symptom groups by type of investigation undertaken, for colorectal cancer.

Lung cancer
Symptom
abdominal pain
asymptomatic
chest infection
chest pain
chronic bronchitis, emphysema
cough
fatigue
haemoptysis
hoarse voice
lymphadenopathy
musculoskeletal pain
not known
other
shortness of breath
weight loss
Total

Chest X-ray
30.0%
14.3%
58.7%
60.6%
40.0%
85.2%
32.3%
78.5%
48.1%
51.9%
61.8%
13.4%
30.1%
60.7%
69.1%
58.4%

Ultrasound
23.3%
0.8%
1.0%
2.3%
0.0%
0.2%
0.8%
0.0%
0.0%
14.8%
4.9%
3.0%
4.0%
1.0%
7.4%
2.1%

MRI
0.0%
0.0%
0.0%
1.5%
0.0%
0.2%
0.8%
0.0%
0.0%
0.0%
2.0%
0.0%
0.0%
0.0%
0.0%
0.3%

Blood test
50.0%
9.5%
12.5%
24.2%
10.0%
21.1%
46.2%
11.4%
14.8%
55.6%
34.3%
3.0%
24.4%
19.5%
57.4%
23.4%

CT
3.3%
0.8%
5.8%
6.1%
2.5%
4.3%
3.1%
3.4%
0.0%
0.0%
2.9%
0.0%
5.7%
4.6%
4.3%
3.9%

Endoscopy
0.0%
0.0%
0.0%
0.0%
0.0%
0.4%
0.8%
0.0%
0.0%
0.0%
1.0%
0.0%
0.6%
0.3%
2.1%
0.4%

n
30
126
104
132
40
507
130
149
27
27
102
67
176
303
94
2014

Table 6.4-4, percentage of cases presenting with symptom groups by type of investigation undertaken, for lung cancer.

Prostate cancer
Symptom
asymptomatic
blood in the semen
blood in the urine
bone pain
change in bowel habit
enlargement of the prostate glan
erectile dysfunction
fatigue
genitourinary tract pain
incontinence
lower urinary tract symptoms
not known
other
painful urination
raised psa
urine retention
weight loss
Total

26

Chest X-ray
0.5%
0.0%
0.0%
45.0%
3.8%
0.8%
0.0%
6.5%
11.8%
0.0%
0.4%
0.0%
12.0%
0.0%
1.0%
0.0%
22.7%
3.0%

Ultrasound
1.0%
7.1%
6.3%
0.0%
7.7%
3.3%
0.0%
4.3%
17.6%
0.0%
2.6%
0.0%
5.5%
1.7%
2.2%
1.7%
9.1%
3.2%

MRI
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
3.9%
0.0%
0.0%
0.0%
0.6%
0.0%
0.2%
0.0%
0.0%
0.2%

Blood test
73.5%
71.4%
50.0%
67.5%
88.5%
87.4%
86.0%
76.1%
78.4%
72.2%
87.9%
22.5%
74.1%
81.4%
66.9%
23.1%
90.9%
74.0%

CT
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
1.0%
0.0%
0.4%
0.0%
0.0%
0.2%

Endoscopy
0.5%
0.0%
0.6%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.3%
0.0%
0.0%
0.0%
0.0%
0.1%

n
200
14
160
40
26
246
50
46
51
18
931
89
309
59
508
121
44
2912

Table 6.4-5, percentage of cases presenting with symptom groups by type of investigation undertaken, for prostate cancer.

6.4.3 Change in management

30.0%

Fraction of all cases

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

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

27

Cancer type
Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

Blood tests CT
1
0
1
0
11
0
0
0
6
0
3
2
0
0
3
3
0
1
0
36
1
0
1
0
0
0
0
4
0
0
73

Investigation type for cases which would have changed management

Endoscopy MRI
USS
XRay
Not Known Total
5
11
2
14
0
8
41
22
0
23
0
1
1
47
7
0
6
25
12
15
66
1
1
0
4
0
2
8
45
128
3
21
8
13
229
2
1
1
26
0
1
31
5
3
0
3
0
0
11
1
4
0
1
0
0
6
3
0
0
2
0
5
16
11
1
1
5
0
0
18
64
2
10
3
45
9
136
29
2
9
15
1
4
62
0
1
2
2
0
11
16
1
0
0
0
1
0
2
1
0
8
0
0
1
13
4
42
1
1
2
2
55
2
0
0
4
1
2
9
19
1
2
33
0
1
57
30
3
1
17
0
0
51
4
2
9
19
1
12
83
18
2
7
18
1
2
49
1
0
2
7
0
1
11
0
1
0
1
0
0
3
4
29
1
4
0
1
39
1
0
0
18
0
0
19
1
0
0
12
0
1
14
0
0
0
0
0
2
2
12
3
7
18
1
3
48
7
1
2
3
0
1
14
1
0
1
0
0
0
2
301
238
98
276
74
98
1158

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

All
Blood tests
CT
X-Ray
Endoscopy
MRI
USS
Unknown
Total

Breast
0.4%
1.7%
1.3%
0.5%
1.6%
0.4%
0.5%
6.4%

0.0%
0.2%
0.0%
0.2%
0.8%
0.4%
0.5%
2.2%

Colorectal Lung
0.4%
1.7%
5.0%
0.1%
0.8%
0.3%
0.5%
8.9%

0.1%
3.2%
0.1%
0.5%
0.1%
2.3%
0.4%
6.9%

Prostate
Haemo
Other
Brain
1.2%
0.7%
0.2%
0.0%
0.1%
2.1%
2.2%
9.4%
0.1%
0.1%
1.6%
0.4%
0.3%
1.1%
0.8%
0.0%
0.7%
1.1%
2.9%
9.8%
0.0%
0.1%
0.1%
0.0%
0.4%
0.6%
0.6%
0.4%
2.9%
5.7%
8.4%
20.1%

Table 6.4-7, the investigations which would have changed management. The figures are the number of investigations for
which management would have been changed with a denominator all cancers of that type by all cases, by cancer type.

6.5 Routes to diagnosis

An urgent referral pathway for suspected cancer has now been in operation since 2000, with supporting
criteria for referral being provided by NICE. Nevertheless, patients enter the secondary care system in
other ways as well. Those being referred as an emergency are a particular concern because of the poorer
outcomes that are associated with this route to diagnosis.11

28

Overall, over half of all cases were referred through the two week urgent referral pathway, while 12.9%
were referred as an emergency. A proportion of these will have entered secondary care as an emergency
without having been in contact with primary care. These are likely to also be patients with zero visits to the
GP (Table 6.2.1). Emergency presentations were particularly high in the 0-24 age group, and for brain, leukaemia, liver, myeloma and pancreas. Two week referrals less likely for some cancers, notably being less than
40% of the total for brain, leukaemia, liver, and myeloma.

6.5.1 Demographic features

Sex
Male
Female
Not Known
Total

Emergency
13.1%
12.7%
13.0%
12.9%

2 week
50.8%
57.3%
48.1%
53.9%

Routine

4.9%
5.0%
0.0%
4.9%

Not referred by
practice
7.3%
6.7%
1.9%
7.0%

2.8%
6.3%
4.3%
4.7%
7.1%
5.1%
7.3%
7.7%
6.1%
6.1%
3.6%
3.8%
3.3%
3.7%
4.9%

Not referred by
practice
10.2%
6.3%
11.7%
3.9%
8.6%
7.4%
7.0%
7.3%
7.2%
5.9%
6.8%
7.5%
8.5%
8.6%
7.3%

5.6%
1.5%
4.6%
7.4%
10.4%
6.4%
6.0%
6.2%
6.5%
5.1%
3.3%
3.0%
3.5%
3.5%
5.0%

Not referred by
practice
4.4%
10.8%
3.7%
5.3%
6.1%
2.6%
7.0%
5.8%
7.0%
5.7%
6.9%
7.7%
8.7%
7.7%
6.6%

Private

17.1%
12.2%
14.8%
14.8%

Not known
6.8%
6.1%
22.2%
6.5%

Total
100%
100%
100%
100%

n
9759
9066
54
18879

Table 6.5-1, type of referral, by sex of patient.

Males, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All males

Emergency
39.8%
12.7%
20.2%
15.5%
15.2%
16.5%
11.4%
12.3%
11.2%
10.3%
11.5%
11.6%
15.8%
18.5%
13.1%

2 week
25.0%
49.2%
42.6%
50.4%
48.2%
46.7%
48.4%
49.7%
51.4%
52.4%
54.0%
54.1%
47.9%
47.3%
50.7%

Routine

Private

11.1%
17.5%
14.9%
18.6%
13.7%
19.1%
18.7%
16.8%
18.2%
19.4%
18.2%
16.3%
15.7%
13.7%
17.2%

Not known
11.1%
7.9%
6.4%
7.0%
7.1%
5.1%
7.3%
6.1%
5.9%
6.0%
5.9%
6.7%
8.8%
8.2%
6.7%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
108
63
94
129
197
272
455
749
1256
1367
1534
1419
1135
793
9571

Table 6.5-2, type of referral, by age band of patient, for males.

Females, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All females

Emergency
45.6%
7.7%
10.1%
9.9%
7.3%
10.1%
9.6%
9.9%
12.5%
12.3%
12.2%
13.0%
15.9%
17.1%
12.7%

2 week
24.4%
50.8%
49.5%
53.1%
59.4%
62.6%
55.4%
59.8%
57.3%
57.6%
60.1%
60.1%
56.1%
53.0%
57.4%

Routine

Private

14.4%
20.0%
24.8%
18.1%
11.8%
14.2%
15.1%
12.7%
11.0%
12.9%
12.2%
10.7%
9.5%
10.5%
12.2%

Not known
5.6%
9.2%
7.3%
6.2%
5.0%
4.2%
7.0%
5.6%
5.7%
6.4%
5.4%
5.5%
6.4%
8.3%
6.1%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
90
65
109
243
424
625
616
789
947
953
1037
1096
940
955
8889

Table 6.5-3, type of referral, by age band of patient, for females.

Communication difficulty
None
Communication difficulty
Not known
Total

Emergency
12.6%
17.1%
11.5%
12.9%

2 week
54.5%
48.7%
44.5%
53.9%

Routine

Private

14.9%
13.3%
12.2%
14.8%

Table 6.5-4, type of referral, by presence of communication difficulty.

5.1%
2.4%
3.9%
4.9%

Not referred by
practice
6.8%
9.6%
7.2%
7.0%

Not known
6.0%
8.9%
20.6%
6.5%

Total
100%
100%
100%
100%

n
17252
1142
485
18879

29

Housebound?
No
Yes
Not Known
Total

Emergency

2 week

12.0%
22.9%
15.6%
12.9%

55.4%
41.3%
40.7%
53.9%

Routine

5.2%
2.4%
3.5%
4.9%

Not referred by
practice
6.5%
12.2%
8.5%
7.0%

5.7%
4.7%
4.9%
2.0%
5.1%
6.4%
5.7%
1.6%
2.8%
3.8%
2.2%
6.4%
5.5%
3.8%
2.8%
3.7%
5.7%
8.5%
5.6%
5.5%
5.8%
8.4%
14.0%
4.4%
9.6%
9.5%
1.3%
6.2%
2.6%
0.0%
4.9%

Not referred by
practice
6.2%
15.0%
5.0%
8.6%
6.5%
3.9%
12.9%
7.8%
10.5%
13.1%
11.4%
8.2%
4.0%
7.6%
8.3%
3.2%
9.2%
6.9%
7.2%
5.1%
11.8%
8.4%
10.5%
7.8%
10.8%
7.9%
5.3%
8.1%
10.6%
1.4%
7.0%

Private

15.2%
10.2%
13.6%
14.8%

Not known
5.7%
10.9%
18.0%
6.5%

Total
100%
100%
100%
100%

n
16876
1298
705
18879

Table 6.5-5, type of referral, by housebound status.

6.5.2 Tumour type

Cancer type
Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

Emergency

2 week

7.8%
39.3%
3.7%
15.1%
14.8%
6.0%
20.0%
7.8%
30.7%
27.7%
20.3%
17.8%
4.7%
29.1%
28.2%
9.9%
7.4%
23.0%
29.0%
6.6%
13.1%
14.3%
19.3%
21.0%
10.2%
7.9%
5.3%
15.9%
30.2%
10.8%
12.9%

58.8%
12.8%
75.9%
49.3%
51.4%
64.6%
34.3%
59.7%
22.1%
34.6%
49.0%
41.4%
66.5%
48.1%
33.3%
58.2%
58.5%
47.4%
40.8%
55.5%
49.0%
41.2%
29.8%
40.4%
56.6%
42.1%
65.8%
38.1%
36.0%
12.2%
53.9%

Routine
15.8%
17.5%
5.8%
19.7%
16.4%
15.9%
18.6%
21.7%
24.9%
11.5%
8.2%
18.8%
16.4%
10.1%
17.9%
17.3%
12.2%
8.1%
12.3%
21.5%
12.8%
17.6%
14.0%
17.6%
7.8%
27.8%
18.4%
23.3%
14.8%
5.4%
14.8%

Private

Not known
5.8%
10.7%
4.7%
5.3%
5.7%
3.2%
8.6%
1.6%
9.1%
9.2%
8.9%
7.4%
3.0%
1.3%
9.5%
7.7%
7.0%
6.2%
5.1%
5.8%
7.5%
10.1%
12.3%
8.8%
4.8%
4.8%
3.9%
8.5%
5.8%
70.3%
6.5%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
920
234
3046
152
2566
435
70
129
574
130
2014
760
878
79
252
596
229
422
390
2912
398
119
57
319
166
126
76
567
189
74
18879

Table 6.5-6, type of referral, by cancer type.

Ethnic category
White British
White other
Nonwhite
Not Known
Total

Emergency
12.8%
15.2%
15.5%
11.3%
12.9%

2 week
54.7%
47.3%
50.9%
52.8%
53.9%

Table 6.5-7, type of referral, by ethnic category.

30

Routine
15.1%
13.9%
14.8%
13.3%
14.8%

Private
4.9%
5.7%
3.5%
5.5%
4.9%

Not referred by
practice
6.7%
9.8%
7.7%
7.5%
7.0%

Not known
5.9%
8.1%
7.6%
9.6%
6.5%

Total
100%
100%
100%
100%
100%

n
14644
837
1159
2239
18879

6.5.3 Presenting symptom

Breast cancer
Symptom
asymptomatic
breast abscess
breast pain
change to breast appearance
change to nipple appearance
fatigue
lump in breast
neck pain
nipple discharge
not known
other
shortness of breath
weight loss
Total

Emergency
10.5%
12.5%
4.5%
4.4%
3.4%
62.5%
1.9%
50.0%
3.2%
5.0%
21.1%
37.5%
0.0%
3.7%

2 week

Routine

23.7%
75.0%
69.4%
72.8%
82.8%
12.5%
84.3%
50.0%
66.7%
19.0%
48.6%
37.5%
57.1%
75.9%

Private

2.6%
0.0%
17.9%
10.5%
8.0%
25.0%
4.7%
0.0%
12.7%
0.0%
14.7%
0.0%
0.0%
5.8%

1.3%
12.5%
4.5%
1.8%
2.3%
0.0%
5.2%
0.0%
9.5%
3.0%
8.3%
0.0%
0.0%
4.9%

Not referred by
practice
44.1%
0.0%
0.7%
7.0%
2.3%
0.0%
1.8%
0.0%
4.8%
23.0%
4.6%
12.5%
14.3%
5.0%

Not known
17.8%
0.0%
3.0%
3.5%
1.1%
0.0%
2.2%
0.0%
3.2%
50.0%
2.8%
12.5%
28.6%
4.7%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
152
8
134
114
87
8
2254
2
63
100
109
8
7
3046

Table 6.5-8, type of referral with symptom groups by type of investigation, for breast cancer.

Colorectal cancer
Symptom
abdominal pain
anaemia
asymptomatic
bowel obstruction
change in bowel habit
epigastric pain
fatigue
nausea
not known
other
rectal hemorrhage
rectal pain
shortness of breath
weight loss
Total

Emergency
27.8%
13.4%
3.9%
50.0%
9.1%
30.0%
17.8%
23.1%
7.1%
19.4%
9.8%
23.3%
36.2%
9.5%
14.8%

2 week

Routine

37.8%
51.3%
37.7%
23.7%
63.3%
10.0%
50.0%
46.2%
17.9%
51.2%
52.4%
50.0%
40.4%
72.6%
51.4%

14.2%
17.2%
6.5%
0.0%
15.8%
40.0%
16.1%
15.4%
5.4%
11.8%
23.3%
16.7%
12.8%
10.7%
16.4%

Private
6.3%
3.4%
1.3%
0.0%
5.6%
10.0%
6.8%
0.0%
0.0%
3.5%
6.8%
0.0%
4.3%
1.2%
5.1%

Not referred by
practice
7.9%
9.5%
29.9%
15.8%
3.4%
0.0%
5.1%
7.7%
23.2%
7.1%
4.0%
6.7%
4.3%
3.6%
6.5%

Not known
6.0%
5.2%
20.8%
10.5%
2.8%
10.0%
4.2%
7.7%
46.4%
7.1%
3.8%
3.3%
2.1%
2.4%
5.7%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
381
232
77
38
678
10
118
13
56
170
632
30
47
84
2566

Table 6.5-9, type of referral with symptom groups by type of investigation, for colorectal cancer.

Lung cancer
Symptom
abdominal pain
asymptomatic
chest infection
chest pain
chronic bronchitis, emphysema
cough
fatigue
haemoptysis
hoarse voice
lymphadenopathy
musculoskeletal pain
not known
other
shortness of breath
weight loss
Total

Emergency
20.0%
4.8%
32.7%
25.0%
17.5%
14.4%
35.4%
12.1%
7.4%
14.8%
19.6%
11.9%
26.7%
29.0%
18.1%
20.3%

2 week
46.7%
27.8%
36.5%
50.8%
40.0%
66.7%
26.9%
68.5%
66.7%
70.4%
44.1%
14.9%
37.5%
40.6%
63.8%
49.0%

Routine
16.7%
6.3%
6.7%
6.1%
10.0%
7.1%
8.5%
6.7%
14.8%
7.4%
14.7%
4.5%
12.5%
7.9%
6.4%
8.2%

Private
6.7%
1.6%
2.9%
3.0%
2.5%
1.6%
3.8%
2.0%
0.0%
0.0%
2.0%
1.5%
4.0%
2.0%
1.1%
2.2%

Not referred by
practice
10.0%
41.3%
16.3%
8.3%
17.5%
5.7%
12.3%
6.7%
3.7%
0.0%
14.7%
16.4%
13.6%
10.2%
3.2%
11.4%

Table 6.5-10, type of referral with symptom groups by type of investigation, for lung cancer.

Not known
0.0%
18.3%
4.8%
6.8%
12.5%
4.5%
13.1%
4.0%
7.4%
7.4%
4.9%
50.7%
5.7%
10.2%
7.4%
8.9%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
30
126
104
132
40
507
130
149
27
27
102
67
176
303
94
2014

31

Prostate cancer
Symptom
asymptomatic
blood in the semen
blood in the urine
bone pain
change in bowel habit
enlargement of the prostate glan
erectile dysfunction
fatigue
genitourinary tract pain
incontinence
lower urinary tract symptoms
not known
other
painful urination
raised psa
urine retention
weight loss
Total

Emergency
4.0%
0.0%
6.3%
10.0%
3.8%
3.3%
2.0%
8.7%
2.0%
22.2%
3.9%
2.2%
13.9%
3.4%
2.4%
42.1%
13.6%
6.6%

2 week
47.0%
57.1%
70.6%
67.5%
65.4%
60.2%
60.0%
65.2%
68.6%
55.6%
61.7%
20.2%
58.3%
61.0%
50.0%
11.6%
65.9%
55.5%

Routine
26.5%
42.9%
11.9%
5.0%
15.4%
26.4%
30.0%
13.0%
17.6%
11.1%
24.5%
11.2%
15.5%
25.4%
24.0%
14.0%
11.4%
21.5%

Private
9.0%
0.0%
7.5%
5.0%
15.4%
3.7%
6.0%
0.0%
7.8%
0.0%
5.0%
2.2%
3.9%
5.1%
7.9%
1.7%
4.5%
5.5%

Not referred by
practice
8.5%
0.0%
1.3%
5.0%
0.0%
2.8%
0.0%
6.5%
3.9%
5.6%
1.6%
19.1%
4.9%
0.0%
8.3%
19.8%
2.3%
5.1%

Not known
5.0%
0.0%
2.5%
7.5%
0.0%
3.7%
2.0%
6.5%
0.0%
5.6%
3.3%
44.9%
3.6%
5.1%
7.5%
10.7%
2.3%
5.8%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
200
14
160
40
26
246
50
46
51
18
931
89
309
59
508
121
44
2912

Table 6.5-11, type of referral with symptom groups by type of investigation, for prostate cancer.

6.6 Commentary
The place of first presentation varies significantly by cancer site. For some, it reflects the fact that the
presenting symptom can be a medical or surgical emergency. An example is an uncontrolled fit due to
brain cancer, haematemesis (vomiting blood) due to stomach cancer or bowel obstruction due to colorectal
cancer. Nevertheless, a proportion of those presenting as an emergency may have delayed seeking medical
help from the GP or may have experienced difficulties 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 specific presenting symptoms (breast, melanoma) usually only required
one consultation before referral and two thirds of all cases required one or two. The number of consultations
is sometimes taken as a measure of the alacrity with which a diagnosis is reached. However, this measure
should take account of the nature of general practice consultations. These are relatively short, are more
commonly initiated by the patient, make use of interval reassessment, with the results of any diagnostic
tests ordered only being available after several days. Nevertheless, it is apparent from this audit that for
some cancers, typically those with non-specific and relatively common symptoms, a greater number of
consultations occur before referral.
In nearly 10% of cases there were zero consultations. These are likely to be patients who went directly
to A&E or whose cancer was an incidental finding whilst under specialist care for a co-morbid condition.
Patients with communication difficulties and those who were housebound were more likely to record zero
consultations.
The most common presenting symptoms for each of the four main cancers concurred with the NICE criteria
for urgent referral. It is notable that, of those recorded, haemoptysis was the presenting symptom for less
than 10% of all cases of lung cancer.
The data on use of investigations and expressed need for better access to diagnostics broadly bears out the
improvements in access proposed in Improving Outcomes: a strategy for cancer. There is one exception,
however, in that for lung cancer this study indicates that only in 0.1% of cases would better access to X-ray
have changed management.

32

Two other reports provide data that can be compared with the findings of this audit. The National Cancer
Patient Experience Survey 201012 obtained direct feedback from 67000 cancer patients who were admitted
to hospital in the first quarter of 2010. It found that of those patients who saw their GP before going to
hospital, 16% did so three or four times and 9% saw their GP five or more times. These findings are broadly
similar to the audit apart from the greater proportion consulting five times or more.
The NCIN Data Briefing on Routes to Diagnosis analysed the route by which patients entered the secondary
care system. It utilised a combination of data from the National Cancer Data Repository, Cancer Waiting
Times and Hospital Episode Statistics. It found that 25% of cases were referred through the two week wait
pathway and 23% presented as emergencies. This contrasts with the findings of this audit that 53.9% were
referred by the two week wait pathway and that 12.9% presented as emergencies. The differences in these
findings may be explained by differences in the patient cohort, differences in definitions (two week wait
referral compared to two week wait diagnosis for example), case ascertainment and the exclusion of screendetected cases. A recent analysis comparing case ascertainment using the National Cancer Data Repository
and 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 of emergency
presentations (NCIN personal communication). Nevertheless, these significant differences require further
detailed analysis so that future cancer audits using different source data can be reconciled.

33

7.1 Patient interval

Participating practices were asked to estimate from the clinical records the date when the patient first
developed their presenting symptom. This is not a reliable or consistent method of ascertaining the patient
interval and the data that follows should be interpreted with considerable caution. For example, in 20% of
cases the duration of symptoms was zero days, while for a further 30% the duration was unknown. The
following tables relate the duration of patient delay to demographic features, tumour type, referral route
and presenting symptom (for the four common cancers only).

7.1.1 Demographic features

Sex
Male
Female
Not known
Total

0 days
20.0%
19.3%
31.5%
19.7%

1-14 days
16.7%
22.7%
11.1%
19.6%

15-31 days
10.7%
11.3%
5.6%
11.0%

32-62 days 63-182 days

7.3%
7.4%
7.5%
7.4%
1.9%
3.7%
7.4%
7.4%

183+ days
Not known
4.8%
33.0%
4.6%
27.2%
7.4%
38.9%
4.7%
30.2%

Total
100.0%
100.0%
100.0%
100.0%

32-62 days 63-182 days

3.7%
2.8%
4.8%
9.5%
5.3%
12.8%
7.0%
7.8%
10.7%
8.6%
9.2%
8.1%
9.7%
9.7%
7.9%
8.8%
7.9%
7.8%
8.0%
7.7%
7.0%
7.9%
6.6%
6.3%
6.0%
6.1%
5.8%
6.2%
7.2%
7.4%

183+ days
Not known
5.6%
20.4%
7.9%
20.6%
7.4%
24.5%
11.6%
24.8%
7.6%
23.9%
5.1%
25.7%
5.7%
28.6%
5.7%
30.3%
5.3%
31.2%
4.3%
33.9%
5.1%
33.2%
4.5%
36.0%
3.5%
37.8%
2.9%
36.1%
4.8%
33.0%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

183+ days
Not known
4.4%
21.1%
3.1%
30.8%
10.1%
20.2%
4.9%
25.1%
5.7%
21.5%
6.9%
19.7%
4.2%
25.6%
4.4%
23.3%
3.3%
28.1%
4.6%
25.7%
4.5%
28.5%
3.1%
28.2%
4.6%
29.9%
5.0%
35.7%
4.5%
27.2%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

9759
9066
54
18879

Table 7.1-1, patient interval, by sex of patient.

Males, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All males

0 days
24.1%
25.4%
16.0%
15.5%
18.8%
17.3%
16.0%
19.5%
20.1%
18.9%
19.8%
20.4%
21.4%
23.7%
20.0%

1-14 days
29.6%
20.6%
26.6%
19.4%
18.8%
19.9%
17.4%
16.8%
16.8%
16.0%
16.8%
15.9%
15.5%
15.8%
16.8%

15-31 days
13.9%
11.1%
7.4%
14.0%
11.7%
14.7%
13.0%
10.9%
10.9%
11.1%
10.2%
10.4%
9.7%
9.6%
10.8%

108
63
94
129
197
272
455
749
1256
1367
1534
1419
1135
793
9571

Table 7.1-2, patient interval, by age band of patient, for males.

Females, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All females

0 days
26.7%
18.5%
22.9%
14.8%
12.7%
16.2%
20.5%
19.6%
19.0%
19.5%
18.1%
21.2%
21.0%
19.9%
19.2%

1-14 days
28.9%
21.5%
28.4%
31.3%
26.7%
28.5%
21.1%
22.8%
22.5%
22.9%
20.3%
22.1%
21.2%
20.1%
22.8%

15-31 days
6.7%
7.7%
10.1%
9.5%
16.5%
11.4%
12.7%
12.7%
10.6%
11.6%
12.3%
11.2%
10.5%
9.0%
11.4%

32-62 days 63-182 days

3.3%
8.9%
7.7%
10.8%
4.6%
3.7%
5.3%
9.1%
10.6%
6.4%
8.6%
8.8%
7.0%
8.9%
8.2%
8.9%
8.8%
7.8%
6.9%
8.7%
7.5%
8.6%
7.9%
6.3%
7.0%
5.9%
5.5%
4.7%
7.5%
7.5%

Table 7.1-3, patient interval, by age band of patient, for females.

34

90
65
109
243
424
625
616
789
947
953
1037
1096
940
955
8889

Communication difficulty
None
Communication difficulty
Not known
Total

0 days
19.7%
21.5%
15.9%
19.7%

1-14 days
20.0%
15.5%
15.1%
19.6%

15-31 days
11.1%
10.2%
9.7%
11.0%

32-62 days 63-182 days

7.5%
7.6%
6.3%
5.9%
6.0%
5.6%
7.4%
7.4%

183+ days
Not known
4.8%
29.4%
4.2%
36.4%
3.3%
44.5%
4.7%
30.2%

Total
100.0%
100.0%
100.0%
100.0%

n
17252
1142
485
18879

32-62 days 63-182 days

7.7%
7.7%
4.7%
4.5%
5.0%
6.4%
7.4%
7.4%

183+ days
Not known
4.8%
29.0%
4.1%
38.1%
2.8%
45.1%
4.7%
30.2%

Total
100.0%
100.0%
100.0%
100.0%

n
16876
1298
705
18879

32-62 days 63-182 days

7.4%
7.4%
8.1%
8.7%
6.7%
6.8%
7.1%
7.4%
7.4%
7.4%

183+ days
Not known
4.6%
29.9%
5.3%
30.6%
5.1%
30.0%
4.9%
32.6%
4.7%
30.2%

Total
100.0%
100.0%
100.0%
100.0%
100.0%

n
14644
837
1159
2239
18879

Table 7.1-4, patient interval, by presence of communication difficulty.

Housebound?
No
Yes
Not Known
Total

0 days
19.4%
24.8%
16.5%
19.7%

1-14 days
20.0%
15.6%
16.2%
19.6%

15-31 days
11.3%
8.2%
8.1%
11.0%

Table 7.1-5, patient interval, by housebound status.

Ethnic category
White British
White other
Nonwhite
Not Known
Total

0 days
19.4%
18.8%
23.1%
20.5%
19.7%

1-14 days
20.2%
18.6%
17.7%
17.0%
19.6%

15-31 days
11.2%
9.9%
10.5%
10.5%
11.0%

Table 7.1-6, patient interval, by ethnic category.

7.1.2 Tumour type

Cancer type
Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

0 days
29.0%
21.8%
17.2%
19.7%
19.2%
20.2%
25.7%
10.1%
19.0%
18.5%
19.3%
16.8%
17.7%
16.5%
19.4%
15.9%
13.5%
16.6%
20.3%
22.2%
27.1%
22.7%
26.3%
23.2%
15.1%
16.7%
14.5%
18.9%
28.0%
6.8%
19.7%

1-14 days
27.7%
31.6%
32.2%
15.1%
16.5%
23.9%
25.7%
12.4%
15.9%
11.5%
19.6%
21.1%
9.2%
20.3%
14.7%
16.3%
14.4%
23.0%
26.9%
10.4%
18.6%
21.0%
19.3%
14.4%
30.7%
21.4%
19.7%
14.8%
19.6%
4.1%
19.6%

15-31 days
7.4%
9.8%
11.5%
9.2%
12.0%
10.6%
7.1%
12.4%
8.2%
10.8%
12.7%
13.8%
9.5%
22.8%
11.1%
21.8%
15.3%
11.6%
13.3%
6.7%
8.5%
13.4%
8.8%
13.5%
10.2%
13.5%
14.5%
11.1%
13.8%
2.7%
11.0%

32-62 days 63-182 days

3.9%
4.6%
5.6%
7.3%
5.9%
5.9%
8.6%
12.5%
10.8%
11.4%
9.4%
10.1%
2.9%
2.9%
20.9%
13.2%
4.7%
4.2%
7.7%
3.1%
8.2%
6.5%
9.9%
7.8%
7.7%
7.6%
8.9%
6.3%
4.4%
7.1%
11.7%
11.2%
14.4%
14.0%
8.8%
10.0%
9.0%
8.2%
5.0%
5.8%
4.3%
3.8%
6.7%
9.2%
5.3%
17.5%
6.9%
5.3%
3.0%
10.8%
10.3%
5.6%
9.2%
10.5%
5.1%
7.2%
4.8%
5.8%
2.7%
2.7%
7.4%
7.4%

183+ days
Not known
3.5%
23.9%
2.6%
21.4%
4.0%
23.3%
11.2%
23.7%
5.3%
24.8%
6.4%
19.3%
4.3%
31.4%
10.1%
20.9%
3.0%
45.1%
2.3%
46.2%
2.5%
31.2%
4.9%
25.8%
9.6%
38.7%
5.1%
20.3%
3.6%
39.7%
3.0%
20.0%
7.0%
21.4%
3.3%
26.8%
1.5%
20.8%
5.3%
44.6%
3.0%
34.7%
8.4%
18.5%
3.5%
19.3%
5.0%
31.7%
9.0%
21.1%
9.5%
23.0%
10.5%
21.1%
6.5%
36.3%
1.6%
26.5%
5.4%
75.7%
4.7%
30.2%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

n
920
234
3046
152
2566
435
70
129
574
130
2014
760
878
79
252
596
229
422
390
2912
398
119
57
319
166
126
76
567
189
74
18879

Table 7.1-7, patient interval, by cancer type.

35

7.1.3 Presenting symptoms

Breast cancer
Symptom
asymptomatic
breast abscess
breast pain
change to breast appearance
change to nipple appearance
fatigue
lump in breast
neck pain
nipple discharge
not known
other
shortness of breath
weight loss
Total

0 days
24.3%
57.1%
21.1%
34.1%
19.4%
33.3%
20.3%
50.0%
17.3%
29.4%
30.3%
40.0%
0.0%
17.2%

1-14 days
5.9%
28.6%
34.2%
25.9%
13.4%
16.7%
45.6%
0.0%
40.4%
41.2%
30.3%
20.0%
0.0%
32.2%

15-31 days
0.0%
0.0%
17.5%
16.5%
14.9%
0.0%
15.0%
0.0%
19.2%
11.8%
19.7%
0.0%
0.0%
11.5%

32-62 days
63-182 days
0.0%
0.7%
0.0%
14.3%
14.0%
10.5%
5.9%
5.9%
14.9%
20.9%
16.7%
16.7%
7.2%
7.4%
0.0%
0.0%
7.7%
3.8%
5.9%
5.9%
7.9%
7.9%
20.0%
0.0%
100.0%
0.0%
5.9%
5.9%

183+ days
Not known
0.7%
68.4%
0.0%
12.5%
2.6%
14.9%
11.8%
25.4%
16.4%
23.0%
16.7%
25.0%
4.6%
17.7%
50.0%
0.0%
11.5%
17.5%
5.9%
83.0%
3.9%
30.3%
20.0%
37.5%
0.0%
71.4%
4.0%
23.3%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

183+ days
Not known
2.4%
21.0%
1.7%
49.6%
1.3%
83.1%
0.0%
21.1%
8.6%
14.3%
0.0%
20.0%
3.4%
27.1%
7.7%
15.4%
0.0%
87.5%
1.8%
30.6%
7.0%
15.7%
6.7%
23.3%
2.1%
27.7%
9.5%
19.0%
5.3%
24.8%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

183+ days
Not known
0.0%
40.0%
0.8%
81.7%
1.9%
33.7%
0.8%
26.5%
2.5%
60.0%
4.1%
16.0%
3.1%
38.5%
2.7%
12.1%
0.0%
11.1%
3.7%
14.8%
2.0%
20.6%
0.0%
76.1%
1.7%
39.2%
1.7%
29.0%
5.3%
37.2%
2.5%
31.2%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

152
8
134
114
87
8
2254
2
63
100
109
8
7
3046

Table 7.1-8, patient interval, by symptom group, for breast cancer.

Colorectal cancer
Symptom
abdominal pain
anaemia
asymptomatic
bowel obstruction
change in bowel habit
epigastric pain
fatigue
nausea
not known
other
rectal hemorrhage
rectal pain
shortness of breath
weight loss
Total

0 days
20.2%
24.1%
14.3%
23.7%
16.4%
30.0%
22.9%
15.4%
3.6%
25.9%
18.8%
26.7%
19.1%
17.9%
19.2%

1-14 days
25.5%
6.9%
1.3%
39.5%
14.5%
30.0%
11.9%
15.4%
1.8%
17.1%
19.6%
13.3%
21.3%
10.7%
16.5%

15-31 days
13.9%
9.1%
0.0%
2.6%
15.6%
0.0%
14.4%
30.8%
0.0%
8.8%
11.9%
6.7%
12.8%
10.7%
12.0%

32-62 days
63-182 days
8.7%
8.4%
4.3%
4.3%
0.0%
0.0%
10.5%
2.6%
13.4%
17.3%
20.0%
0.0%
13.6%
6.8%
15.4%
0.0%
1.8%
5.4%
5.3%
10.6%
13.9%
13.1%
13.3%
10.0%
6.4%
10.6%
17.9%
14.3%
10.8%
11.4%

381
232
77
38
678
10
118
13
56
170
632
30
47
84
2566

Table 7.1-9, patient interval, by symptom group, for colorectal cancer.

Lung cancer
Symptom
abdominal pain
asymptomatic
chest infection
chest pain
chronic bronchitis, emphysema
cough
fatigue
haemoptysis
hoarse voice
lymphadenopathy
musculoskeletal pain
not known
other
shortness of breath
weight loss
Total

0 days
16.7%
11.1%
19.2%
19.7%
15.0%
19.1%
18.5%
26.2%
14.8%
33.3%
18.6%
10.4%
19.3%
23.1%
16.0%
19.3%

1-14 days
10.0%
1.6%
26.0%
32.6%
12.5%
21.7%
17.7%
34.2%
22.2%
25.9%
26.5%
6.0%
15.9%
17.8%
5.3%
19.6%

15-31 days
16.7%
4.0%
11.5%
9.1%
7.5%
15.4%
12.3%
13.4%
25.9%
11.1%
20.6%
4.5%
9.7%
13.9%
11.7%
12.7%

32-62 days
63-182 days
6.7%
10.0%
0.0%
0.8%
6.7%
1.0%
8.3%
3.0%
2.5%
0.0%
12.2%
11.4%
6.9%
3.1%
7.4%
4.0%
22.2%
3.7%
0.0%
11.1%
7.8%
3.9%
0.0%
3.0%
8.0%
6.3%
6.6%
7.9%
16.0%
8.5%
8.2%
6.5%

Table 7.1-10, patient interval, by symptom group, for lung cancer.

36

30
126
104
132
40
507
130
149
27
27
102
67
176
303
94
2014

Prostate cancer
Symptom
asymptomatic
blood in the semen
blood in the urine
bone pain
change in bowel habit
enlargement of the prostate
erectile dysfunction
fatigue
genitourinary tract pain
incontinence
lower urinary tract symptoms
not known
other
painful urination
raised psa
urine retention
weight loss
Total

0 days
17.5%
21.4%
31.3%
12.5%
23.1%
17.1%
18.0%
28.3%
25.5%
16.7%
20.4%
6.7%
19.7%
25.4%
28.1%
35.5%
20.5%
22.2%

1-14 days
1.0%
28.6%
35.0%
7.5%
19.2%
8.5%
0.0%
13.0%
19.6%
0.0%
8.3%
5.6%
17.5%
20.3%
5.9%
9.9%
11.4%
10.4%

15-31 days
0.5%
14.3%
4.4%
7.5%
11.5%
4.9%
2.0%
13.0%
17.6%
16.7%
8.7%
0.0%
10.7%
15.3%
3.1%
5.0%
9.1%
6.7%

32-62 days
63-182 days
1.0%
1.5%
21.4%
0.0%
3.1%
0.6%
12.5%
17.5%
3.8%
0.0%
9.3%
7.3%
8.0%
8.0%
6.5%
6.5%
11.8%
3.9%
5.6%
5.6%
5.9%
9.7%
1.1%
0.0%
6.5%
5.8%
8.5%
10.2%
0.6%
1.2%
5.0%
0.8%
6.8%
20.5%
5.0%
5.8%

183+ days
Not known
0.5%
78.0%
0.0%
14.3%
3.8%
21.9%
2.5%
40.0%
0.0%
42.3%
9.3%
43.5%
26.0%
38.0%
2.2%
30.4%
2.0%
19.6%
16.7%
38.9%
8.3%
38.8%
0.0%
86.5%
4.2%
35.6%
1.7%
18.6%
2.0%
59.1%
2.5%
41.3%
4.5%
27.3%
5.3%
44.6%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
200
14
160
40
26
246
50
46
51
18
931
89
309
59
508
121
44
2912

Table 7.1-11, patient interval, by symptom group, for prostate cancer.

7.1.4 Referral route

Emergency
2 week
Routine
Private
Not referred by practice
Not known
Total

0 days
28.6%
18.9%
18.8%
21.5%
16.9%
12.5%
19.7%

1-14 days
25.0%
22.5%
13.4%
22.4%
9.2%
7.2%
19.6%

15-31 days
9.9%
12.9%
10.1%
12.8%
4.2%
5.5%
11.0%

32-62 days
63-182 days
5.6%
4.9%
9.1%
8.8%
6.6%
8.5%
7.2%
8.7%
2.7%
2.6%
3.3%
2.8%
7.4%
7.4%

183+ days
Not known
2.5%
23.6%
5.2%
22.6%
7.3%
35.2%
5.6%
21.8%
1.5%
62.7%
2.0%
66.7%
4.7%
30.2%

Total
100%
100%
100%
100%
100%
100%
100%

n
2432
10175
2789
931
1323
1229
18879

Table 7.1-12, patient interval, by referral route.

7.2 Primary care interval

The primary care interval was defined as the time between first presentation and date of referral. First
presentation was defined as first notification to any health care professional working within the Primary Health
Care Team about a symptom or sign which was probably due to the cancer. Date of referral was defined as the
date that the referral letter was sent, or if not available the date the proforma was completed or letter written.
The following tables relate the duration of the primary care interval to demographic features, tumour type,
referral route and presenting symptom (for the four common cancers only).

7.2.1 Demographic features

Sex
Male
Female
Not Known
Total

0 days
24.7%
38.8%
33.3%
31.5%

1-14 days
27.0%
22.5%
7.4%
24.8%

15-31 days
12.5%
8.4%
5.6%
10.6%

32-62 days 63-182 days

7.9%
6.7%
6.9%
5.9%
5.6%
9.3%
7.4%
6.3%

183+ days
Not known
3.2%
18.0%
2.4%
15.0%
3.7%
35.2%
2.9%
16.6%

Total
100.0%
100.0%
100.0%
100.0%

n
9759
9066
54
18879

Table 7.2-1, primary care interval, by sex of patient.

37

Males, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All males

0 days
31.5%
30.2%
29.8%
30.2%
26.4%
30.1%
28.6%
26.2%
26.9%
21.1%
21.8%
24.1%
23.3%
26.7%
24.7%

1-14 days
28.7%
27.0%
28.7%
28.7%
27.4%
24.3%
25.5%
27.1%
25.0%
30.2%
29.4%
25.4%
25.4%
27.0%
27.1%

15-31 days
9.3%
7.9%
12.8%
7.8%
13.2%
12.5%
11.2%
14.0%
12.9%
13.6%
14.0%
12.5%
11.5%
9.3%
12.5%

32-62 days 63-182 days

8.3%
4.6%
4.8%
9.5%
5.3%
6.4%
8.5%
6.2%
7.6%
6.6%
7.4%
8.5%
9.5%
5.3%
7.5%
6.8%
8.1%
6.8%
8.6%
7.0%
7.8%
6.5%
8.1%
7.1%
7.7%
6.7%
6.6%
6.3%
7.9%
6.7%

183+ days
Not known
0.9%
16.7%
6.3%
14.3%
0.0%
17.0%
4.7%
14.0%
2.0%
16.8%
4.0%
13.2%
3.5%
16.5%
3.3%
15.1%
3.9%
16.3%
2.9%
16.5%
2.5%
17.9%
3.5%
19.3%
3.4%
21.9%
3.7%
20.4%
3.3%
17.8%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

183+ days
Not known
3.3%
10.0%
6.2%
15.4%
5.5%
8.3%
2.9%
7.8%
2.4%
9.2%
2.1%
9.0%
1.8%
16.6%
2.5%
13.1%
1.6%
15.6%
3.4%
13.6%
2.8%
15.9%
2.6%
15.3%
2.6%
18.3%
1.8%
20.3%
2.5%
14.9%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

183+ days
Not known
2.9%
15.8%
2.7%
21.3%
2.3%
32.2%
2.9%
16.6%

Total
100.0%
100.0%
100.0%
100.0%

n
17252
1142
485
18879

32-62 days 63-182 days

7.5%
6.4%
7.1%
5.2%
6.0%
6.1%
7.4%
6.3%

183+ days
Not known
2.8%
15.1%
2.9%
27.7%
3.5%
32.3%
2.9%
16.6%

Total
100.0%
100.0%
100.0%
100.0%

n
16876
1298
705
18879

32-62 days 63-182 days

7.3%
6.4%
8.2%
4.7%
7.9%
7.9%
7.3%
5.9%
7.4%
6.3%

183+ days
Not known
2.8%
16.1%
2.6%
19.4%
2.1%
16.7%
3.5%
18.5%
2.9%
16.6%

Total
100.0%
100.0%
100.0%
100.0%
100.0%

n
14644
837
1159
2239
18879

108
63
94
129
197
272
455
749
1256
1367
1534
1419
1135
793
9571

Table 7.2-2, primary care interval, by age band of patient, for males.

Females, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All females

0 days
20.0%
44.6%
40.4%
41.2%
48.6%
48.2%
43.5%
40.9%
39.5%
36.6%
36.4%
35.1%
36.6%
36.0%
38.9%

1-14 days
38.9%
16.9%
14.7%
21.4%
21.0%
22.2%
22.1%
22.1%
22.0%
22.9%
22.1%
23.8%
22.0%
22.8%
22.4%

15-31 days
7.8%
4.6%
8.3%
11.5%
7.5%
6.9%
5.4%
8.1%
8.1%
8.0%
10.0%
11.0%
8.8%
7.4%
8.4%

32-62 days 63-182 days

13.3%
6.7%
4.6%
7.7%
12.8%
10.1%
9.9%
5.3%
5.4%
5.9%
6.4%
5.3%
6.8%
3.9%
8.1%
5.2%
7.1%
6.1%
7.3%
8.2%
6.4%
6.5%
6.8%
5.4%
6.3%
5.4%
5.7%
6.0%
6.9%
5.9%

90
65
109
243
424
625
616
789
947
953
1037
1096
940
955
8889

Table 7.2-3, primary care interval, by age band of patient, for females.

Communication difficulty
None
Communication difficulty
Not known
Total

0 days
31.8%
29.7%
24.1%
31.5%

1-14 days
25.1%
22.3%
19.6%
24.8%

15-31 days
10.6%
10.0%
9.3%
10.6%

32-62 days 63-182 days

7.4%
6.3%
7.5%
6.5%
7.0%
5.6%
7.4%
6.3%

Table 7.2-4, primary care interval, by presence of communication difficulty.

Housebound?
No
Yes
Not Known
Total

0 days
32.2%
27.7%
22.6%
31.5%

1-14 days
25.3%
21.2%
19.1%
24.8%

15-31 days
10.7%
8.3%
10.4%
10.6%

Table 7.2-5, primary care interval, by housebound status.

Ethnic category
White British
White other
Nonwhite
Not Known
Total

0 days
31.4%
33.8%
31.5%
31.0%
31.5%

1-14 days
25.1%
24.3%
22.8%
24.0%
24.8%

15-31 days
10.8%
7.0%
11.1%
9.6%
10.6%

Table 7.2-6, primary care interval, by ethnic category.

38

7.2.2 Tumour type

Cancer type
Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

0 days
31.1%
33.3%
65.2%
36.8%
29.2%
44.1%
5.7%
33.3%
19.9%
16.9%
11.8%
23.0%
50.7%
20.3%
10.3%
34.7%
34.5%
22.7%
22.6%
17.3%
20.4%
26.9%
19.3%
24.5%
37.3%
20.6%
47.4%
28.0%
24.3%
12.2%
31.5%

1-14 days
31.1%
24.4%
17.1%
22.4%
23.3%
24.1%
24.3%
23.3%
27.9%
19.2%
28.8%
27.6%
22.4%
31.6%
20.2%
20.5%
18.8%
32.7%
31.3%
31.0%
22.4%
21.0%
28.1%
18.2%
25.3%
24.6%
26.3%
22.9%
18.5%
5.4%
24.8%

15-31 days
10.1%
7.3%
2.7%
10.5%
11.5%
7.4%
15.7%
12.4%
10.1%
10.8%
13.1%
12.6%
5.8%
16.5%
13.9%
12.2%
15.3%
10.0%
10.0%
15.7%
12.6%
10.1%
8.8%
12.2%
12.7%
22.2%
6.6%
11.3%
15.3%
4.1%
10.6%

32-62 days 63-182 days

5.7%
4.3%
4.3%
5.1%
1.6%
1.4%
7.2%
9.9%
8.3%
8.5%
9.4%
3.9%
12.9%
10.0%
9.3%
5.4%
6.3%
5.1%
6.9%
8.5%
11.3%
8.7%
8.8%
8.0%
7.2%
3.5%
6.3%
12.7%
13.1%
13.1%
11.2%
8.9%
8.3%
7.0%
11.6%
5.5%
10.0%
9.0%
7.6%
7.0%
10.1%
6.5%
11.8%
9.2%
10.5%
8.8%
6.9%
14.4%
4.2%
3.0%
7.1%
4.8%
5.3%
3.9%
6.7%
6.7%
12.7%
7.4%
4.1%
1.4%
7.4%
6.3%

183+ days
Not known
3.2%
14.6%
2.6%
23.1%
0.9%
11.1%
2.0%
11.2%
4.1%
15.2%
2.5%
8.5%
5.7%
25.7%
3.9%
12.4%
1.6%
29.3%
3.1%
34.6%
2.7%
23.6%
4.1%
15.8%
2.4%
8.0%
0.0%
12.7%
4.8%
24.6%
2.2%
10.2%
2.6%
13.5%
0.9%
16.6%
2.8%
14.4%
3.8%
17.5%
3.3%
24.9%
5.9%
15.1%
1.8%
22.8%
4.7%
19.1%
2.4%
15.1%
4.0%
16.7%
3.9%
6.6%
3.0%
21.3%
4.2%
17.5%
1.4%
71.6%
2.9%
16.6%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

n
920
234
3046
152
2566
435
70
129
574
130
2014
760
878
79
252
596
229
422
390
2912
398
119
57
319
166
126
76
567
189
74
18879

Table 7.2-7, primary care interval, by cancer type.

7.2.3 Presenting symptom

Breast cancer
Symptom
asymptomatic
breast abscess
breast pain
change to breast appearance
change to nipple appearance
fatigue
lump in breast
neck pain
nipple discharge
not known
other
shortness of breath
weight loss
Total

0 days
18.4%
50.0%
56.0%
62.3%
71.3%
37.5%
73.8%
50.0%
63.5%
10.0%
24.8%
25.0%
0.0%
65.2%

1-14 days
4.6%
37.5%
20.9%
21.1%
14.9%
12.5%
17.6%
0.0%
25.4%
3.0%
22.9%
37.5%
28.6%
17.1%

15-31 days
2.6%
0.0%
6.0%
3.5%
2.3%
12.5%
2.1%
0.0%
3.2%
1.0%
10.1%
0.0%
28.6%
2.7%

32-62 days
63-182 days
0.7%
0.0%
12.5%
0.0%
7.5%
4.5%
0.9%
3.5%
4.6%
2.3%
12.5%
12.5%
0.7%
0.6%
0.0%
50.0%
0.0%
1.6%
3.0%
0.0%
10.1%
11.9%
0.0%
12.5%
28.6%
0.0%
1.6%
1.4%

183+ days
Not known
0.0%
73.7%
0.0%
0.0%
1.5%
3.7%
0.0%
8.8%
1.1%
3.4%
0.0%
12.5%
0.9%
4.3%
0.0%
0.0%
0.0%
6.3%
0.0%
83.0%
3.7%
16.5%
0.0%
25.0%
0.0%
14.3%
0.9%
11.1%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
152
8
134
114
87
8
2254
2
63
100
109
8
7
3046

Table 7.2-8, primary care interval, by symptom, for breast cancer.

39

Colorectal cancer
Symptom
abdominal pain
anaemia
asymptomatic
bowel obstruction
change in bowel habit
epigastric pain
fatigue
nausea
not known
other
rectal hemorrhage
rectal pain
shortness of breath
weight loss
Total

0 days
21.3%
17.2%
9.1%
31.6%
33.0%
20.0%
16.1%
0.0%
7.1%
20.0%
44.6%
16.7%
17.0%
36.9%
29.2%

1-14 days
22.6%
26.7%
15.6%
31.6%
22.3%
20.0%
28.0%
53.8%
1.8%
21.8%
24.1%
33.3%
31.9%
21.4%
23.3%

15-31 days
13.1%
12.1%
2.6%
5.3%
13.6%
10.0%
17.8%
15.4%
1.8%
18.2%
7.1%
6.7%
12.8%
13.1%
11.5%

32-62 days
63-182 days
11.5%
10.0%
4.7%
6.9%
7.8%
3.9%
0.0%
0.0%
10.6%
9.9%
20.0%
10.0%
11.9%
8.5%
23.1%
7.7%
1.8%
1.8%
6.5%
10.0%
5.4%
6.8%
20.0%
10.0%
10.6%
14.9%
6.0%
13.1%
8.3%
8.5%

183+ days
Not known
5.2%
16.3%
7.8%
24.6%
2.6%
58.4%
2.6%
28.9%
4.0%
6.6%
10.0%
10.0%
3.4%
14.4%
0.0%
0.0%
0.0%
85.7%
2.4%
21.2%
3.8%
8.2%
3.3%
10.0%
0.0%
12.8%
2.4%
7.1%
4.1%
15.2%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

183+ days
Not known
0.0%
23.3%
2.4%
76.2%
1.9%
27.9%
1.5%
18.2%
2.5%
47.5%
3.4%
9.5%
1.5%
29.2%
2.7%
10.7%
0.0%
11.1%
0.0%
3.7%
4.9%
14.7%
1.5%
73.1%
3.4%
25.0%
2.6%
24.1%
3.2%
14.9%
2.7%
23.6%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

381
232
77
38
678
10
118
13
56
170
632
30
47
84
2566

Table 7.2-9, primary care interval, by symptom, for colorectal cancer.

Lung cancer
Symptom
abdominal pain
asymptomatic
chest infection
chest pain
chronic bronchitis, emphysema
cough
fatigue
haemoptysis
hoarse voice
lymphadenopathy
musculoskeletal pain
not known
other
shortness of breath
weight loss
Total

0 days
13.3%
7.1%
10.6%
10.6%
7.5%
5.9%
15.4%
18.1%
25.9%
29.6%
3.9%
7.5%
21.0%
16.5%
9.6%
11.8%

1-14 days
13.3%
9.5%
18.3%
34.1%
30.0%
33.9%
23.8%
43.6%
37.0%
51.9%
24.5%
7.5%
26.1%
28.1%
37.2%
28.8%

15-31 days
26.7%
1.6%
19.2%
12.1%
7.5%
16.6%
14.6%
13.4%
11.1%
11.1%
20.6%
3.0%
9.1%
10.9%
13.8%
13.1%

32-62 days
63-182 days
13.3%
10.0%
1.6%
1.6%
13.5%
8.7%
14.4%
9.1%
2.5%
2.5%
16.8%
14.0%
9.2%
6.2%
5.4%
6.0%
14.8%
0.0%
0.0%
3.7%
12.7%
18.6%
4.5%
3.0%
10.8%
4.5%
10.9%
6.9%
10.6%
10.6%
11.3%
8.7%

30
126
104
132
40
507
130
149
27
27
102
67
176
303
94
2014

Table 7.2-10, primary care interval, by symptom, for lung cancer.

Prostate cancer
Symptom
asymptomatic
blood in the semen
blood in the urine
bone pain
change in bowel habit
enlargement of the prostate
erectile dysfunction
fatigue
genitourinary tract pain
incontinence
lower urinary tract symptoms
not known
other
painful urination
raised psa
urine retention
weight loss
Total

0 days
17.5%
28.6%
34.4%
2.5%
15.4%
11.4%
14.0%
10.9%
21.6%
22.2%
13.2%
10.1%
11.0%
15.3%
24.4%
38.8%
9.1%
17.3%

1-14 days
16.0%
21.4%
33.8%
22.5%
50.0%
35.4%
28.0%
37.0%
31.4%
44.4%
39.2%
5.6%
35.6%
27.1%
22.6%
14.0%
52.3%
31.0%

15-31 days
7.5%
7.1%
13.8%
22.5%
26.9%
21.5%
20.0%
15.2%
15.7%
22.2%
18.8%
4.5%
18.4%
18.6%
12.0%
5.8%
11.4%
15.7%

32-62 days
63-182 days
6.0%
3.0%
21.4%
7.1%
5.6%
4.4%
15.0%
12.5%
7.7%
0.0%
6.5%
7.3%
14.0%
10.0%
10.9%
8.7%
7.8%
11.8%
5.6%
0.0%
9.9%
7.4%
1.1%
1.1%
9.4%
11.7%
13.6%
13.6%
3.7%
6.5%
0.8%
2.5%
11.4%
6.8%
7.6%
7.0%

Table 7.2-11, primary care interval, by symptom, for prostate cancer.

40

183+ days
Not known
3.5%
46.5%
7.1%
7.1%
2.5%
5.6%
2.5%
22.5%
0.0%
0.0%
5.7%
12.2%
6.0%
8.0%
2.2%
15.2%
5.9%
5.9%
0.0%
5.6%
4.6%
6.9%
0.0%
77.5%
2.6%
11.3%
10.2%
1.7%
3.7%
27.0%
0.0%
38.0%
4.5%
4.5%
3.8%
17.5%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
200
14
160
40
26
246
50
46
51
18
931
89
309
59
508
121
44
2912

7.2.4 Referral route

Symptom
Emergency
2 week
Routine
Private
Not referred by practice
Not known
Total

0 days
34.3%
38.9%
21.2%
33.6%
10.4%
8.6%
31.5%

1-14 days
27.3%
28.0%
25.7%
31.0%
4.8%
7.5%
24.8%

15-31 days
9.3%
11.7%
14.5%
9.5%
2.6%
3.9%
10.6%

32-62 days
63-182 days
6.5%
6.1%
8.1%
6.1%
10.3%
11.2%
7.3%
6.8%
2.4%
2.0%
2.7%
2.5%
7.4%
6.3%

183+ days
Not known
2.9%
13.7%
2.5%
4.7%
5.8%
11.3%
4.0%
7.8%
0.7%
77.0%
0.9%
73.9%
2.9%
16.6%

Total
100%
100%
100%
100%
100%
100%
100%

n
2432
10175
2789
931
1323
1229
18879

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

7.3 Referral interval

Referral interval was defined as the period between referral and the date the patient first attended in
secondary care, either for assessment in the outpatient clinic, admission or investigation. The following
tables relate the referral interval to demographic features, tumour type, referral route and presenting
symptom. Because of sample and cell size, this has been done for the four common cancers only.

7.3.1 Demographic features

Sex
Male
Female
Not Known
Total

0 days
9.1%
8.8%
9.3%
8.9%

1-14 days
45.0%
51.7%
27.8%
48.2%

15-31 days
17.1%
16.1%
11.1%
16.6%

32-62 days 63-182 days

10.4%
3.9%
7.8%
2.3%
11.1%
5.6%
9.1%
3.1%

183+ days
Not known
1.4%
13.2%
1.1%
12.2%
0.0%
35.2%
1.3%
12.7%

Total
100.0%
100.0%
100.0%
100.0%

32-62 days 63-182 days

7.4%
3.7%
9.5%
4.8%
8.5%
4.3%
9.3%
4.7%
10.7%
2.5%
11.8%
4.0%
10.5%
4.6%
10.1%
3.6%
10.4%
4.2%
12.8%
4.1%
10.6%
3.7%
9.7%
3.4%
9.1%
4.1%
9.0%
3.9%
10.4%
3.9%

183+ days
Not known
0.9%
16.7%
0.0%
11.1%
2.1%
17.0%
1.6%
12.4%
1.5%
15.2%
0.4%
12.1%
1.1%
14.9%
1.7%
11.1%
1.7%
11.0%
2.0%
11.5%
1.3%
12.3%
1.5%
13.3%
0.8%
16.0%
1.8%
16.0%
1.5%
13.1%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

183+ days
Not known
1.1%
10.0%
4.6%
12.3%
0.9%
7.3%
0.0%
8.2%
1.2%
10.1%
0.3%
8.3%
1.5%
12.5%
0.8%
10.5%
1.5%
12.4%
0.7%
11.9%
1.2%
12.3%
1.4%
11.5%
1.6%
14.4%
0.7%
16.0%
1.1%
12.1%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

9759
9066
54
18879

Table 7.3-1, referral interval, by sex of patient.

Males, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All males

0 days
29.6%
6.3%
12.8%
5.4%
9.6%
9.2%
8.1%
8.1%
7.6%
7.6%
8.3%
8.1%
11.8%
12.6%
9.1%

1-14 days
32.4%
54.0%
44.7%
46.5%
44.7%
46.0%
42.2%
48.7%
47.2%
45.0%
45.8%
45.2%
42.5%
41.0%
44.9%

15-31 days
9.3%
14.3%
10.6%
20.2%
15.7%
16.5%
18.5%
16.6%
18.0%
17.0%
18.0%
18.7%
15.8%
15.8%
17.2%

108
63
94
129
197
272
455
749
1256
1367
1534
1419
1135
793
9571

Table 7.3-2, referral interval, by age band of patient, for males.

Females, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All females

0 days
34.4%
6.2%
6.4%
7.0%
5.2%
5.6%
7.0%
5.6%
7.7%
8.6%
8.9%
8.7%
11.1%
13.3%
8.7%

1-14 days
33.3%
36.9%
43.1%
55.1%
56.8%
59.2%
49.0%
57.5%
52.7%
52.5%
53.3%
52.6%
46.9%
46.6%
51.9%

15-31 days
11.1%
20.0%
22.0%
15.2%
17.9%
15.8%
19.8%
15.5%
15.5%
15.3%
14.6%
16.1%
17.3%
15.1%
16.1%

32-62 days 63-182 days

7.8%
2.2%
15.4%
4.6%
15.6%
4.6%
10.7%
3.7%
6.8%
1.9%
7.8%
2.9%
7.8%
2.4%
7.2%
2.9%
7.5%
2.7%
8.6%
2.4%
7.7%
2.0%
7.9%
1.7%
7.0%
1.7%
6.4%
1.9%
7.8%
2.3%

Table 7.3-3, referral interval, by age band of patient, for females.

90
65
109
243
424
625
616
789
947
953
1037
1096
940
955
8889

41

Communication difficulty
None
Communication difficulty
Not known
Total

0 days
8.7%
12.8%
7.6%
8.9%

1-14 days
49.0%
40.2%
39.6%
48.2%

15-31 days
16.8%
15.3%
14.6%
16.6%

32-62 days 63-182 days

9.2%
3.1%
9.8%
3.9%
6.0%
3.7%
9.1%
3.1%

183+ days
Not known
1.3%
12.0%
0.9%
17.2%
0.4%
28.0%
1.3%
12.7%

Total
100.0%
100.0%
100.0%
100.0%

n
17252
1142
485
18879

32-62 days 63-182 days

9.4%
3.1%
6.5%
2.9%
7.5%
3.3%
9.1%
3.1%

183+ days
Not known
1.3%
11.3%
1.0%
22.4%
0.9%
28.9%
1.3%
12.7%

Total
100.0%
100.0%
100.0%
100.0%

n
16876
1298
705
18879

32-62 days 63-182 days

9.0%
3.1%
10.6%
3.6%
11.7%
3.5%
8.3%
3.2%
9.1%
3.1%

183+ days
Not known
1.3%
12.1%
1.0%
16.8%
1.4%
13.3%
1.4%
15.0%
1.3%
12.7%

Total
100.0%
100.0%
100.0%
100.0%
100.0%

n
14644
837
1159
2239
18879

Table 7.3-4, referral interval, by presence of communication difficulty.

Housebound?
No
Yes
Not Known
Total

0 days
8.4%
16.1%
9.2%
8.9%

1-14 days
49.5%
37.3%
37.2%
48.2%

15-31 days
17.0%
13.8%
13.0%
16.6%

Table 7.3-5, referral interval, by housebound status.

Ethnic category
White British
White other
Nonwhite
Not Known
Total

0 days
8.9%
9.6%
9.1%
8.4%
8.9%

1-14 days
48.9%
41.8%
43.2%
48.8%
48.2%

15-31 days
16.8%
16.6%
17.8%
15.0%
16.6%

Table 7.3-6, referral interval, by ethnic category.

7.3.2 Tumour type

Cancer type
Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

0 days
5.3%
26.9%
2.7%
7.9%
10.9%
3.0%
14.3%
3.9%
22.8%
15.4%
15.6%
13.0%
2.1%
21.5%
14.3%
6.0%
5.2%
17.1%
20.5%
4.1%
9.0%
5.9%
15.8%
13.8%
5.4%
3.2%
2.6%
10.4%
23.3%
4.1%
8.9%

1-14 days
45.3%
28.2%
66.1%
46.7%
44.3%
55.2%
34.3%
48.8%
27.0%
38.5%
43.9%
44.1%
54.8%
46.8%
40.9%
49.5%
56.8%
51.7%
45.1%
45.9%
45.2%
51.3%
40.4%
36.1%
56.0%
38.1%
52.6%
38.3%
40.7%
12.2%
48.2%

Table 7.3-7, referral interval, by cancer type.

42

15-31 days
23.2%
12.0%
16.2%
21.1%
16.0%
20.9%
12.9%
20.9%
13.8%
12.3%
13.9%
17.5%
17.7%
13.9%
17.1%
19.6%
15.3%
12.6%
12.8%
19.5%
14.3%
11.8%
12.3%
16.9%
15.1%
19.8%
19.7%
12.9%
9.5%
6.8%
16.6%

32-62 days 63-182 days

9.5%
3.5%
7.3%
3.0%
4.4%
0.8%
11.8%
2.0%
11.8%
3.9%
7.8%
4.4%
8.6%
2.9%
7.0%
7.0%
15.7%
2.6%
9.2%
0.0%
5.0%
1.2%
8.9%
3.0%
11.3%
5.7%
7.6%
1.3%
8.3%
4.8%
10.7%
2.2%
7.4%
2.2%
3.6%
0.9%
5.6%
0.8%
12.7%
5.3%
8.8%
2.5%
10.9%
5.9%
10.5%
1.8%
10.7%
4.1%
5.4%
1.8%
19.8%
7.9%
13.2%
2.6%
14.3%
6.9%
5.8%
1.6%
6.8%
1.4%
9.1%
3.1%

183+ days
Not known
2.0%
11.3%
0.9%
21.8%
0.6%
9.2%
0.0%
10.5%
1.0%
12.1%
1.1%
7.6%
2.9%
24.3%
0.8%
11.6%
1.6%
16.6%
3.1%
21.5%
1.2%
19.0%
1.6%
11.8%
1.6%
6.9%
0.0%
8.9%
0.4%
14.3%
1.7%
10.2%
0.9%
12.2%
0.5%
13.7%
1.8%
13.3%
1.8%
10.7%
1.5%
18.6%
0.8%
13.4%
0.0%
19.3%
2.2%
16.3%
0.6%
15.7%
0.8%
10.3%
2.6%
6.6%
1.8%
15.5%
1.6%
17.5%
0.0%
68.9%
1.3%
12.7%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

n
920
234
3046
152
2566
435
70
129
574
130
2014
760
878
79
252
596
229
422
390
2912
398
119
57
319
166
126
76
567
189
74
18879

7.3.3 Presenting symptom

Breast cancer
Symptom
asymptomatic
breast abscess
breast pain
change to breast appearance
change to nipple appearance
fatigue
lump in breast
neck pain
nipple discharge
not known
other
shortness of breath
weight loss
Total

0 days
12.5%
12.5%
1.5%
1.8%
0.0%
37.5%
1.5%
50.0%
1.6%
2.0%
14.7%
12.5%
0.0%
2.7%

1-14 days
30.9%
50.0%
59.7%
61.4%
64.4%
37.5%
72.7%
50.0%
57.1%
24.0%
45.0%
50.0%
28.6%
66.1%

15-31 days
7.2%
25.0%
24.6%
19.3%
24.1%
25.0%
16.2%
0.0%
20.6%
3.0%
17.4%
0.0%
28.6%
16.2%

32-62 days
63-182 days
2.0%
0.0%
12.5%
0.0%
8.2%
0.7%
8.8%
0.9%
5.7%
2.3%
0.0%
0.0%
3.9%
0.6%
0.0%
0.0%
4.8%
3.2%
1.0%
0.0%
11.0%
1.8%
0.0%
0.0%
0.0%
14.3%
4.4%
0.8%

183+ days
Not known
0.7%
46.7%
0.0%
0.0%
1.5%
3.7%
0.0%
7.9%
2.3%
1.1%
0.0%
0.0%
0.5%
4.5%
0.0%
0.0%
0.0%
12.7%
0.0%
70.0%
0.9%
9.2%
0.0%
37.5%
14.3%
14.3%
0.6%
9.2%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
152
8
134
114
87
8
2254
2
63
100
109
8
7
3046

Table 7.3-8, referral interval by symptom, for breast cancer.

Colorectal cancer
Symptom
abdominal pain
anaemia
asymptomatic
bowel obstruction
change in bowel habit
epigastric pain
fatigue
nausea
not known
other
rectal hemorrhage
rectal pain
shortness of breath
weight loss
Total

0 days
21.3%
9.5%
3.9%
42.1%
6.6%
20.0%
14.4%
23.1%
1.8%
14.7%
6.6%
16.7%
27.7%
4.8%
10.9%

1-14 days
35.7%
40.1%
27.3%
21.1%
52.1%
20.0%
43.2%
46.2%
12.5%
45.3%
48.3%
40.0%
40.4%
54.8%
44.3%

15-31 days
15.7%
15.5%
11.7%
5.3%
18.0%
10.0%
17.8%
15.4%
5.4%
12.9%
16.6%
20.0%
12.8%
19.0%
16.0%

32-62 days
63-182 days
6.8%
4.7%
17.2%
4.3%
11.7%
1.3%
2.6%
2.6%
13.4%
3.7%
30.0%
10.0%
8.5%
1.7%
15.4%
0.0%
5.4%
0.0%
7.6%
2.4%
15.3%
4.9%
6.7%
3.3%
2.1%
2.1%
7.1%
6.0%
11.8%
3.9%

183+ days
Not known
0.8%
15.0%
1.3%
12.1%
2.6%
41.6%
0.0%
26.3%
1.3%
4.9%
0.0%
10.0%
1.7%
12.7%
0.0%
0.0%
0.0%
75.0%
0.6%
16.5%
0.6%
7.6%
0.0%
13.3%
2.1%
12.8%
1.2%
7.1%
1.0%
12.1%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

183+ days
Not known
13.3%
13.3%
1.6%
51.6%
2.9%
23.1%
0.8%
16.7%
0.0%
27.5%
0.8%
9.5%
0.8%
24.6%
0.0%
9.4%
11.1%
11.1%
0.0%
3.7%
1.0%
12.7%
0.0%
70.1%
1.7%
18.2%
0.7%
19.1%
1.1%
9.6%
1.2%
19.0%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

381
232
77
38
678
10
118
13
56
170
632
30
47
84
2566

Table 7.3-9, referral interval by symptom, for colorectal cancer.

Lung cancer
Symptom
abdominal pain
asymptomatic
chest infection
chest pain
chronic bronchitis, emphysema
cough
fatigue
haemoptysis
hoarse voice
lymphadenopathy
musculoskeletal pain
not known
other
shortness of breath
weight loss
Total

0 days
16.7%
4.8%
25.0%
18.2%
22.5%
10.1%
24.6%
9.4%
7.4%
3.7%
18.6%
4.5%
22.2%
23.1%
14.9%
15.6%

1-14 days
40.0%
19.0%
33.7%
43.2%
35.0%
54.8%
30.0%
65.8%
55.6%
74.1%
42.2%
13.4%
38.6%
40.6%
53.2%
43.9%

15-31 days
13.3%
15.1%
9.6%
14.4%
10.0%
18.5%
13.8%
11.4%
11.1%
18.5%
20.6%
3.0%
10.8%
10.6%
13.8%
13.9%

32-62 days
63-182 days
3.3%
0.0%
7.1%
0.8%
5.8%
0.0%
6.1%
0.8%
5.0%
0.0%
4.9%
1.4%
5.4%
0.8%
2.7%
1.3%
3.7%
0.0%
0.0%
0.0%
3.9%
1.0%
7.5%
1.5%
6.3%
2.3%
4.0%
2.0%
6.4%
1.1%
5.0%
1.2%

30
126
104
132
40
507
130
149
27
27
102
67
176
303
94
2014

Table 7.3-10, referral interval by symptom, for lung cancer.

43

Prostate cancer
Symptom
asymptomatic
blood in the semen
blood in the urine
bone pain
change in bowel habit
enlargement of the prostate
erectile dysfunction
fatigue
genitourinary tract pain
incontinence
lower urinary tract symptoms
not known
other
painful urination
raised psa
urine retention
weight loss
Total

0 days
2.0%
0.0%
2.5%
2.5%
3.8%
0.8%
0.0%
6.5%
0.0%
16.7%
2.5%
2.2%
9.4%
1.7%
1.6%
28.9%
4.5%
4.1%

1-14 days
43.0%
57.1%
55.6%
55.0%
73.1%
48.4%
52.0%
54.3%
51.0%
55.6%
50.3%
11.2%
50.8%
45.8%
40.6%
9.9%
63.6%
45.9%

15-31 days
19.0%
14.3%
18.8%
25.0%
11.5%
21.1%
18.0%
13.0%
23.5%
11.1%
21.8%
7.9%
16.8%
30.5%
20.9%
9.9%
11.4%
19.5%

32-62 days
63-182 days
14.0%
5.0%
21.4%
7.1%
11.9%
3.1%
2.5%
0.0%
7.7%
3.8%
14.6%
6.5%
16.0%
10.0%
10.9%
2.2%
13.7%
5.9%
11.1%
0.0%
13.1%
6.0%
4.5%
5.6%
9.1%
3.2%
15.3%
3.4%
15.4%
6.1%
10.7%
6.6%
11.4%
2.3%
12.7%
5.3%

183+ days
Not known
0.5%
16.5%
0.0%
0.0%
2.5%
5.6%
2.5%
12.5%
0.0%
0.0%
0.8%
7.7%
2.0%
2.0%
2.2%
10.9%
2.0%
3.9%
0.0%
5.6%
1.8%
4.5%
1.1%
67.4%
1.6%
9.1%
1.7%
1.7%
2.6%
13.0%
1.7%
32.2%
2.3%
4.5%
1.8%
10.7%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
200
14
160
40
26
246
50
46
51
18
931
89
309
59
508
121
44
2912

Table 7.3-11, referral interval by symptom, for prostate cancer.

7.3.4 Referral route

Symptom
Emergency
2 week
Routine
Private
Not referred by practice
Not known
Total

0 days
53.4%
1.0%
1.0%
6.0%
11.9%
3.7%
8.9%

1-14 days
20.8%
72.8%
11.8%
64.3%
11.1%
9.0%
48.2%

15-31 days
7.6%
17.8%
28.4%
16.6%
6.3%
9.0%
16.6%

32-62 days
63-182 days
5.7%
1.8%
3.7%
0.8%
37.4%
14.5%
5.9%
1.3%
4.0%
2.2%
4.5%
1.8%
9.1%
3.1%

183+ days
Not known
0.7%
10.0%
1.3%
2.6%
2.3%
4.7%
1.2%
4.6%
0.5%
64.1%
0.9%
71.3%
1.3%
12.7%

Total
100%
100%
100%
100%
100%
100%
100%

n
2432
10175
2789
931
1323
1229
18879

Table 7.3-12, referral interval by referral route.

7.4 Commentary
The data on patient delay should be interpreted with considerable caution, for the reasons previously stated,
namely that information on duration of symptoms is not always recorded in the clinical record. When it is,
the information may not have been elicited in a systematic way and reflects the doctors interpretation of the
patients statements. Overall, 12% of patients were recorded as having symptoms for two months or more
prior to first presentation. There were some surprising patient delays relating to alarm symptoms 12% of
those with breast lump, 26% of those with change in bowel habit and 20% of those with rectal bleeding
delayed for more than two months before consulting. This underlines the importance of communicating
messages to the public on the importance of seeking medical advice promptly.
There was little impact on the primary care interval relating to housebound status, communication difficulty
or ethnicity. The duration of this interval was shorter for women, related to the high proportion of two week
wait referrals for breast cancer. Some symptoms were associated with delays of two months or more, over
15% of cases of colorectal cancer presenting with anaemia, and of lung cancer presenting with cough or
musculoskeletal pain.
For the referral period, the fractions with zero and one - 14 day duration correlate well with emergency
and two week wait referrals. Similarly, the larger fraction of patients who are housebound or have
communication difficulties that have short referral delay is likely to represent their greater likelihood to be
referred as emergencies.

44

Stage at diagnosis was determined by the practice following review of the available clinical records and
hospital correspondence, and was assigned to categories that equate to the grouped staging described by
SEER. Of all the cancers included in this audit, 46% were identified as confined to the organ, 25% with
local (regional) spread and 18% with metastatic disease. For 11% the stage was unknown. Solid tumours
comprised 91% of the total. Of these, 52% were confined to the organ. There was a large variation in the
fraction of tumours diagnosed with organ confined disease. If tumours with unknown stage had the same
distribution as those recorded then these figures ranged from Brain (80%), Melanoma (78%) and Testicular
(74%) down to Pancreatic (22%), Ovarian (28%) and Lung (28%). The following tables relate stage at
diagnosis to demographic features, tumour type, referral route and presenting symptom (for the four
common cancers only).

8.1 Demographic factors

Sex
Male
Female
Not Known
All persons

Organ
Local spread Distant mets
46.9%
22.5%
19.0%
44.2%
27.9%
17.0%
24.1%
20.4%
14.8%
45.5%
25.1%
18.0%

Not known
11.5%
10.9%
40.7%
11.3%

Total
100.0%
100.0%
100.0%
100.0%

Organ
Local spread Distant mets
48.1%
21.3%
12.0%
57.1%
17.5%
12.7%
62.8%
18.1%
11.7%
50.4%
20.9%
14.7%
39.6%
31.5%
16.8%
50.0%
24.3%
15.1%
47.5%
23.5%
16.5%
44.9%
24.7%
20.4%
50.1%
21.3%
17.4%
50.8%
21.9%
17.6%
45.6%
24.6%
20.3%
46.4%
21.3%
19.8%
44.2%
22.1%
20.3%
41.5%
21.7%
22.4%
46.9%
22.6%
18.9%

Not known
18.5%
12.7%
7.4%
14.0%
12.2%
10.7%
12.5%
10.0%
11.1%
9.7%
9.5%
12.5%
13.4%
14.4%
11.5%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

n
9,759
9,066
54
18,879

Table 8.1-1, stage, by sex of patient.

Males, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All males

n
108
63
94
129
197
272
455
749
1,256
1,367
1,534
1,419
1,135
793
9,571

Table 8.1-2, stage, by age band of patient, for males.

45

Females, by ageband
0-24
25
30
35
40
45
50
55
60
65
70
75
80
85+
All females

Organ
Local spread Distant mets
42.2%
22.2%
12.2%
50.8%
24.6%
12.3%
56.9%
23.9%
11.0%
50.6%
28.8%
10.7%
50.2%
32.5%
7.3%
49.4%
30.6%
13.4%
48.1%
29.7%
11.0%
44.2%
30.5%
16.2%
42.6%
27.3%
19.2%
42.1%
27.8%
19.3%
42.5%
27.3%
21.1%
45.6%
24.7%
18.2%
39.3%
29.4%
19.0%
40.3%
25.1%
18.7%
44.1%
27.9%
17.0%

Not known
23.3%
12.3%
8.3%
9.9%
9.9%
6.6%
11.2%
9.0%
10.9%
10.8%
9.1%
11.5%
12.3%
15.8%
11.0%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

n
90
65
109
243
424
625
616
789
947
953
1,037
1,096
940
955
8,889

Table 8.1-3, stage, by age band of patient, for females.

Communication difficulty
None
Communication difficulty
Not known
Total

Organ
Local spread Distant mets
46.6%
25.3%
17.6%
36.7%
27.6%
22.1%
29.5%
13.8%
22.7%
45.5%
25.1%
18.0%

Not known
10.5%
13.7%
34.0%
11.3%

Total
100.0%
100.0%
100.0%
100.0%

n
17,252
1,142
485
18,879

Local spread Distant mets

25%
17%
26%
27%
19%
27%
25%
18%

Not known
10%
16%
28%
11%

Total
100.0%
100.0%
100.0%
100.0%

n
16,876
1,298
705
18,879

Local spread

Not known

Total

Table 8.1-4, stage, by presence of communication difficulty.

Housebound?
No
Yes
Not Known
Total

Organ
47%
31%
27%
46%

Table 8.1-5, stage by housebound status.

Ethnic category

Organ

White British
White other
Nonwhite
Not Known
Total
Table 8.1-6, stage, by ethnic category.

46

46.0%
42.4%
43.7%
44.8%
45.5%

25.1%
28.6%
28.2%
22.7%
25.1%

Distant mets
18.4%
17.1%
16.1%
17.1%
18.0%

10.6%
11.9%
12.0%
15.3%
11.3%

100.0%
100.0%
100.0%
100.0%
100.0%

n
14,644
837
1,159
2,239
18,879

8.2 Tumour type

Cancer type
Bladder
Brain
Breast
Cervical
Colorectal
Endometrial
Gallbladder
Laryngeal
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Myeloma
Oesophageal
Oropharyngeal
Ovarian
Pancreatic
Prostate
Renal
Sarcoma
Small Intestine
Stomach
Testicular
Thyroid
Vulval
Other
Unknown Primary
No Information
Total

Organ
Local spread Distant mets
67.6%
18.5%
4.9%
72.2%
13.7%
5.1%
48.2%
33.8%
8.7%
30.9%
43.4%
13.2%
39.9%
30.9%
21.9%
62.5%
23.7%
5.5%
30.0%
27.1%
35.7%
58.1%
33.3%
2.3%
46.2%
6.4%
4.2%
39.2%
14.6%
33.1%
24.7%
29.5%
35.6%
34.6%
23.3%
19.6%
70.7%
14.8%
5.5%
35.4%
39.2%
6.3%
36.5%
8.7%
22.2%
31.5%
32.9%
24.3%
40.2%
46.7%
7.9%
24.4%
32.2%
36.0%
19.7%
29.2%
41.8%
61.4%
15.6%
14.0%
50.0%
15.3%
28.1%
47.1%
28.6%
17.6%
40.4%
26.3%
21.1%
28.5%
35.7%
28.8%
70.5%
16.3%
8.4%
51.6%
25.4%
11.1%
50.0%
35.5%
3.9%
41.1%
25.9%
14.3%
1.6%
4.8%
87.3%
10.8%
6.8%
6.8%
45.5%
25.1%
18.0%

Not known
9.0%
9.0%
9.3%
12.5%
7.2%
8.3%
7.1%
6.2%
43.2%
13.1%
10.2%
22.5%
9.0%
19.0%
32.5%
11.2%
5.2%
7.3%
9.2%
9.0%
6.5%
6.7%
12.3%
6.9%
4.8%
11.9%
10.5%
18.7%
6.3%
75.7%
11.3%

Total
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%

n
920
234
3,046
152
2,566
435
70
129
574
130
2,014
760
878
79
252
596
229
422
390
2,912
398
119
57
319
166
126
76
567
189
74
18,879

Table 8.2-1, stage, by cancer type.

47

8.3 Presenting symptom

Breast cancer
Symptom
asymptomatic
breast abscess
breast pain
change to breast appearance
change to nipple appearance
fatigue
lump in breast
neck pain
nipple discharge
not known
other
shortness of breath
weight loss
Total

Organ
Local spread Distant mets
61.8%
23.0%
7.2%
37.5%
25.0%
25.0%
50.7%
30.6%
9.7%
35.1%
45.6%
12.3%
52.9%
39.1%
3.4%
25.0%
37.5%
37.5%
49.0%
35.8%
6.2%
0.0%
0.0%
100.0%
73.0%
15.9%
4.8%
42.0%
20.0%
5.0%
16.5%
21.1%
56.9%
12.5%
12.5%
75.0%
28.6%
14.3%
42.9%
48.2%
33.8%
8.7%

Not known
7.9%
12.5%
9.0%
7.0%
4.6%
0.0%
9.0%
0.0%
6.3%
33.0%
5.5%
0.0%
14.3%
9.3%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
152
8
134
114
87
8
2254
2
63
100
109
8
7
3046

Table 8.3-1, stage by symptom, for breast cancer.

Colorectal cancer
Symptom
abdominal pain
anaemia
asymptomatic
bowel obstruction
change in bowel habit
epigastric pain
fatigue
nausea
not known
other
rectal hemorrhage
rectal pain
shortness of breath
weight loss
Total

Organ
Local spread Distant mets
29.4%
31.0%
32.8%
45.3%
33.6%
13.4%
58.4%
14.3%
19.5%
42.1%
28.9%
21.1%
40.3%
33.9%
19.5%
10.0%
30.0%
60.0%
32.2%
33.1%
25.4%
23.1%
30.8%
46.2%
32.1%
19.6%
14.3%
32.4%
24.7%
35.3%
49.4%
29.3%
15.2%
26.7%
53.3%
13.3%
34.0%
38.3%
25.5%
27.4%
31.0%
35.7%
39.9%
30.9%
21.9%

Table 8.3-2, stage by symptom, for colorectal cancer.

48

Not known
6.8%
7.8%
7.8%
7.9%
6.3%
0.0%
9.3%
0.0%
33.9%
7.6%
6.2%
6.7%
2.1%
6.0%
7.2%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

n
381
232
77
38
678
10
118
13
56
170
632
30
47
84
2566

Lung cancer
Symptom
abdominal pain
asymptomatic
chest infection
chest pain
chronic bronchitis, emphysema
cough
fatigue
haemoptysis
hoarse voice
lymphadenopathy
musculoskeletal pain
not known
other
shortness of breath
weight loss
Total

Organ
Local spread Distant mets
10.0%
23.3%
63.3%
49.2%
23.8%
19.0%
29.8%
32.7%
26.9%
22.0%
32.6%
35.6%
42.5%
22.5%
20.0%
24.9%
37.9%
30.2%
16.9%
23.8%
49.2%
34.9%
32.9%
24.2%
11.1%
33.3%
40.7%
7.4%
22.2%
70.4%
17.6%
18.6%
57.8%
17.9%
16.4%
35.8%
15.3%
22.2%
53.4%
25.1%
30.7%
30.4%
18.1%
24.5%
40.4%
24.7%
29.5%
35.6%

Not known
3.3%
7.9%
10.6%
9.8%
15.0%
7.1%
10.0%
8.1%
14.8%
0.0%
5.9%
29.9%
9.1%
13.9%
17.0%
10.2%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

Not known
5.5%
14.3%
8.1%
2.5%
7.7%
8.9%
8.0%
0.0%
9.8%
5.6%
9.5%
31.5%
9.7%
6.8%
6.5%
10.7%
9.1%
9.0%

Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

30
126
104
132
40
507
130
149
27
27
102
67
176
303
94
2014

Table 8.3-3, stage by symptom, for lung cancer.

Prostate cancer
Symptom
asymptomatic
blood in the semen
blood in the urine
bone pain
change in bowel habit
enlargement of the prostate glan
erectile dysfunction
fatigue
genitourinary tract pain
incontinence
lower urinary tract symptoms
not known
other
painful urination
raised psa
urine retention
weight loss
Total

Organ
Local spread Distant mets
75.5%
14.0%
5.0%
57.1%
14.3%
14.3%
63.8%
12.5%
15.6%
35.0%
5.0%
57.5%
50.0%
19.2%
23.1%
64.6%
16.7%
9.8%
70.0%
20.0%
2.0%
39.1%
17.4%
43.5%
54.9%
19.6%
15.7%
66.7%
11.1%
16.7%
63.1%
17.8%
9.7%
44.9%
13.5%
10.1%
48.5%
9.1%
32.7%
66.1%
15.3%
11.9%
71.9%
16.3%
5.3%
47.1%
15.7%
26.4%
25.0%
22.7%
43.2%
61.4%
15.6%
14.0%

200
14
160
40
26
246
50
46
51
18
931
89
309
59
508
121
44
2912

Table 8.3-4, stage by symptom, for prostate cancer.

49

8.4 Presentation route

Emergency
2 week
Routine
Private
Not referred by practice
Not known
Total

Organ
Local spread Distant mets
34.1%
24.8%
28.3%
47.1%
27.5%
16.5%
54.0%
20.4%
13.7%
47.5%
26.4%
17.0%
45.5%
21.4%
20.9%
34.3%
19.9%
18.1%
45.5%
25.1%
18.0%

Not known
12.7%
8.9%
11.8%
9.1%
12.2%
27.7%
11.3%

Total
100%
100%
100%
100%
100%
100%
100%

n
2432
10175
2789
931
1323
1229
18879

Table 8.4-1, stage by route of diagnosis.

8.5 Commentary
This is the most comprehensive description of stage at diagnosis yet to become available. Levels of recording
vary considerably by cancer registry and by cancer site, but even in the best circumstances are in the
region of 75% complete across all cancer types. In this audit we received stage data on 89% of all cases
and the proportion is higher if only solid tumours are considered. The data for a small number of sites
should be interpreted with caution. The staging for myeloma and leukaemia are not compatible with the
options offered in this audit and therefore the data for these sites are not reliable . Brain cancer very rarely
undergoes distant spread (though it is a site for secondary spread) and the reported 5.1% with distant
spread may be unreliable.
When all cancers are considered, there are notable differences in stage at diagnosis for those with
communication difficulty and housebound status. Cancer diagnosis in these population sub-groups merits
further investigation to determine the underlying reasons. Age >75 yrs was associated with more advanced
stage for prostate cancer but with earlier stage for lung cancer.
For emergency presentations, compared to other referrals, there are about 25% fewer with organ-confined
disease, mirrored by a greater proportion with disseminated disease. Even so, a third of emergency
presentations have disease confined to the organ or origin. We need to know more about the way that
symptoms develop in these patients in order to understand where interventions to reduce emergency
presentation can be most effectively targeted.

50

This first national audit of cancer diagnosis in primary care gained the participation of 14% of all the
practices in England, a remarkable level of voluntary participation. It has demonstrated that high quality,
reliable information on the primary care pathway to cancer diagnosis can be collected through audit utilising
primary care records. It has provided unique insights into the diagnostic pathway for the rarer cancers, for
which it obtained data on significant numbers in all cases.
There are important potential sources of bias to be acknowledged. Participation was voluntary, and in a few
cases selective. It is possible that those practices most interested in cancer care volunteered to participate,
and therefore the findings represent better practice. Against this, one in six of all English general practices
participated and the effect is unlikely to be a major bias.
Practices were required to audit all cases occurring in a specified period. There are 250,000 cases of cancer
annually in England. When this figure is adjusted by the exclusion criteria for the audit and the proportion of
practices participating, there is no evidence of significant exclusion of cases.
Data was extracted from clinical records and hospital correspondence. This was done by a range of
individuals, sometimes a clinician and sometimes an administrative assistant. In all cases it was reviewed at
a practice meeting and then by a cancer network clinical lead. There is scope for errors of interpretation, for
example in deciding on the date of first consultation or the stage of disease. Such potential sources of error
apply to most studies of diagnostic intervals and we do not believe that this audit was more susceptible for
some reason. We particularly stress caution in the interpretation of the patient interval, since this is better
determined by means other than scrutiny of GP records.
Two other important reports have been published in recent months, the NCIN analysis of Routes to Diagnosis
and the Patient Experience survey. In several respects the findings of this audit bear out the findings of those
reports. For example, in finding that two-thirds of patients consult once or twice before referral. Where they
differ, for example on the proportion of emergency presentations, it is important to carefully analyse the
reasons. The valuable understanding of cancer diagnosis that is being built up through these separate pieces
of work will be stronger for doing so.
This report provides a descriptive overview of the results of the audit. It offers an opportunity to Cancer
Networks and PCTs to benchmark their own local results against a national picture. There remain some
significant pieces of work to be undertaken. For example, over 4000 free text comments were made on
reasons for delay in diagnosis and these are currently being analysed using a combination of qualitative
and quantitative methods. The oversight group have put in place a process by which requests for access
to the data by bona fide researchers and NHS organisations for the purpose of additional analysis can be
considered.
As a result of the experience of conducting this audit, some changes have been made to the fields and
explanatory 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 on
the introduction of practice cancer profiles.
Future audit of the part played by general practice in cancer diagnosis may develop in several directions. The
cancer diagnostic pathway spans primary and secondary care. Combining primary and secondary care audit
for specific cancer sites has the potential to offer valuable insights into the sometimes poorly understood
interaction between two, informing future commissioning needs.

51

1. In the absence of a NICE Quality Standard or NHS Commissioning Board guidance, commissioners
might like to consider the following points when commissioning cancer care in primary care settings.
Specifically, the findings from this report could inform the setting of criteria for good practice in cancer
diagnosis in primary care.
2. The findings of this report could be used to inform plans to improve access to diagnostics as outlined in
Improving Outcomes: a Strategy for Cancer
3. The Cancer Diagnosis Audit Tool could be a useful tool for practices, Cancer Networks and
commissioners to identify local areas for improvement and to monitor the impact of service
improvements.
4. The systematic use of national level data on the audit of cancer diagnosis could be used in order to
monitor the impact on primary care outcomes of policy in the area of early diagnosis.
5. The Cancer Diagnosis Audit Tool could be used by practices to review their quality of care in the area of
cancer diagnosis. Aspects of care that might be examined could include
The number of consultations prior to referral
The proportion of patients with cancer who present as an emergency
The quality of care experienced by patients who are disadvantaged by virtue of being housebound,
having communication difficulties, being old or from an ethnic minority
The use of appropriate basic investigations prior to referral
6. Analytical support could be made available for those commissioners and networks that make localitywide use of the audit tool.
7. Primary care audit could be combined with other data, from secondary care audit or from the
Association of Public Health Observatories Practice Profiles, for example, to generate more detailed
understanding of factors influencing the pathway to diagnosis.
8. The role of co-morbidities should be examined in future audit.

Acknowledgements
We wish to specifically acknowledge the contributions of Nicola Cooper and Chris Carrigan at NCIN, as well
as the support of the Cancer Network GP leads at the time of this audit.

52

The Audit steering group comprised:

David Weller
Peter Rose
Ian Watson
Kathy Elliott
Jennifer Benjamin
Imran Rafi
Rosie Loftus
Sara Hiom
Cathy Burton
Richard Neal

The sub-group overseeing this national analysis comprised:

David Weller
Peter Vedsted
Rosie Loftus
Cathy Burton
Kathy Elliott
Sara Hiom
Imran Rafi

53

Data Security and Data Transfer

Summary
This document describes the governance arrangements around the collation and analysis of data from the
National Audit of Cancer Diagnosis in Primary Care, at a national level. It also describes the steps by which
this data is anonymised before being submitted to the National Cancer Action Team. The data submitted
will be held securely at the South West Public Health Observatory (SWPHO) within the custodianship of
the National Cancer Intelligence Network (NCIN). Data security and the governance procedures around the
release of data are also described.

Roles and contact details

Project Lead

Professor Greg Rubin

greg.rubin@durham.ac.uk

NCAT Sponsor

Kathy Elliott
kathy.elliott@gstt.nhs.uk

Project Analyst and Dr Sean McPhail

primary contact for
sean.mcphail@nhs.net
data exchange
01179 706 474 x364
Address
correspondence

for Dr Sean McPhail

South West Public Health Observatory
Grosvenor House
149 Whiteladies Road
Bristol
BS8 2RA

Information
Custodian

Chris Carrigan, Head of NCIN Co-ordinating Team

chris.carrigan@nhs.net
020 7061 8377

Local
Guardian

Caldicott Dr Julia Verne, Director of the South West Public Health

Observatory
julia.verne@swpho.nhs.uk
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 for the
South West of England. This is a server which is an integral part of the South West Public Health Observatory
local area network. The SWPHO network has a hardened CISCO PIX firewall and anti-virus software which
are approved to a NHS code of connection standard.
User access is through PC terminals, running Windows XP, physically within the organisation. These are
password protected and can only be used by members of the organisation. In addition, access to the data
is restricted to those who use it as part of their daily work. The building in which the data is held is secure
with two independent alarm systems. Daytime access requires both a pin number and a swipe-card to pass
through two locked doors. Servers are located behind further doors with separate pin coded security locks,
accessible only by nominated IT support staff. The SWPHO security policy is fully implemented and complies
with ISO 17799 and 27001.
Data backups are held encrypted on magnetic tapes on site in a locked fireproof safe.

Anonymisation
Using the process described below and embodied in the accompanying spreadsheet will pseudo-anonymise
the patients and GP surgeries. Each patient and GP surgery will be assigned a new ID number. Each network
or PCT that submits data will hold the file which will cross reference the new ID number to a list of GP
surgeries, meaning that practices are anonymous within the national analysis.
This type of pseudo-anonymisation will allow the NCAT to inform a submitting network/PCT if analysis of
the data reveals issues of clinical significance, and for the network/PCT to trace these to their source, all the
while preserving the anonymity of the GP surgeries at a national level.
The pseudo-anonymisation process will also allow data quality issues within the dataset to be investigated
by grouping patients by their GP surgery while anonymising both their identity and that of their GP surgery.
Careful data quality work of this nature is necessary to ensure robustness of the resultant analyses.

Use and release of data

The analytical programme for the project will be determined by an Analysis Steering Group chaired by
Professor Greg Rubin and the NCIN Lead for Analysis and Information. This group will design and oversee
the analysis of the national dataset, taking all appropriate steps to ensure that the resultant outputs are
clinically and statistically robust.
Quality assurance of analytical outputs will take place within the NCIN with input from the Analysis Steering
Group.
Release of analytical outputs will take place as determined by the Project Lead, NCAT Sponsor, and
Information Custodian.

55

Preparing and sending the data

Preparing the data for anonymisation
The data sheets sent back from each GP surgery can either be combined by manually cut-and-pasting them
into a single spreadsheet or via the more automated procedure described below and in the accompanying
spreadsheet:
1. Copy all the audit spreadsheets returned by your GPs into a single directory. These should be the raw
data files submitted by each GP practice before any data processing is done on them. A quick way of
doing 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 from the menu.
d. Type xls for the search text and run the search.
e. This should find all the spreadsheets in your directory and its sub-directories.
f. Press Ctrl-A to select all the spreadsheets.
g. Copy them all to a fresh directory.
h. Check that you havent included any spreadsheets that dont include GP audit data.
2. Save the National Audit of Cancer Diagnoses - anonymisation v1.2.xls spreadsheet that you received
along with this document into the same directory.
3. Open the National Audit of Cancer Diagnoses - anonymisation v1.2.xls spreadsheet.
4. Follow the instructions in the National Audit of 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 the
accompanying spreadsheet. Full instructions are included in the spreadsheet itself.
Sending the data
1. If the anonymisation has been successful two new spreadsheets will have been created in the same
directory RCGP audit data to submit.csv and RCGP audit network data.csv.
2. Check that these spreadsheets contain the number of patients and GP surgeries that you expect them
to.
3. Save the RCGP audit network data.csv spreadsheet for your records.
4. The spreadsheet named RCGP audit data to submit.csv should be emailed as an attachment to sean.
mcphail@nhs.net.
Data should only be sent via the national email facility NHS Contact (i.e. email addresses ending with @
nhs.net). All data should be accompanied with the Name, Address, and Telephone Number of the sender.
Receipt of data will be confirmed within two working days.
If you have any problems with or questions about processing or sending the data please contact Sean
McPhail for assistance (sean.mcphail@nhs.net, 01179 706 474 x364).

56

CANCER PATHWAY NOTES

Template Heading

What is wanted

Why this is wanted

Patient ID

Some way for your practice to identify the patient. Please do

not use patient name, DOB or any other identifiable data.
Consider using computer number

To allow the GP practice to identify and differentiate

between 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 need
not be completed

DoB
Gender
Ethnicity
Country of origin
Problems communicating
Housebound

Date of birth
Male or Female
Ethnicity of patient
Patient's country of origin
Any communication problems the patient has
Is the patient housebound

To help determine any relationship between

age/gender/ethnicity/language/communication
problems/access and the likelihood of urgent referral
or diagnosis of cancer

Diagnosis

Enter the diagnosis of the primary cancer Please note that the
audit should only include confirmed malignancies and
EXCLUDES non-melanotic carcinomas of the skin. Also
EXCLUDE CIN, for example of the cervix, or other carcinoma in
situ.

This will allow comparison about the referral process

for different types of cancer

Date
patient
noted
first
symptoms or signs of cancer

For all date entries please enter date as dd/mm/yy. This will
allow a hidden program to calculate the number of days
between different dates. If the notes only refer to the month
(i.e. diarrhoea since May 2007), put '15th' as the day of the
month (i.e. 15/05/07) If the date is not known, please enter 'NK'

The cancer journey starts when the patient first notices

a symptom or sign that is suggestive of cancer. There
may be long delays before the patient then presents to
Primary Care. Noting how long the patient waited
before presenting may provide useful information

57

Date patient reported symptom

or sign to Primary Care

First notification to any health care professional working within

the Primary Health Care Team about a symptom or sign which
was probably due to the cancer

about barriers to attending for health care. It may also

help inform which cancers need Health Promotion
campaigns 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 in

certain cancers.

Date Referral Sent

Date that the referral letter was sent from Primary Care. If this
is not available, please use the date that the referral letter or
proforma was completed.

To identify if delays in practice systems significantly

affect overall waits for treatment from first
presentation.

Type of referral

The urgency with which a patient was referred for further

investigation or management

To allow GPs to review the urgency with which they

referred their patient

Date first seen by specialist

Date the patient first had contact with secondary care following
the referral, whether for an investigation or an out patient
appointment

Delays in informing practice

Were there avoidable delays to
this patient's journey

58

Do you think that there were avoidable delays in the practice

being informed?
Reflect on the referral process and consider what things may
have improved the diagnostic journey for the patient, and how
things may have been improved

This information (if available) will help give information

about any delays around diagnosis or communication
Powerful learning tool and opportunity to make
suggestions about how the referral process could be
improved.

localities

participating
practices

Cancer Network

Participating PCTs /
localities

No of
participating
practices

% uptake

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

Avon, Somerset,
Wiltshire

Banes
Bristol
N Somerset

8
15
9

30%
26%
35%

59

60

Southwark

Not available

South West
London

5 PCTS

39

Not available

Peninsula

Plymouth

31

Not available

Dorset

Not recorded

Not available

Not available

Avon, Somerset,
Wiltshire

Banes
Bristol
N Somerset
Somerset
S Gloucestershire
Wiltshire

8
15
9
6
6
11

30%
26%
35%
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 and
Medway

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

North of England

4 PCOs

22

Limited to a
quota from
each PCO

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Analysis of the QResearch database. NHS Information Centre 2009
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Department of Health (2007): Cancer Reform Strategy. Department of Health: London, England
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NHS Information Centre (2009): The national lung cancer audit 2009
4.
Baughan P, ONeill B, Fletcher E (2009): Auditing the diagnosis of cancer in primary care: the

experience in Scotland. Br J Cancer 101(Suppl 2): S87S91
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www.dur.ac.uk/resources/school.health/erdu/AnalysisofSEAforcancerdiagnosis-Updatedfinalreport.
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The Royal College of General Practitioners is a network of over 42,000 family doctors working to improve
care for patients. We work to encourage and maintain the highest standards of general medical practice
and act as the voice of GPs on education, training, research and clinical standards.

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