1. Henrik Møller, Carolynn Gildea, David Meechan, Greg Rubin, Thomas Round, Peter Vedsted Cancer Epidemiology and Population Health, KCL (HM) Public Health England, Knowledge & Intelligence (CG, DM, HM) Durham University (GR) Primary Care and Public Health Sciences, KCL (TR) Cancer Diagnosis in Primary Care, Aarhus University (HM, PV) Association between use of the English urgent referral pathway for suspected cancer and mortality outcome in cancer patients: cohort study

2. >1 in 2 people in the UK with develop cancer (Ahmad 2015) >300,000 patients are diagnosed and >150,000 die every year from cancer in the UK (CRUK) Late diagnosis is a major contributing factor to relatively poorer cancer survival rates in the UK (Richards 2009) >10,000 premature cancer deaths per year could be avoided if survival rates matched the best in Europe ( Abdel- Rahman 2007) Nearly 1 in 4 patients diagnosed via an emergency admission route with poorer 1 year survival (Elliss Brookes 2012) Cancer in the UK

3. Colorectal Cancer 1yr RS Lung Cancer 1yr RS Breast Cancer 1yr RSOvarian Cancer 1yr RS ICBP: 1 year relative survival Coleman et al, Lancet 2011

4. Delays in Symptomatic Cancer Diagnosis Model of Total Patient Delay (Walter 2012)

5. Cancer: National Awareness and Early Diagnosis Initiative (NAEDI) (Hiom 2015)

6. Most of those with cancer present with symptoms, and most of these presentations are to primary care (Rubin 2011) Suspecting a diagnosis of cancer in general practice is not straightforward: average full time GP 7-8 new cancer cases/year (Richards 2009) Low predictive value of even “red flag” symptoms eg PPV rectal bleeding 2.4% (Jones 2007) Many patients have multiple GP visits prior to referral especially those with cancers of greater diagnostic difficulty (Lyratzopoulos 2014) Primary Care and Cancer

7. Three or more general practitioner consultations before hospital referral (Lyratzopoulos 2012)

8. Referral guidelines for suspected cancer, DoH 2000 Referral guidelines for suspected cancer, NICE 2005 ”Urgent referral” (Two week wait/2ww) The patient is seen by a specialist within 14 days, and The patient is treated within 62 days from referral or within 31 days from the decision to treat Updated NICE referral guidance due for publication May 2015 Referral for suspected cancer

9. Change in diagnostic intervals 2001/02 – 2007/08 (Neal 2013)

10. The “waiting time paradox” (Torring 2011)

11. Urgent Referrals 2009-2014

12. Variation in a care process Variation in a relevant outcome ? Use of the urgent referral pathway and mortality outcome in cancer patients

15. Histogram of referral ratio Referral ratio

16. Histogram of conversion rate Conversion rate

17. Histogram of detection rate Detection rate

18. Strategy of analysis Mortality of urgently referred cancer patients Mortality of other cancer patients ? =

19. Strategy of analysis Mortality of urgently referred cancer patients Mortality of other cancer patients Mortality of cancer patients from GP practices with high use of urgent referral ? Mortality of cancer patients from GP practices with low use of urgent referral = ? =

20. r: 0.42 Data: England; 2009; 215,284 cancer patients from 8049 GP practices

21. Cohort analysis of death rates, adjusted for age, sex and cancer type Cox proportional hazards regression Sensitivity analyses Analysis

22. Analysis by tertiles of distributions

25. Analysis by deciles of distributions

26. A. Hazard ratio for death, by decile of referral ratio.

27. B. Hazard ratio for death, by decile of conversion rate.

28. C. Hazard ratio for death, by decile of detection rate.

29. Joint effects of referral ratio, conversion rate and detection rate

41. High use of urgent referral Underlying mechanisms? Low mortality; (High survival)

42. High use of urgent referral Short delay; Earlier stage; Treatment options Low mortality; (High survival) Underlying mechanisms?

43. High use of urgent referral Short delay; Earlier stage; Treatment options Low mortality; (High survival) GP’s awareness of cancer ? Underlying mechanisms?

44. High use of urgent referral Short delay; Earlier stage; Treatment options Low mortality; (High survival) GP’s awareness of cancer ? Underlying mechanisms?

46. The analysis suggests that urgent referral for suspected cancer is efficacious. The roles of a direct mechanism (via reduced delay) and indirect mechanisms (via awareness) are not known. GP practices with consistent low use of urgent referral may benefit their cancer patients from using it more often, and from being more aware of signs of cancer. Conclusions and implications

47. r: 0.42

48. Referral ratio Detection rate r: 0.42

49. 27% of patients: 1.07 (1.05-1.08) 57% of patients 1.00 16% of patients 0.95 (0.94-0.97)