A quarter of patients with cancer see their GP several times before being referred

BMJ 2011; 343 doi: (Published 25 November 2011) Cite this as: BMJ 2011;343:d7601
  1. Susan Mayor
  1. 1London

Three quarters of patients who see their GP with symptoms that lead to a cancer diagnosis are referred extremely promptly—within one or two visits—but a quarter had three or more consultations before they were referred to a specialist, shows an audit of general practices. About 3% saw their GP five times or more before being referred.

GPs were best are spotting cancers with obvious symptoms. Nearly three quarters (72%) of patients who were given a diagnosis of breast cancer were referred after seeing their GP just once, as were 69% of patients with melanoma, 62% with endometrial cancer, and 61% with testicular cancer, shows the audit, which was carried out by the Royal College of General Practitioners.

Patients were more likely to need three or more consultations if they had lymphoma, myeloma, or cancer of the lung, ovary, pancreas, or stomach. Men aged 25 to 29 also had more visits to their GP before they were referred.

The audit was carried out to look into the reasons for delays in diagnosing cancer in England, as part of the NHS’s national awareness and early diagnosis initiative, which since 2008 has aimed to increase the public’s awareness of cancer symptoms.

It included 1170 practices (14% of all practices in England) in 20 cancer networks that voluntarily submitted data on 18 879 patients who were given a diagnosis of cancer between April 2009 and April 2010.

There were some surprise findings relating to alarm symptoms, indicating that some public health messages are not getting through. More than a quarter (26%) of patients with a change in bowel habit delayed for more than two months before going to see their GP, as did 20% of those with rectal bleeding and 12% of those with a breast lump.

Nearly one in 10 patients (9.4%) patients who were given a diagnosis of cancer never saw their GP with their symptoms, presenting instead to hospital accident and emergency departments (4.5%) or outpatient departments (3.9%). Presentations to emergency departments, including those of patients referred by their GP, were particularly high in patients under 24 years old and in patients with leukaemia and myeloma and cancer of the brain, liver, and pancreas.

Overall more than half of all patients with cancer were referred through the two week urgent referral pathway. Of all the cancers included in the audit, 46% were identified as confined to the organ, 25% had local (regional) spread, and 18% were metastatic.

Greg Rubin, professor of general practice and primary care at the University of Durham and the report’s lead author, said, “The good news is that many patients are being identified as needing specialist assessment promptly. For some patients, better access to cancer diagnostics would have reduced any delay in referral.”

The audit showed that rapid access to investigations would have changed the GPs’ management in 6% of cases. GPs said that prompt access to ultrasonography would have changed their management of cancers where this test can help in assessment, including in ovarian, pancreatic, and renal cancers. Similarly GPs thought that better access to gastroscopy would benefit referral decisions in cases of oesophageal and stomach cancers and to magnetic resonance imaging for brain cancers.

Professor Rubin said that the report findings should be used to support quality improvement initiatives designed to improve cancer diagnosis and to improve access to diagnostic tests.


Cite this as: BMJ 2011;343:d7601


  • National Audit of Cancer Diagnosis in Primary Care is available at

View Abstract

Log in

Log in through your institution


* For online subscription