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Rethinking diagnostic delay in cancer: how difficult is the diagnosis?

BMJ 2014; 349 doi: (Published 10 December 2014) Cite this as: BMJ 2014;349:g7400
  1. Georgios Lyratzopoulos, clinical senior research associate1,
  2. Jane Wardle, professor of clinical psychology2,
  3. Greg Rubin, professor of general practice and primary care3
  1. 1Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
  2. 2Health Behaviour Research Centre, University College London, London, UK
  3. 3School of Medicine, Pharmacy and Health, University of Durham, Durham, UK
  1. Correspondence to: G Lyratzopoulos gl290{at}
  • Accepted 12 November 2014

Georgios Lyratzopoulos, Jane Wardle, and Greg Rubin argue that delays in referral for suspected cancer are unlikely to be caused by poor professional performance and explore other potential causes and strategies for improvement

The timely diagnosis of cancer is a frequent theme in the lay press and an increasingly common topic for quality improvement initiatives.1 2

The UK’s health secretary has advocated ranking general practices on the NHS Choices website according to how promptly patients subsequently diagnosed with cancer are referred to specialist services for suspected cancer.3 But is such a policy based on evidence? Its main assumption is that the multiple visits made by these patients to primary care before referral chiefly reflect poor professional performance rather than factors such as clinical complexity, reasonable watchful waiting, or the need for appropriate investigations in primary care. We review the occurrence of multiple pre-referral consultations and discuss how a better understanding of variation between cancers might improve the timeliness of diagnosis.

How common are multiple consultations?

Most patients with cancer present to primary care with symptoms that have low or very low positive predictive values. Even “red flag” symptoms (such as rectal bleeding, dysphagia, haemoptysis, and haematuria) have positive predictive values for cancer of <10% in men,4 and these values are typically up to twofold lower for women and even lower for young adults and children (<1%).5 This means that the great majority of patients with such symptoms will not have cancer.

Despite the low specificity of cancer symptoms, about 80% of patients subsequently diagnosed with cancer are referred to a hospital specialist after one (50%) or two (30%) consultations.6 7 But a substantial minority (20%) of patients with cancer visit a primary care doctor with relevant symptoms three or more times before referral. This number is often considered …

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