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

BMJ 2015; 351 doi: (Published 13 October 2015) Cite this as: BMJ 2015;351:h5102
  1. Henrik Møller, professor15,
  2. Carolynn Gildea, senior cancer intelligence analyst2,
  3. David Meechan, director2,
  4. Greg Rubin, professor3,
  5. Thomas Round, clinical research fellow4,
  6. Peter Vedsted, professor5
  1. 1Cancer Epidemiology and Population Health, King’s College London, London SE1 9RT, UK
  2. 2Public Health England, Knowledge & Intelligence Team (East Midlands), Sheffield, UK
  3. 3School of Medicine, Pharmacy and Health, University of Durham, Stockton on Tees, UK
  4. 4Division of Health and Social Care, King’s College London
  5. 5Research Unit for General Practice, Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark
  1. Correspondence to: H Møller henrik.moller{at}
  • Accepted 7 September 2015


Objective To assess the overall effect of the English urgent referral pathway on cancer survival.

Setting 8049 general practices in England.

Design Cohort study. Linked information from the national Cancer Waiting Times database, NHS Exeter database, and National Cancer Register was used to estimate mortality in patients in relation to the propensity of their general practice to use the urgent referral pathway.

Participants 215 284 patients with cancer, diagnosed or first treated in England in 2009 and followed up to 2013.

Outcome measure Hazard ratios for death from any cause, as estimated from a Cox proportional hazards regression.

Results During four years of follow-up, 91 620 deaths occurred, of which 51 606 (56%) occurred within the first year after diagnosis. Two measures of the propensity to use urgent referral, the standardised referral ratio and the detection rate, were associated with reduced mortality. The hazard ratio for the combination of high referral ratio and high detection rate was 0.96 (95% confidence interval 0.94 to 0.99), applying to 16% (n=34 758) of the study population. Patients with cancer who were registered with general practices with the lowest use of urgent referral had an excess mortality (hazard ratio 1.07 (95% confidence interval 1.05 to 1.08); 37% (n=79 416) of the study population). The comparator group for these two hazard ratios was the remaining 47% (n=101 110) of the study population. This result in mortality was consistent for different types of cancer (apart from breast cancer) and with other stratifications of the dataset, and was not sensitive to adjustment for potential confounders and other details of the statistical model.

Conclusions Use of the urgent referral pathway could be efficacious. General practices that consistently have a low propensity to use urgent referrals could consider increasing the use of this pathway to improve the survival of their patients with cancer.


  • The English national Cancer Waiting Times database was obtained from NHS England, containing data from the National Cancer Waiting Times Monitoring Dataset.

  • Contributors: HM and TR had the idea for the study. HM and PV drafted the study protocol, and all authors contributed to the final protocol and analysis plan. HM and CG analysed the data, and all authors contributed to the interpretation of the results. HM led the writing of the manuscript to which all authors contributed. HM is the guarantor. HM and CG contributed equally to the paper.

  • Funding: The study was supported by a Cancer Research UK (CRUK) early diagnosis policy research grant and by the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’’s College London. The views expressed are those of the authors and not necessarily those of CRUK, NHS, NIHR, or the Department of Health. The researchers were independent of the funders, and the researchers alone interpreted the data and decided to publish.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from CRUK and the NIHR for the submitted work; GR reports personal fees from medx GmbH, outside the submitted work, led the national audit of cancer diagnosis in primary care on behalf of the Royal College of General Practitioners (RCGP) between 2010 and 2012, and was the RCGP clinical lead for cancer between 2012 and March 2014; TR has been partly funded by a CRUK research grant for the national awareness and early diagnosis initiative since 2011, receives funding from the RCGP as clinical lead for their e-learning programme (essential knowledge updates), has been a member of the National Cancer Research Institute’s primary care clinical studies group since 2011, and has represented the RCGP on the National Institute for Health and Care Excellence’s National Collaborating Centre for Cancer management board since 2012.

  • Ethical approval: Ethics committee approval not required for research based on routine data. Approval according to section 251 of the NHS Act 2006 applies to cancer registration and cancer intelligence in Public Health England.

  • Data sharing: The analysis is based on routine data from the NHS and Public Health England. No additional data are available from the authors.

  • The lead author (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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