Intended for healthcare professionals


Early diagnosis of cancer: systems approach to support clinicians in primary care

BMJ 2023; 380 doi: (Published 09 February 2023) Cite this as: BMJ 2023;380:e071225

Linked Editorial

Direct access to imaging for cancer from primary care

  1. Georgia B Black, THIS Institute postdoctoral fellow1,
  2. Georgios Lyratzopoulos, professor of cancer epidemiology2,
  3. Charles A Vincent, professor of psychology3,
  4. Naomi J Fulop, professor of healthcare organisation and management1,
  5. Brian D Nicholson, academic clinical lecturer in general practice4
  1. 1Department of Applied Health Research, University College London, London, UK
  2. 2ECHO (Epidemiology of Cancer Healthcare and Outcomes), Department of Behavioural Science and Health, University College London, UK
  3. 3Department of Experimental Psychology, University of Oxford, Oxford, UK
  4. 4Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
  5. Correspondence to: G B Black

Georgia Black and colleagues argue that rather than focusing on the initial consultation efforts to reduce diagnosis times should look at the wider system

The substantial deficit in primary care contacts and diagnostic testing for suspected cancer during the covid-19 pandemic fed into a backlog of patients awaiting investigations.1 Modelling using NHS datasets suggests that these delays will result in around 3500 additional deaths from breast, colorectal, oesophageal, and lung cancer over the next few years in England alone.2

Delays in cancer diagnosis vary according to type of cancer. For example, the median time between presentation in primary care and referral for specialist assessment in England is 24 days for multiple myeloma compared with 0 days for breast cancer.34 Urgent referral pathways are designed to expedite cancer diagnosis for patients with concerning symptoms, and testicular and breast cancers are far more likely to be diagnosed through this route (73% and 71%, respectively). By contrast, only 6% of brain cancers and 20% of leukaemia cases are diagnosed through urgent referral pathways.5

The differential diagnosis is wider for patients with non-specific symptoms, so multiple primary care consultations are often required to establish the diagnosis.6 Referral processes also depend on the severity of presenting symptoms, and many patients with pancreatic, liver, and stomach cancers are diagnosed during emergency hospital admissions.4

Current approaches to improving diagnostic accuracy and timeliness place most weight on improving the initial primary care consultation. However, the diagnostic process is more often dynamic, involving many different encounters and healthcare professionals. A wider approach that shifts the approach away from individuals and onto the whole system is likely to have a bigger impact.

Reasons for delays

People with symptoms that may indicate underlying cancer fall into two groups: patients with alarm or “red flag” symptoms with relatively …

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