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Research

Delays in referral from primary care worsen survival for patients with colorectal cancer: a retrospective cohort study

Chanpreet S Arhi, Elaine M Burns, Alex Bottle, George Bouras, Paul Aylin, Paul Ziprin and Ara Darzi
British Journal of General Practice 2020; 70 (696): e463-e471. DOI: https://doi.org/10.3399/bjgp20X710441
Chanpreet S Arhi
Department of Surgery and Cancer, Imperial College London, London.
Roles: Clinical research fellow
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Elaine M Burns
Department of Surgery and Cancer, Imperial College London, London.
Roles: Clinical lecturer
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Alex Bottle
School of Public Health, Imperial College London, London.
Roles: Reader in medical statistics
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George Bouras
Department of Surgery and Cancer, Imperial College London, London.
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Paul Aylin
School of Public Health, Imperial College London, London.
Roles: Professor in epidemiology and public health
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Paul Ziprin
Department of Surgery and Cancer, Imperial College London, London.
Roles: Consultant surgeon
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Ara Darzi
Department of Surgery and Cancer, Imperial College London, London.
Roles: Professor of surgery
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Abstract

Background Delays in referral for patients with colorectal cancer may occur if the presenting symptom is falsely attributed to a benign condition.

Aim To investigate whether delays in referral from primary care are associated with a later stage of cancer at diagnosis and worse prognosis.

Design and setting A national retrospective cohort study in England including adult patients with colorectal cancer identified from the cancer registry with linkage to Clinical Practice Research Datalink, who had been referred following presentation to their GP with a ‘red flag’ or ‘non-specific’ symptom.

Method The hazard ratios (HR) of death were calculated for delays in referral of between 2 weeks and 3 months, and >3 months, compared with referrals within 2 weeks.

Results A total of 4527 (63.5%) patients with colon cancer and 2603 (36.5%) patients with rectal cancer were included in the study. The percentage of patients presenting with red-flag symptoms who experienced a delay of >3 months before referral was 16.9% of those with colon cancer and 13.5% of those with rectal cancer, compared with 35.7% of patients with colon cancer and 42.9% of patients with rectal cancer who presented with non-specific symptoms. Patients referred after 3 months with red-flag symptoms demonstrated a significantly worse prognosis than patients who were referred within 2 weeks (colon cancer: HR 1.53; 95% confidence interval [CI] = 1.29 to 1.81; rectal cancer: HR 1.30; 95% CI = 1.06 to 1.60). This association was not seen for patients presenting with non-specific symptoms. Delays in referral were associated with a significantly higher proportion of late-stage cancers.

Conclusion The first presentation to the GP provides a referral opportunity to identify the underlying cancer, which, if missed, is associated with a later stage in diagnosis and worse survival.

  • cancer
  • colorectal cancer
  • delays
  • primary care
  • referral
  • stage
  • survival
  • Received August 4, 2019.
  • Revision requested October 14, 2019.
  • Accepted January 16, 2020.
  • © British Journal of General Practice 2020
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British Journal of General Practice: 70 (696)
British Journal of General Practice
Vol. 70, Issue 696
July 2020
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Delays in referral from primary care worsen survival for patients with colorectal cancer: a retrospective cohort study
Chanpreet S Arhi, Elaine M Burns, Alex Bottle, George Bouras, Paul Aylin, Paul Ziprin, Ara Darzi
British Journal of General Practice 2020; 70 (696): e463-e471. DOI: 10.3399/bjgp20X710441

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Delays in referral from primary care worsen survival for patients with colorectal cancer: a retrospective cohort study
Chanpreet S Arhi, Elaine M Burns, Alex Bottle, George Bouras, Paul Aylin, Paul Ziprin, Ara Darzi
British Journal of General Practice 2020; 70 (696): e463-e471. DOI: 10.3399/bjgp20X710441
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Keywords

  • cancer
  • colorectal cancer
  • delays
  • primary care
  • referral
  • stage
  • survival

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  • CA125 test result, test-to-diagnosis interval, and stage in ovarian cancer at diagnosis: a retrospective cohort study using electronic health records
  • Targeted encouragement of GP consultations for possible cancer symptoms: a randomised controlled trial
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Print ISSN: 0960-1643
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