We know from other research that many factors contribute to rates of cancer survival, and while the UK has the lowest rates of one-year cancer survival compared to the other countries in our study, we found no association between cancer survival and guideline adherence.
- Dr Brian Nicholson, University of Oxford.
A study exploring how primary care practitioners follow cancer-specific diagnostic guidelines has found international variation in adherence to recommendations to test or refer for suspected cancer, as well as differences in guideline content between countries.
The secondary analysis of the International Cancer Benchmarking Partnership’s survey of 2,795 primary care practitioners across six countries also reveals that on balance, GPs across England, Northern Ireland and Wales are less likely to follow recommendations for definitive action for cancer referral and diagnosis than their non-UK counterparts.
Importantly, the study finds no association between adherence to guideline recommendations for definitive action and one-year cancer survival rates.
The findings are published in the British Journal of General Practice.
The research aimed to explain the variation in cancer survival between nations with comparable health systems by exploring the international differences between clinical guidelines and their thresholds for referral, the definitive action they recommend, and guideline adherence by clinicians.
The analysis was conducted by a group of researchers from the Universities of Oxford, Bangor, Belfast, Exeter and Durham who looked at data from 10 jurisdictions across six countries - the UK (Wales, Northern Ireland, England), Denmark, Norway, Sweden, Canada (Manitoba, Ontario) and Australia (New South Wales, Victoria).
The authors looked at primary care practitioners’ responses to five clinical case-reports presenting symptoms and signs of lung, colorectal and ovarian cancer and compared them with investigation and referral recommendations in cancer guidelines for each respective jurisdiction. In addition, a more expansive set of questions to UK GPs was analysed. They showed:
- UK adherence to the recommended definitive action for lung cancer was lower than other jurisdictions (47% versus 58%),
- UK adherence to the recommended definitive action for the two colorectal cancer case-reports was similar (45% versus 46%) or higher (67% versus 38%) than other jurisdictions,
- Only the UK and Denmark had ovarian cancer guidelines, but no definitive action was recommended for the clinical case-report presented. 38% of UK GPs would take definitive diagnostic action versus 61% of non-UK GPs,
- Nine out of 10 UK GPs reported they would ignore clinical guidance if they suspected their patient had cancer but their symptoms did not fit the criteria for urgent referral, and refer them for tests anyway. 20% of these said they would record the patient’s history in such a way that allowed them to fit the guidelines for urgent referral.
The survey data was collected before the introduction of the new 2015 NICE guideline for managing suspected cancer. In a change to its 2005 predecessor, the updated NICE guideline uses more recent evidence from research to support a reduction in the referral threshold and moves towards symptom-based recommendations.
The authors recommend that uptake by general practitioners should therefore be monitored carefully for factors that determine adherence or non-adherence.
Study lead author, Dr Brian Nicholson, a GP and clinical fellow in Oxford University’s Nuffield Department of Primary Care Health Sciences, said:
“We know from other research that many factors contribute to rates of cancer survival, and while the UK has the lowest rates of one-year cancer survival compared to the other countries in our study, we found no association between cancer survival and guideline adherence.”
“What’s interesting here is the tendency for GPs to “bend the rules” to ensure patients presenting with concerning symptoms, who do not fit rigid referral criteria, get rapid assessment anyway. This suggests some GPs shared the view of patients, who would prefer to be investigated for suspected cancer at a much lower risk threshold than was recommended at the time of the study.”
“The new 2015 NICE guideline reduces the suspected cancer referral threshold for GPs to allow for more referrals. Since our data suggests that GPs would sometimes already operate outside the guidelines, perhaps the lower threshold used in the new guideline more closely represents current GP best practice.”
Notes for editors