Study finds GPs are unwilling to refer patients for bowel cancer checks

GPs can be reluctant to refer patients with symptoms of bowel cancer for further investigations, a study by the Universities of Birmingham and Exeter has found.

In 2015 the University of Birmingham led the CREDIBLE study, which investigated the feasibility of using electronic patient records to flag up those aged between 60 and 79 needing urgent referral for symptoms of bowel cancer – also known as colorectal cancer. The symptoms are set out by National Institute for Health and Care Excellence (NICE) guidelines and include persistent diarrhoea, iron deficiency anaemia, rectal bleeding, or a test showing blood in the stool – also known as positive faecal occult blood tests (FOBt).

As part of the CREDIBLE study, the authors interviewed GPs and practice managers at 18 GP practices in Britain to explore attitudinal and contextual influences on GPs in their decisions to refer patients.

Professor Tom Marshall, of the University of Birmingham’s Institute of Applied Health Research, said: “Our data indicates that GPs in our study were often reluctant to refer patients for a variety of reasons.

“In some cases, they were aware of pressure to avoid over-referral and wished to avoid being identified as having a high referral rate.

“Some GPs considered that referral would scare patients and weighed this against a low perceived risk of cancer.

“Before referring, some GPs therefore required additional evidence: their own suspicion of cancer, or clinical features such as weight loss, positive FOBt results, or bowel symptoms. NICE red flag symptoms alone were not regarded as sufficient.

“Anaemia was often perceived as common and therefore not always warranting investigation.”

He said that due to a lack of familiarity with referral guidelines, some GPs used personally devised decision rules and diagnostic strategies which hindered further investigation.

From the data, the researchers identified two groups of patients that may be at greater risk of non-referral: minority ethnic groups with anaemia, because GPs sometimes attributed this to diet, and patients with anxiety, which GPs sometimes believed could be exacerbated by a referral.

Professor Marshall added: “Healthcare commissioners should support and encourage GPs to refer patients meeting urgent referral criteria for cancer.

“Further research could test the belief that anaemia is less predictive of colorectal cancer in minority ethnic groups.

“Research also is needed to identify the strategies most likely to promote referral. This could include drawing attention to the need to increase referrals, highlighting practices that refer too few patients and making GPs aware that most symptomatic patients prefer to be investigated. Particular attention may be needed on strategies to increase referral thresholds for overly-anxious patients.”

Professor Willie Hamilton, at the University of Exeter Medical School, a practicing GP, said: “Britain still has a much higher rate of cancer deaths than the rest of Europe, and this paper is important in identifying areas where the GP can get it wrong, so we can identify opportunities to do better. This is essential as early diagnosis saves lives. However, it’s important to note that we are making progress - UK cancer survival figures are continually improving.”

To request interviews please call Emma McKinney, Communications Manager (Health Sciences), University of Birmingham, tel: +44 (0) 121 414 6681. For out of hours enquiries please call +44 (0) 7789 921 165.

• The University of Birmingham is ranked amongst the world’s top 100 institutions. Its work brings people from across the world to Birmingham, including researchers, teachers and more than 5,000 international students from over 150 countries.
• The University of Exeter Medical School is improving the health of the South West and beyond, through the development of high quality graduates and world-leading research that has international impact.
• Kidney et al (2017). ‘Cancer suspicion in general practice, urgent referral, and time to diagnosis: a population-based GP survey nested within a feasibility study using information technology to flag-up patients with symptoms of colorectal cancer’. British Journal of General Practice. DOI: https://doi.org/10.3399/bjgpopen17X101109
• Read the full study.
• Annual incidence of colorectal cancer is 66 per 100 000 population. A full-time GP will expect to see one case per year.
• This study was funded by the National Awareness and Early Diagnosis Initiative (NAEDI). Tom Marshall and Sheila Greenfield are partly funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for the West Midlands (CLAHRC-WM) programme. The views expressed in this publication are not necessarily those of the NIHR, the Department of Health, University of Birmingham, or the CLAHRC-WM.