Direct Access to Diagnostic Tests for Cancer: Best Practice Referral Pathways for General Practitioners

Objectives

Improve earlier cancer diagnosis and survival by enabling general practitioners to refer patients directly for selected diagnostic tests when urgent two-week suspected-cancer referral is not appropriate but symptoms require investigation.[1]This forms part of Improving Outcomes: A Strategy for Cancer and is supported by more than £450 million over four years for earlier diagnosis, including public awareness, expanded diagnostic access and additional secondary-care testing and treatment.[1][2]

• Expand direct access to non-obstetric ultrasound for possible ovarian cancer, chest X-ray for possible lung cancer, flexible sigmoidoscopy for colorectal symptoms and brain magnetic resonance imaging for concerning neurological presentations.[1][2][3]
• Improve recognition of possible ovarian cancer by identifying women needing urgent referral for ascites or a pelvic or abdominal mass, and by investigating persistent or frequent abdominal distension, early satiety, pelvic or abdominal pain, and urinary symptoms, particularly among women aged 50 or over.[4]
• Increase early lung cancer detection through symptom-led chest X-ray referral, clearer radiological reporting and public awareness of characteristic symptoms, while prioritising urgent assessment for high-probability presentations.[5]
• Strengthen colorectal cancer screening, referral and diagnostic pathways, particularly for people whose symptoms do not meet established high-risk urgent-referral criteria and who may otherwise experience delayed diagnosis and higher mortality.[6]
• Support risk-based investigation of possible brain cancer through urgent specialist review and appropriate access to brain imaging, while avoiding imaging for isolated headache where a primary headache diagnosis is established without abnormal neurological features.[7][8]

Clinical objectives include lowering appropriate thresholds for investigation, raising awareness of symptoms that warrant assessment, and facilitating faster diagnosis through locally available diagnostic services.[2][3]The programme also seeks to reduce avoidable emergency presentation, which accounted for around 40% of lung cancer diagnoses in 2007, 25% of colorectal cancer diagnoses in 2008 and 58% of brain tumour diagnoses.[5][6][7]

Implementation

Deliver the programme through clinical guidance for primary and secondary care, service providers and commissioners, using best-practice diagnostic pathways and local arrangements for direct access.[1]The Cancer Diagnostics Advisory Board, chaired by the National Cancer Director, coordinates implementation with Department of Health support and a multidisciplinary working group involving government, the National Health Service, professional colleges, charities, academia, patient representatives and primary care.[2][9]

• Apply clinical judgement when identifying patients for direct testing, explain potential incidental findings where relevant, and use local diagnostic pathways without extending the guide into management after the test.[1][2][10][11]
• Use ovarian cancer assessment beginning with clinical examination and cancer antigen 125 testing where examination is unremarkable; arrange urgent pelvic ultrasound within two weeks when cancer antigen 125 exceeds 35 IU/ml, and refer through the urgent suspected-cancer pathway when ultrasound suggests cancer.[4]
• Use chest X-ray as the preferred first-line test for suspected lung cancer, include concise clinical information on requests, seek reporting ideally within one working day, and refer urgently to a lung cancer multidisciplinary team where chest X-ray or computed tomography suggests cancer.[5][12]
• Provide immediate referral or emergency admission for severe lung cancer presentations such as superior vena caval obstruction, stridor or massive haemoptysis.[5]
• Enable direct flexible-sigmoidoscopy referral or one-stop assessment for eligible people with rectal bleeding, permit commissioners to extend provision where capacity allows, and use computed tomography colonography rather than lower gastrointestinal endoscopy for frail older people where appropriate.[13][14]
• Continue national bowel cancer screening, extend eligibility up to the 75th birthday, and pilot flexible-sigmoidoscopy screening for people aged around 55.[6]
• Arrange direct brain magnetic resonance imaging alongside urgent specialist referral where rapid access is available, consider imaging for selected focal neurological, cognitive, behavioural or headache presentations, and use computed tomography where magnetic resonance imaging is unsuitable or for suspected subarachnoid haemorrhage.[15][16][8][10]
• Maintain follow-up and further investigation after a normal brain scan when clinically indicated, because normal imaging does not exclude all neurological pathology.[10]

Develop pathways from evidence-based guidance, primary-care research and expert input from general practice, radiology, pathology, relevant specialties, the National Institute for Health and Care Excellence and Royal Colleges.[2][4][15]Implementation includes diagnostic baselining, General Practitioner questionnaire data, assessment of referral routes and diagnostic activity, data collection, and consideration of tariffs.[1][2]A national expectation for 2012/13 was that fewer than 1% of patients would wait more than six weeks for a diagnostic test.[1]Beyond this waiting-time expectation, baseline work and cited epidemiological evidence, the document does not specify a comprehensive common indicator set, reporting timetable, evaluation methodology or detailed accountability framework.[1][2][3]

Monitoring & Evaluation

Monitoring and evaluation are principally framed around improving timely access to diagnostic tests, assessing baseline referral arrangements, and using epidemiological, diagnostic-route and symptom-risk evidence to target earlier cancer diagnosis. A core service expectation was that fewer than 1 per cent of patients should wait over six weeks for a diagnostic test.[1]The document does not set out a single formal evaluation framework, consolidated indicator set, reporting timetable, surveillance system or accountability process for all four pathways.[1][2][3]

• Monitor diagnostic access through baselining, General Practitioner questionnaire data, referral-route assessments and counts of patients diagnosed through different routes.[2]
• Use evidence on emergency presentations, urgent referrals and diagnostic access to identify opportunities to improve earlier diagnosis, particularly for colorectal cancer, brain tumours and ovarian cancer.[3]
• Apply symptom-associated risks from primary-care studies to support ovarian cancer referral decisions, particularly for women over 50 or at elevated risk, while recognising that a cancer antigen 125 result below the threshold does not exclude cancer in symptomatic women.[4][17]
• Maintain safety-netting and clinical review for women with recurrent or persistent ovarian cancer symptoms, including follow-up at six weeks where cancer antigen 125 is below the threshold.[4]
• Use evidence on lung cancer stage and route to diagnosis as contextual measures of late diagnosis: 70% of cases were diagnosed at stage IIIB or IV in 2010, and approximately 40% were diagnosed through emergency admission in 2007.[5]
• Use clinical information on chest X-ray requests and symptom-associated predictive risks to support estimation of lung cancer pre-test probability and more informative radiology reporting.[12][18]
• Track colorectal cancer incidence, survival, diagnostic route and screening coverage as relevant contextual data, while recognising that these do not constitute a specified implementation indicator framework.[6]
• Recognise that only around half of colorectal cancers present with the high-risk symptom pattern qualifying for urgent referral, and that patients without this pattern experience longer time to diagnosis and higher mortality.[6]
• Use approximate symptom-specific colorectal cancer risks to inform referral decisions, noting that risk rises when common symptoms coexist with other abdominal symptoms.[19][14]
• Interpret brain cancer incidence trends cautiously because changes in coding, data collection and diagnostic methods limit comparisons over time.[7]
• Use epidemiological and referral-route information to understand the need for earlier brain tumour diagnosis: in England in 2007, emergency presentation accounted for 58% of diagnoses, whereas 1% followed an urgent General Practitioner suspected-cancer referral.[7]
• Continue clinical follow-up and further investigation where needed after a normal brain scan, since normal imaging does not exclude all neurological pathology.[10]
• Coordinate implementation through the Cancer Diagnostics Advisory Board, chaired by the National Cancer Director, with Department of Health and multidisciplinary working-group support; however, the source does not define this as a formal accountability or reporting mechanism.[2][9]

Costing & Financing

Financing information is limited. The Department of Health committed additional funding to support direct General Practitioner access to diagnostic tests for earlier cancer diagnosis, and the cancer strategy planned investment of more than 450 million Pounds sterling over four years for earlier diagnosis.[1][2]The document does not provide a complete costed implementation plan, local allocations, recurrent expenditure, funding-gap assessment or economic case for the individual ovarian, lung, colorectal and brain diagnostic pathways.[2][4][5][13][7]

• Invest more than 450 million Pounds sterling over four years in earlier diagnosis, including cancer-sign and symptom awareness, increased General Practitioner access to diagnostic tests, and additional secondary-care testing and treatment.[2]
• Provide additional Department of Health funding for direct General Practitioner access to diagnostic tests, although the amount, budget period, allocation method and currency are not specified.[1]
• Consider tariffs as an implementation support mechanism for direct-access diagnostic pathways, without specifying tariff levels or payment arrangements.[1]
• Allow commissioners to extend colorectal direct-access services according to local preference and available capacity, without identifying associated budgets or resource allocations.[13]
• Recognise that chest X-ray radiation exposure is estimated at 0.015 millisieverts, equivalent to 2.5 days of background radiation; this is a safety estimate rather than a financial cost.[12]
• Exclude specified costing, financing, resource-mobilisation, funding-gap and economic-assumption details for the ovarian, lung, colorectal and brain pathway recommendations.[4][5][19][16][11]