Introduction
As part of the NHS Long Term Plan, ambitions were set that from 2028, an extra 55,000 people will survive for five years or more following cancer diagnosis. The aim was in part to minimize time taken from initial presentation to definitive diagnosis of cancer. “Serious non-specific symptom” (SNSS) cancer pathways were developed in 2019, to aid GPs in referral of patients with vague alarm symptoms, that were still concerning for malignancy, although maybe not fitting a pre-existing system specific, cancer referral pathway (1). Non-specific symptoms commonly include weight loss, unexplained pain and fatigue which could suggest an underlying cancer diagnosis. Within our trust, GPs can refer for an urgent CT Chest, Abdomen and Pelvis, and results are reviewed in a weekly multi-disciplinary meeting. Following this, patients are either discharged back to their GP with advice, or referred on to appropriate cancer pathways. Due to common presentations such as weight loss, this is currently run by the Gastroenterology department. Benign disease is also highlighted to GPs to consider appropriate onward referral.
Aims & Methods
This audit aimed to look at patients referred to our local SNSS pathway, evaluate cancer pick-up rate, cancer type, and benign disease prevalence. To date, there are little relevant published data within the UK, despite information being available within Europe, such as one Danish study which detected a pick-up rate of between 11-20% (2). We designed a retrospective audit looking at all patients referred via the SNSS pathway from February 2023 to September 2023 in South Tyneside and Sunderland NHS Foundation Trust. Electronic notes were reviewed. We looked at referral indication, inappropriate referrals (those that met pre-existing suspected cancer pathways), cancer pick-up rate, type, and whether this was metastatic at diagnosis.
Results
502 patients were reviewed, over 30 MDT meetings. This was evenly split between male (45%) and female (55%) patients, with an average age of 71 years. The most common symptom prompting referral was weight loss, in 74.1% of referrals. Of these patients, 7.5% were diagnosed with cancer. Other common symptoms included fatigue (22.5%), abdominal pain (20.7%), anorexia (13.9%) and generalised pain (13.1%). The overall cancer pick-up rate was 8.6%, with 43 patients found to have a cancer diagnosis. Almost 6% of patients were inappropriately referred to this pathway, having met criteria for pre-existing system specific cancer pathways. However, excluding these patients, overall cancer pick-up rate remained at 8.4%. The most common primary cancers were upper gastrointestinal (25.6%), lung (23.3%) and haematology (11.6%). 37.2% of cancer diagnoses had metastatic disease. Benign pathology was detected in 65% of patients.
Conclusion
Overall cancer-pick up rates in our audit, suggest that the SNSS pathway has a similar pick-up rate to existing urgent suspected cancer pathways (around 7%). This shows that the pathway is valuable in assessing vague symptoms that may not meet pre-existing diagnostic pathways but still have a high incidence of cancer. This is a valuable tool for GPs to use when they have clinical concern about cancer, but non-specific presentations. There are areas for improvement, with 5.6% of inappropriate referrals, potentially highlighting a lack of awareness of pre-existing criteria for cancer diagnostic pathways. We suggest that further national analysis could be done, on impact and effectiveness of SNSS pathways, including long-term outcomes of patients, as improvements in 5-year cancer survival remain unclear.
References
1. NHS Cancer Programme: Faster Diagnosis Framework (2019) , www.england.nhs.uk/cancer/faster-diagnosis [accessed 21 March 2025]
2. Grønnemose, R.B., Hansen, P.S., Worsøe Laursen, S. et al. Risk of cancer and serious disease in Danish patients with urgent referral for serious non-specific symptoms and signs of cancer in Funen 2014–2021. Br J Cancer 130, 1304–1315 (2024). https://doi.org/10.1038/s41416-024-02620-y