Consultations for clinical features of possible cancer and associated urgent referrals before and during the COVID-19 pandemic: an observational cohort study from English primary care

Abstract

Background: It remains unclear to what extent reductions in urgent referrals for suspected cancer during the COVID-19 pandemic were the result of fewer patients attending primary care compared to GPs referring fewer patients.

Methods: Cohort study including electronic health records data from 8,192,069 patients from 663 English practices. Weekly consultation rates, cumulative consultations and referrals were calculated for 28 clinical features from the NICE suspected cancer guidelines. Clinical feature consultation rate ratios (CRR) and urgent referral rate ratios (RRR) compared time periods in 2020 with 2019.

Findings: Consultations for cancer clinical features decreased by 24.19% (95% CI: 24.04-24.34%) between 2019 and 2020, particularly in the 6-12 weeks following the first national lockdown. Urgent referrals for clinical features decreased by 10.47% (95% CI: 9.82-11.12%) between 2019 and 2020. Overall, once patients consulted with primary care, GPs urgently referred a similar or greater proportion of patients compared to previous years.

Conclusion: Due to the significant fall in patients consulting with clinical features of cancer there was a lower than expected number of urgent referrals in 2020. Sustained efforts should be made throughout the pandemic to encourage the public to consult their GP with cancer clinical features.

Fig. 1. Clinical feature consultation rates by week, cumulative clinical feature reports per week (in thousands), and cumulative urgent referrals per week (in thousands) for breast lump, change in bowel habit, cough, and microscopic haematuria.

These clinical features were selected to highlight disctinct patterns observed across the three panels that are considred in turn in the discussion.

Fig. 2. Urgent referral rate ratios (RRR) comparing the periods before and after lockdown in 2020 with respect to 2019.

Clinical feature-urgent referral pairings are ordered alphabetically by the cancer site of the urgent referral and then the paired clinical feature.

Fig. 3. Overall reduction in consultations and associated urgent referrals for clinical features of cancer for 2020 compared to 2019.

The percentage change in consultations/referrals between 2019 and 2020 was calculated as the ratio of the difference in the number of consultations/referrals between both years by the number of consultations/referrals in the reference year of 2019.