Like a Complete Unknown: An Audit of the Quality of the Referrals to the Cancer of Unknown Primary Clinic at a Tertiary Care Centre

TL;DR

This study audits referrals to a cancer clinic where the primary tumor site is unknown, finding that only half met quality standards.

Contribution

The study identifies specific deficiencies in referral quality and highlights the need for standardization and education.

Findings

Only 55% of referrals met the criteria for adequacy based on NICE guidelines.

Deficiencies were most common in CT scans and immunohistochemistry assessments.

Referral quality varied significantly by specialty, with the lowest rates in emergency and family medicine.

Abstract

Background: Carcinoma of Unknown Primary (CUP) constitutes approximately 3% of all advanced cancer cases globally, posing a distinct and complex medical challenge due to its metastatic nature, with no identifiable primary tumour site despite comprehensive investigations. Aim: This study aimed to assess the quality of referrals to the Cancer of Unknown Primary Clinic at the Princess Margaret Cancer Centre (PMCC) by conducting a retrospective audit of initial referrals between January 2022 and March 2023. Methods: The adequacy of referrals was evaluated based on adherence to NICE guidelines, focusing on essential diagnostic investigations such as comprehensive history, physical examination, CT scans, and pathological assessment with immunohistochemistry. Our cohort consisted of 97 patients with a median age of 66 years. Results: The results indicated that only 55% of referrals met the criteria for adequacy, with significant deficiencies in computed tomography (CT) scans and immunohistochemistry (IHC). Notably, the adequacy of referrals varied by specialty, with the lowest rates in emergency medicine and family medicine, and the highest rates in medical oncology, gastroenterology, and neurosurgery. Conclusions: These findings underscore the need for improved standardization and education to enhance referral quality, ensuring that patients with CUP receive appropriate and timely care. This study marks the initial phase of the Knowledge-to-Action cycle, highlighting areas for quality improvement in the referral process to the CUP clinic.

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