Characteristics of Optimal Cancer Referrals Made by Primary Care Clinicians: Scoping Review

TL;DR

This study reviews what makes cancer referral letters effective, finding that detailed symptom descriptions and test results are important but more research is needed to improve cancer diagnoses.

Contribution

The study identifies key elements of optimal cancer referral letters and highlights gaps in evidence linking referral content to diagnostic outcomes.

Findings

Referral letters often lack detailed symptom information like duration and appearance.

Including clinical examination findings and test results may improve diagnostic outcomes.

There is limited evidence on whether guidelines or templates improve referral effectiveness.

Abstract

In England, over 2 million patients are referred each year on urgent pathways to investigate suspected cancer. The content and quality of referrals have often been audited, but there is no consensus on what should be included in a referral to optimise diagnostic outcomes.

To identify and describe the characteristics of referral letters for suspected cancer from primary to secondary care that may optimise diagnostic outcomes.

The scoping review employed the methodology developed by Arksey and O'Malley in 2005 and further expanded by Levac and Colquhoun 2010. We searched PubMed, Embase, and PsycINFO to identify relevant studies in English Language published between 2000 and 2023. All findings were reported according to PRISMA guidelines for scoping reviews.

Of 3463 identified records, only thirteen met the inclusion criteria, employing qualitative and mixed methods, as well as retrospective audits of referrals. The studies noted that symptom information such as duration, appearance, and descriptive qualities was often missing. There was limited evidence suggesting that the inclusion of clinical examination findings, test information, and the motivation of the referring clinician were beneficial. Evidence relating to the benefits of guidelines and template referral forms was mixed. There was a paucity of research linking referral content to patient diagnostic outcomes.

Despite a small number of studies retrieved, there was broad consensus about the benefit of conveying detailed information in referrals for suspected cancer, particularly with respect to comprehensive symptom description and relevant tests and clinical examinations. Further research linking referral quality to diagnostic outcomes would be beneficial to drive improvement to diagnostic outcomes.

Every year in England, primary care clinicians urgently refer over 2 million people for cancer tests. However, there is no clear agreement on what information these referrals should include to get the best results for patients. This study looked at research about what makes a good cancer referral letter. Out of more than 3,400 studies that we looked at, only 13 had relevant evidence. Many referral letters lacked key details, such as how long symptoms had lasted (e.g. feeling tired) or what they looked like (e.g. a rash or a spot). Some evidence suggested that it could be useful to including test results and physical examination findings. Some research also suggested that it was helpful if the doctor wrote down why they were concerned about cancer in the referral letter. However, it was unclear whether using guidelines or templates made a difference. In general, clear and detailed referral letters seem to help, but there is little research proving they lead to better cancer diagnosis. More studies are needed to understand how improving referrals can benefit patients.

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