Gary A. Abel

Background Initial non-cancer diagnoses that plausibly explain cancer symptoms may be underexplored missed opportunities in cancer diagnosis. Aim To characterise “interim diagnoses” representing potential missed opportunities to diagnose cancer; namely, non-cancer conditions diagnosed before cancer that are associated both with cancer and better and/or worse cancer outcomes. Design and Setting Observational case–control and case-only analyses of registry-linked Clinical Practice Research Datalink data from English primary care. Methods Cancer cases (cancer registry diagnoses, 1/1/2012–31/12/2018) were matched to cancer-free controls on birth year, gender and general practice. Incident non-cancer diagnoses sharing cancer symptoms were sought in the year before the case’s diagnosis. Conditional logistic regression characterised non-cancer diagnoses associated with cancer (Bonferroni-corrected p<0.05). Associations between non-cancer diagnoses and cancer outcomes were tested using logistic regression (stage, route to diagnosis) and parametric regression accelerated failure-time models (1-year survival). Results Analyses of 223,422 patients yielded evidence of 37 “interim diagnoses” across 7 cancer sites that were consistently associated with worse (n=18) or better (n=8) cancer outcomes, or a mixture of worse and better outcomes within or between cancer sites (n=11). For example, gastro-oesophageal reflux disease, gastritis, oesophagitis, or peptic ulcer were associated with worse outcomes in pancreatic, colorectal and ovarian cancers, with better outcomes in stomach cancer, and a mixture in oesophageal cancer. Conclusion We characterise 37 “interim” diagnoses as potential missed opportunities in cancer diagnosis. Safety-netting around these non-cancer diagnoses, focussing on management of clinical uncertainty and robust patient follow-up, may help avoid missed opportunities to diagnose cancer and improve outcomes.

Purpose: Degenerative Cervical Myelopathy (DCM) is the most common form of atraumatic spinal cord compression. Few population estimates have been reported, with most estimates derived from hospital records. The aim was to estimate the incidence of DCM in UK primary care. Methods: Population cohort study using the Clinical Practice Research Datalink (CPRD) Aurum database of English general practices, restricted to adults aged 20 years and over, 2013–2023. Incidence was calculated as new DCM diagnoses per calendar year divided by the registered adult population at each year's midpoint, reported per 100,000 person-years with 95% CIs, crude and age-standardised (AS), by gender and age band. Trends were modelled using negative binomial regression, examining pre- and post-pandemic periods separately. Results: A total of 10,439 incident DCM cases were identified, from 16,585,135 currently registered patients (average age at diagnosis 61.8 years; 55% male). Overall incidence was 7.9 (95% CI 7.8 to 8.1) per 100 000 person-years, higher in men (AS 9.6, 95% CI 9.3 to 9.8) than women (AS 7.5, 95% CI 7.3 to 7.7) peaking at ages 75-79 years (18.9 95% CI 17.8 to 20.1) per 100,000. Over the study period incidence reduced, but pre-pandemic was absent, and incidence rose significantly after 2020, indicating COVID-19-related diagnostic disruption rather than a true decline. Conclusions: DCM incidence in UK primary care is higher than previously reported estimates, peaks in older males, and rose significantly after 2020. Primary care clinicians should be aware DCM may be more common than previously assumed.

Background Primary care is the main route to diagnosis for patients with prostate cancer, either following asymptomatic Prostate Specific Antigen (PSA) testing or investigating prostate-related symptoms. Whilst previous primary care studies suggest an association between symptoms and prostate cancer diagnosis, it remains unknown whether outcomes differ based on the presence or absence of symptoms. Aim To compare prostate cancer stage, grade, and mortality amongst symptomatic patients presenting to primary care with asymptomatic patients. Design and setting Retrospective cohort study using Clinical Practice Research Datalink (CPRD) Aurum. Included adult males aged 50 years and above with first presentation to primary care for coded lower urinary tract symptoms (LUTS), haematuria, or erectile dysfunction between 01/01/2011 and 31/12/2016 with up to two asymptomatic males matched by age, ethnicity, and GP practice. Method Main outcomes: Clinically significant prostate cancer (Gleason Grade Group ≥ 3); Early-stage prostate cancer; Cambridge Prognostic Group; prostate cancer mortality; all-cause mortality. Mixed effect logistic regression modelling was performed. Results 722,597 males were included (262,178 [36.3%] had coded symptoms). Mean age was 64.4 years (SD 9.76). 90.68% identified as White ethnicity. 12,297 new prostate cancer diagnoses within 24 months of index consultation (8,101 [65.88%] in symptomatic group). Clinically significant prostate cancer (Adjusted OR 1.14 95% CI 1.07, 1.23) was more likely in the symptomatic group. No difference was found in stage at diagnosis (aOR 1.02 95% CI 0.95,1.09). Conclusion Investigating symptomatic patients in primary care is more likely to detect clinically significant prostate cancer with no difference in stage at diagnosis.

Background: Timely diagnosis of cancer can be challenging as most individuals present with non-specific symptoms in primary care. One-third of those diagnosed with cancer report receiving a non-cancer diagnosis, before being referred for cancer investigations (‘interim’ diagnosis), presenting a potential missed diagnostic opportunity. Aim: This study explores patients’ experiences of receiving a non-cancer diagnosis before referral for suspected cancer investigation. Design and setting: Secondary qualitative analysis of seven interview datasets collected in UK primary care since 2015. Method: Patient journeys were summarised, charted, and analysed using framework analysis. Patient Public Involvement and Engagement collaborators were involved throughout. Results: A total of n = 58 transcripts in which patients presented to primary care with symptoms and received an interim non-cancer diagnosis were included in the study. We identified eight common scenarios involving an initial non-cancer diagnosis followed by referral for suspected cancer. For example, individuals considered at low risk of cancer reported symptoms being linked to lifestyle factors, and required multiple contacts over time before further investigation was considered. Patients queried interim diagnoses when they felt their symptoms and interpretations had been poorly understood, or they had been given inappropriate investigations or ineffective treatment. While patients recognised the difficulty of deciding when common symptoms required onward referral, they trusted clinicians who were responsive to their concerns, regardless of outcome. Conclusion: Interim diagnoses arise as part of the normal diagnostic process in patients presenting with non-specific symptoms. Challenging these diagnoses in the face of new evidence could mitigate potential delays in diagnosis and improve patient outcomes.

Background: Patient-facing online triage tools potentially offer GPs a way to recognise cancer-related symptoms and features to facilitate appropriate suspected cancer referrals. Little is known about their impact on cancer diagnostic process and outcomes. Aim: To describe patterns of cancer outcome and process indicators associated with the use of online triage tools in primary care. Design and setting: This cross-sectional study examined the association between publicly reported practice-level data on 3053 English general practices. An online triage tool was used that linked to practice-level data and 31 233 594 triage forms completed using an online triage tool in 2022–2023. Method: A cross-sectional analysis (mixed-effects regression) was conducted to evaluate the association between the annual rate of eConsult forms received (weighted to practice registrations) and various cancer diagnosis process and outcome measures. Results: Increased use of online triage forms was associated with higher rates of urgent suspected cancer (USC) referrals and investigations; for example, there was a 7.75% difference in colonoscopy rate (95% confidence interval [CI] = 3.83% to 8.98%) across the 90% mid-range of practices. Despite this, there was no evidence of an association with USC referrals resulting in diagnosis or emergency presentations. Conclusion: Greater use of online triage forms is associated with more investigations and referrals for suspected cancer, but not associated with better diagnostic outcomes. This may indicate that any additional referrals are of lower quality and overall there is an increase in inappropriate use of USC referrals. Research is needed to understand how this impacts investigations and referrals for individual patients.

Background: Patients later diagnosed with cancer may first be diagnosed with another ‘interim’ diagnosis based on their clinical presentation. In some cases, interim diagnoses may be missed opportunities to diagnose cancer. Aim: To explore healthcare professionals’ perspectives of when interim non-cancer diagnoses occur how they have an impact on a cancer diagnosis and what could trigger their prompt review. Design and setting: Interviews were conducted between March and November 2024 with 35 GPs, three other clinicians, and three practice administrators from 31 general practices in southern England, UK. Method: The semi-structured interviews were undertaken via videocall and were analysed using framework analysis. Results: Participants reported that interim diagnoses occurred in cases of diagnostic uncertainty, especially when non-specific symptoms were attributed to common differential diagnoses. Remote consultations were thought to increase the likelihood of interim diagnosis by limiting information gathering. Interim diagnoses were suggested to delay cancer diagnoses, although this was not always seen as avoidable. Clinicians hoped to facilitate opportunities to make a cancer diagnosis by using safety-netting to encourage reattendance, and an informal rule of ‘three strikes and you’re in’. Colleagues providing a ‘fresh pair of eyes’, discussing diagnostic uncertainty in the clinical team, and using past cases as learning opportunities were suggested approaches to facilitate prompt review of interim diagnoses. Conclusion: Consistent safety-netting is required to ensure timely review of non-cancer ‘interim’ diagnoses when there is a possible underlying cancer diagnosis. The range of interim diagnoses and their impact on cancer diagnosis requires further quantification to inform interventions to mitigate their effect.

Introduction: Colorectal cancer has low survival rates when diagnosed late-stage. We previously developed sex-specific dynamic risk prediction models utilising trends in the full blood count (FBC), a blood test commonly performed in primary care, to support early detection. We aimed to externally validate these prediction models. Methods: We performed a hybrid case-control and cohort study of patients with at least one FBC test. We first excluded FBCs within two years before diagnosis (cases) or study exit (controls) and selected the most recent FBC as the baseline test per patient from the resulting data. Patients were aged at least 40 years at baseline and had no history of colorectal cancer. The models included age (years) at baseline and simultaneous trends over historical haemoglobin, mean corpuscular volume (MCV), and platelet measurements measured over five years before baseline to inform two-year risk of colorectal cancer diagnosis. Performance measures included the c-statistic and calibration slope. Results: We included 2,956,977 males and 3,561,349 females, with 0.4% (n=12,578) and 0.3% (n=11,939) diagnosed with colorectal cancer, respectively. The c-statistic (95% CI) was 0.73 (0.72-0.73) for males and 0.74 (0.74-0.75) for females. The calibration slope (95% CI) was 0.92 (0.89-0.94) for males and 0.95 (0.93-0.98) for females. Calibration was good in subgroups of patient data, except under-predicted risk in those aged 70+ years, White individuals, and those with higher IMD. The c-statistic (95% CI) was similar regardless of the number of FBCs used to define trend and increased as the longitudinal trend window increased until around 2.5-3.0 years for men (0.73 (0.71-0.74)) and 3.0-3.5 years for women (0.73 (0.72-0.75)) and decreased with increasing longitudinal windows thereafter. Conclusion: Utilising temporal changes in the FBC test could enhance risk stratification for colorectal cancer. Further research may highlight approaches for improving predictive performance further.

Around two thirds of patients with cancer diagnosed in England first present to primary care¹ so encouraging timely referral of those with signs and symptoms of possible cancer is crucial to improve patient outcomes.

Aims: It is unclear how much diagnostic testing delays have recovered in England since the COVID-19 pandemic, and how this varies locally. We assessed whether imaging and endoscopy delays improved since the pandemic and in the past year; whether local variation in delays widened or narrowed in the past year; and whether current trends differ between local areas. Methods: We analysed public data for eight diagnostic tests (four imaging and four endoscopy) across 103 sub-Integrated Care Boards in England from 2019-2026. To assess recent changes, we compared proportions of patients waiting 6+ weeks in April 2026 with April 2025 using mixed-effects binomial logistic regression. Geographic variation beyond chance, and change in variation in the past year was quantified using modelled random effect variances. This was translated into 25 ^th to 75 ^th percentile values (middle 50%) of local areas. Local area–specific trends were examined using modelled conditional estimates. Findings: The proportion of patients waiting 6 weeks or longer for tests has partially reduced since the pandemic, but has stalled in the past year and even increased for gastro-intestinal endoscopies and MRI. From April 2025 to April 2026, delays increased significantly for gastroscopy (22%-30%; p<0.001), colonoscopy (25%-30%; p=0.002), flexible sigmoidoscopy (27%-33%; p<0.001), and MRI (15%-25%; p<0.001). There was substantial geographic variation beyond chance, with three- to five-fold differences between the middle 50% of local areas. The magnitude of variation persisted over the past year, and significantly increased for MRI. Individual local areas experienced markedly different changes since April 2025, including over a 50% reduction in delays in some areas and doubling in others. Conclusions: Recovery in post-COVID diagnostic delays has recently stalled, and reversed for gastro-intestinal endoscopies and MRI. Substantial geographic variation persists, with divergent local trends. Policy-makers should prioritise reducing overall waiting times and identifying local causes of delays. Lay summary: During the COVID-19 pandemic, waiting times for important diagnostic tests in England—such as imaging scans and endoscopies—became much longer. This study looked at whether those delays have improved, and whether some parts of the country are doing better than others. Using monthly published NHS data from January 2019 to April 2026, we tracked how many patients waited six weeks or longer for eight common diagnostic tests across 106 local areas in England. We found that although waiting times improved somewhat after the pandemic, progress has recently stalled. In the past year, the proportion of people waiting six weeks or more increased noticeably for gastroscopy, colonoscopy, flexible sigmoidoscopy, and MRI. There are also large differences in delays for endoscopy and imaging tests, depending on where people live. In some local areas, the chances of delays are three to five times that in others. Overall, these differences have persisted over the past year, and widened for MRI. In each local area, different things are happening. In some areas, the proportion of patients waiting 6 weeks or more for a test has halved, but in others it has more than doubled. Overall, recovery in waiting times for diagnostic tests in England since the pandemic has stalled, and for endoscopies and MRI, it is starting to reverse. Efforts to improve the system should focus not only on reducing delays overall, but also on understanding why some areas are performing much better than others. What is already known on this topic: Post-pandemic waiting times for diagnostic imaging and endoscopies in England remain well above national targets, but ongoing trends in recovery and local variation in delays have not been formally quantified. What this study adds: Recovery in waiting times for diagnostic imaging and endoscopies has stalled, with delays worsening in the past year for key gastrointestinal endoscopy tests and MRI. There is substantial and persistent geographic variation beyond chance, with threefold to fivefold differences in delays between local areas and markedly different local trends. How this study might affect research, practice or policy: Efforts to reduce diagnostic delays should focus on both improving national performance and reducing geographic variation. To reduce variation in delays, greater understanding is needed about local drivers of diagnostic capacity and demand, and the role of local service organisation.