Inequalities in cancer two-week-wait referrals: a cross-sectional study in English general practice

Background Practices with higher two-week-wait (2WW) referral-rates demonstrate higher survival for several cancers. Yet, there is little up-to-date evidence exploring factors influencing 2WW-referral-rates and whether health inequalities exist, particularly after COVID-19.

Aim To establish which patient-factors (eg, age, sex, ethnicity, deprivation) and practice-factors (eg, remote consultations, frequency of seeing a preferred-GP) independently predict 2WW-referral-rates.

Design & setting A cross-sectional, observational study was performed using data from English general practices for 2021-2022.

Method Multivariable linear regression was used to identify the strongest, independent predictors of 2WW-referral-rates for all-cancers (primary outcome) and for breast, lower-gastrointestinal, lung and skin cancers separately (secondary outcome).

Results The analysis included 6307 practices. Practices with more females, patients aged 75+and with a greater burden of long-term conditions were associated with higher 2WW-referrals for all-cancers, as were practices in Northwest England and those with higher scores for patients feeling involved in care decisions. Conversely, practices with a higher frequency of seeing a preferred-GP were predictive of fewer all-cancer 2WW-referrals. Whilst practices with a higher proportion of current smokers and Asian and Black ethnicity patients predicted fewer all-cancer 2WW-referrals, these associations were strongest for skin cancer, and for breast cancer (except for Black ethnicity). Higher socioeconomic deprivation predicted lower 2WW-referrals for lung cancer only.

Conclusion This study analyses factors influencing 2WW-referral-rates and highlights potential inequalities. This work identifies priority populations, including smokers and Asian and Black ethnicity patients, who may benefit from interventions to increase primary care access. Shared-decision-making may be an underexplored resource for increasing all-cancer 2WW-referral-rates.