Exploring complexity in international primary care referral pathways for the management of suspected cancer


Session type:

Charlotte Lynch1, Brian Nicholson2, Cathy Clelland3, May-Lill Johansen4, Jon Emery5, Ross Lawrenson3, David Weller6, Claire Collins3, Dorte Ejg Jarbol7, Kirubakaran Balasubramaniam7, Alun Surgey8, Laurence Dorman3, Samantha Harrison9
1Cancer Research UK, London, UK, 2University of Oxford, 3Other, 4UiT The Arctic University of Norway, 5University of Melbourne, 6University of Edinburgh, 7University of Southern Denmark, 8Bangor University, 9Cancer Research UK (CRUK)



International variation in cancer outcomes persist. Differences across the cancer patient pathway between countries may be driving this variation, including to some extent, variations in timely diagnosis and stage distribution.  There are many hidden complexities within the time taken until a diagnosis is confirmed for cancer patients, with various elements affecting how swiftly patients move through healthcare systems. The manner of these complexities and possible solutions have not previously been compared internationally.


We aimed to explore the variation in primary care referral pathways for the management of suspected cancer across countries within the International Cancer Benchmarking Partnership (ICBP). We consider how complexity plays a role in factors contributing to international variation in cancer outcomes. This will provide further insights into international differences in primary care management of suspected cancer and develop recommendations to improve timely navigation to enable prompt diagnosis. Schematics displaying the overall referral pathways for suspected cancer in 10 countries have been developed from exploration of existing literature and expert insight from primary care representatives in each country. A thematic analysis was undertaken to identify key contributing factors to complex systems. A descriptive comparative analysis of these factors and the referral pathways is being undertaken across the 10 countries.


Referral pathway schematics for 10 ICBP jurisdictions have been produced. Variation in use of emergency routes, ability to expedite patients for investigation and referral, and provision for patients with unspecific symptoms were the key points of variation.  GP empowerment, cancer specific pathways and communication/coordination/collaboration in the primary and secondary care interface have been identified as key factors likely to drive or reduce complexity.


Complexity of the referral pathways may play a detrimental role in health systems already under stress, particularly in light of the COVID-19 pandemic. The schematics developed within this project provide key learning points from international best practice to streamline the primary care interval, in order to improve earlier diagnosis and more favourable outcomes.

Impact statement

This work allows us to identify opportunities and lessons learnt to streamline primary care referral pathways and facilitate learning and transfer of best practice to aid in earlier diagnosis and improved cancer outcomes