Summary

Denmark has a higher cancer mortality rate than many other Western countries.1 General practitioners (GPs) are often the first point of contact for patients with potential cancer symptoms. These symptoms can be difficult to recognise, leading to delays in referral and diagnosis.2

The Ministry of Health in Denmark introduced Cancer Patient Pathways (CPPs) linking GPs, hospitals and specialist diagnostic centres to improve the diagnostic process. When a GP suspects possible cancer, they can refer patients through one of the clear referral pathways based on the severity of symptoms. Shortly after the introduction of CPPs in Denmark, survival rates increased, excess mortality decreased and diagnosis waiting times shortened.3 4

Problem

Denmark has a higher cancer mortality rate than other Western countries, including Australia, Canada, Norway and Sweden.1 Cancer patients in Denmark are also more frequently treated for advanced cancers – suggesting significant delays in the diagnosis phase.5 6 One of the challenges in diagnosing cancer is the variation in cancer symptoms: 50% of patients present with urgent alarm symptoms clearly indicative of cancer, but 20% present with serious symptoms not specific to cancer and 30% present with non-urgent, vague symptoms.2

In Denmark, GPs are the first point of contact for patients with potential cancer symptoms. They act as the gatekeepers for specialist care, meaning that difficulties in identifying cancer symptoms and restrictive referral criteria between primary and specialist care may increase the risk of late diagnosis. When patients have vague symptoms, they wait up to 2.5 months longer for a diagnosis than patients with urgent ‘alarm symptoms’.2 7

Solution

The Ministry of Health introduced the Cancer Patient Pathways (CPPs) to improve the diagnostic process. GPs can refer patients with predefined alarm symptoms directly to hospitals through an urgent referral pathway. Patients with serious non-specific symptoms first undergo fast-tracked diagnostic tests with their GP, followed by a referral to a hospital-based diagnostic centre if the tests are inconclusive. Patients with vague or low-risk symptoms are managed entirely by their GP. However, GPs have direct access to diagnostic procedures in hospitals or specialist clinics if needed (e.g. sending patients for scans).7 8

 

What has it achieved?

CPPs significantly improved relative survival rates:

  • Cancer patients overall – three-year relative survival increased from 45% to 54%
  • Lung cancer patients – three-year relative survival increased from 11% to 20%
  • Gynaecological cancer patients – three-year relative survival increased from 58% to 75%.4

They also significantly decreased excess mortality in cancer patients overall, lung cancer patients and gynaecological patients.4

16.2% of patients referred to a CPP with serious non-specific symptoms had cancer.8

After the introduction of CPPs, the waiting period for a cancer diagnosis decreased from 49 to 35 days – a median decrease of 17 days.3 

 

Further information

  • A 2017 report by the Ministry of Health in Denmark, with a section on its cancer strategy
  • A paper explaining each of the CPPs
  • A paper on the CPP for patients with serious nonspecific symptoms
  • A paper on relative survival and excess mortality after the introduction of the CPPs

References:

  1. Coleman MP, Forman D, Bryant H, et al. 2011. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet 377(9760): 127-38
  2. Jensen H, Tørring ML, Olesen F, et al. 2014. Cancer suspicion in general practice, urgent referral and time to diagnosis: a population-based GP survey and registry study. BMC Cancer 14(1): 636-47
  3. Jensen H, Tørring ML, Olesen F, et al. 2015. Diagnostic intervals before and after implementation of cancer patient pathways – a GP survey and registry based comparison of three cohorts of cancer patients. BMC Cancer 15(1): 308-18
  4. Jensen H, Tørring ML, Vedsted P. 2017. Prognostic consequences of implementing cancer patient pathways in Denmark: a comparative cohort study of symptomatic cancer patients in primary care. BMC Cancer 17(1): 627-27
  5. Walters S, Maringe C, Butler J, et al. 2013. Breast cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK, 2000-2007: a population-based study. Br J Cancer 108(5): 1195-208
  6. Walters S, Maringe C, Coleman MP, et al. 2013. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007. Thorax 68(6): 551-64
  7. Vedsted P, Olesen F. 2015. A differentiated approach to referrals from general practice to support early cancer diagnosis - the Danish three-legged strategy. Br J Cancer 112 Suppl 1: S65-9
  8. Ingeman ML, Christensen MB, Bro F, et al. 2015. The Danish cancer pathway for patients with serious non-specific symptoms and signs of cancer: a cross-sectional study of patient characteristics and cancer probability. BMC Cancer 15: 421-21