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People who ignore their doctor’s advice about timely cancer testing have poorer outcomes, study finds

patient, doctor
REUTERS/Jessica Rinaldi
Both the youngest patients and the oldest had the highest proportion of no-shows. Men were also more likely than women to skip the referral appointment, as were people who lived furthest from the hospital or in disadvantaged neighborhoods.

A new study underscores the importance of following your primary care physician’s advice when he or she makes an urgent recommendation that you undergo tests for cancer because you are showing possible signs or symptoms of the disease.

While the study found that most people who fail to follow that advice — who delay or skip their initial referral appointments — do not go on to be diagnosed with cancer, it also found that those who do have the disease were more likely to die within 12 months of diagnosis than those with the disease who underwent the tests in a timely manner.

“Our research suggests that more could be done to identify individuals at risk of non-attendance and offer extra support,” says Peter Knapp, the study’s senior author and a professor of health sciences at the University of York in Great Britain, in a released statement.

The study was published Thursday in the journal Cancer Epidemiology.

A bit of background

As background information in the study points out, England’s National Health Service (NHS) requires that patients with suspected cancer see a cancer specialist within two weeks of visiting their general practitioner. This policy was implemented in 2000 to reduce geographical and socioeconomic differences in referral patterns and waiting times. Hospital trusts (units within the NHS that serve specific geographical areas) can be penalized if fewer than 93 percent of their referred patients undergo diagnostic tests within two weeks.


One of the most common reasons for hospital trusts not meeting that target is the failure of patients to show up for their referral appointments.

The current study was conducted in the hopes of identifying the consequences to patients who skip or postpone those appointments.

Study details

For the study, Knapp and his co-authors analyzed data collected from more than 109,000 patients who had been referred by 105 different general practices to a single large cancer center in Leeds, a city in northern England, between April 2009 and December 2016.

Almost all of the patients — 95 percent — attended their referral appointment, but a significant proportion — 5 percent — did not. Most (87 percent) of the no-shows canceled or skipped the appointment, while the rest had other reasons for not going, such as deciding to have the testing done at a cancer center further away or being admitted to a hospital before the appointment.

Both the youngest patients (aged 18 to 29) and the oldest (aged 85 and older) had the highest proportion of no-shows. Men were also more likely than women to skip the referral appointment, as were people who lived furthest from the hospital or in disadvantaged neighborhoods.

Failure to attend the appointment was also higher among people who had been referred because of gastrointestinal symptoms. “This may be due to concerns about unpleasant or embarrassing procedures,” says Knapp.

Effects on outcomes

One in 18 of the patients who skipped the referral appointment went on to be diagnosed with cancer, compared to one in 10 of those who did go. But when the no-shows finally did get diagnosed, their prognoses tended to be significantly worse.


More than one in three (34.6 percent) of the no-show patients with cancer had an advanced stage of the disease when they were finally diagnosed, compared to less than one in five (18.4 percent) of the patients with cancer who did go to the initial referral appointment.

In addition, a higher proportion of the no-shows (34.3 percent) died within a year of diagnosis than of the patients who attended their referral appointments (19.2 percent).

Although patients diagnosed with advanced stage cancer are more likely to die within 12 months than those diagnosed with earlier stages of the disease, the researchers believe the delays in getting tested for cancer don’t fully explain their study’s results. Another possible explanation is that people with symptoms of advanced disease may be more worried and anxious than people with lesser symptoms — and may therefore be more fearful of undergoing diagnostic tests.

Limitations and implications

The study has several important limitations. Most notably, although the participants were ethnically and socioeconomically diverse, they all lived in one country — and in a single area within that country. In addition, all the study’s participants had their health expenses covered by the National Health Service. Thus, they didn’t have to worry about costs when deciding whether to go the referral appointment.

That is not always true in the United States. Indeed, a 2018 survey found that 40 percent of Americans said they had skipped a recommended medical test or treatment specifically because of the cost.

For Americans, therefore, this study highlights not just why it’s important to follow through when your doctor recommends lab or imaging tests to make sure your symptoms are not related to cancer, but also why it’s so important that all people have access to affordable — and timely — medical care.

FMI:  You’ll find the study at Cancer Epidemiology’s website.

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