Background: It is puzzling to note that British and Danish citizens have a poorer cancer prognosis than citizens from other countries, and this study hypothesises that their low cancer survival could be partly rooted in the gatekeeper function undertaken by general practice in these two countries.

Aim: To test the association between principles of gatekeeper systems and cancer survival.

Design and setting: An ecologic study with data from EUROCARE-4 and primary care structure.

Method: This hypothesis was tested in an ecologic study on the association between three principles of gatekeeper systems and cancer survival in 19 European countries for which valid and full data were available.

Results: It was found that healthcare systems with a gatekeeper system do have a significantly lower 1-year relative cancer survival than systems without such gatekeeper functions.

Conclusion: The possible mechanisms behind this finding are discussed, and while all the positive aspects of gatekeeping are recognised, it is strongly recommended that further research be conducted to confirm or reject the study hypothesis on this possible serious adverse effect of gatekeeping.