2WW Referrals Research Articles

Socioeconomic Inequality in the Head and Neck Cancer Referral System: Redressing the Balance.

Socioeconomic deprivation is a known risk factor for head and neck cancer (HNC). Despite this, there is no current way to acknowledge this in two-week wait (2WW) referrals. 2WW HNC referrals have continually risen, and a self-reporting questionnaire was trialled with referrals to the ear, nose and throat (ENT) department with suspected HNC, allowing additional triage information not included in referrals to be obtained. Patients referred through the 2WW pathway for HNC between February 2021 and March 2022 were asked to complete an electronic self-reporting symptom questionnaire. The vetting process resulted in the referral being accepted or regraded to less urgent referral streams. Scottish Index of Multiple Deprivation (SIMD) quintiles were derived using the online postcode checker tool. A total of 984 2WW referrals were retrospectively reviewed. The questionnaire was completed by 717 (72.9%) patients. Regrading of urgency resulted in 292 (29.7%) 2WW appointments not required. Of those regraded, 264 (90.4%) patients completed the questionnaire. A significantly greater number of patients (p = 0.03) from SIMD 4 and SIMD 5 were regraded (33.3%) compared to SIMD 1 and SIMD 2 (26.4%). Patients who did not complete the questionnaire had a higher median age (61.0 years, range: 17-96, IQR: 25.0) compared to those who completed the questionnaire (56.0 years, range: 17-88, IQR: 23.5, p < 0.001). A self-reported symptom questionnaire can help rebalance urgent appointments to those with genuine red flag symptoms. This in turn reduces social inequality in 2WW referrals and reduces the number of inappropriate 2WW appointments.

FP4.14 - The Efficacy of Performing A Quantitative Faecal Immunochemical Test (qFIT) As A Predictor of Colorectal Cancer Before A 2-Week Wait Referral

Abstract Aim 2-week wait (2ww) Colorectal cancer (CRC) referrals have risen along with increased use of colonoscopy, potentially exposing patients to repeated invasive investigation. Current guidelines recommend the use of quantitative faecal immunochemical testing (qFIT) in primary care to prioritise patients for investigation. This study aims to characterise 2ww CRC referrals in a London hospital. Method This is a retrospective quality improvement study, analysing primary care 2ww CRC referrals in October 2022 in a London hospital. Data collected included referral symptoms, completion of a qFIT prior to referral, previous exclusion of CRC, and subsequent investigation outcome. Results Of 173 patients referred on the CRC 2ww pathway in October 2022, 21% did not require further investigation. 16% of patients had undergone a colonoscopy within 12 months excluding CRC. Only 61% of referrals included a qFIT. 71% of these were qFIT positive, and 11% were diagnosed with CRC. The overall CRC detection rate was 2.2%, all with qFIT &amp;gt;200. The PPV of qFIT for CRC was 5%, and 53% for polyps. Conclusion 39% of this patient cohort were referred without qFIT. Those who are qFIT negative or have had CRC excluded in the past 12 months may not require investigation on a 2WW pathway, may be suitable for investigation with lower priority, and may not need invasive investigation at all. Although the use of qFIT has been nationally recommended to prioritise the urgency of investigation, this study suggests this has not been universally adopted. Wider use of qFIT before 2ww referral may guide the use of resources and aid diagnosis and management of patients with symptoms of CRC.

SP9.1 - Enhancing Personalised Care by Introducing Frailty Management On Lower GI 2ww Pathway

Abstract Introduction/Aim Increasing number of patients with suspected lower GI cancer are being sent Straight-To-Test to achieve the 28Day Faster Diagnosis Standards (FDS) following GP referral. This means that elderly frail patients may not get personalised care unique to their needs and undergo unnecessary investigations. Since 2022, we have piloted a frailty pathway incorporated into the protocol for management of LowerGI 2ww referrals. Aiming to provide a holistic and personalised geriatric assessment to improve outcomes and reduce health inequality. This study analyses the outcomes. Methods A prospectively maintained database of all 2ww lowerGI cancer referrals between January2022-November2023 was analysed. Patients age&amp;gt;75 with a frailty score&amp;gt;=5 or performance status&amp;gt;=3, dementia, poly-pharmacy or from care home were referred straight to the frailty-unit for assessment and discussion of the value of further investigation, based on a locally designed SOP. The patient journey was mapped and outcomes compared to the standard pathway. Results Over 22 months-period, 228 patients with suspected cancer were seen on the frailty pathway. The average number of investigations per referral was0.5 for frail patients compared to 1 for other patients on the standard pathway. 49.5% (113 patients) were found to be unfit for further investigations or declined/self-discharged. 5 patients required optimisation prior to investigation. Only 1patient was diagnosed with cancer. The 2ww standard was met in 80% of frail patients compared to 55% in &amp;gt;75s who were sent straight-to-test on the standard pathway. The 28-day FDS standard was met in 50% of frail patients compared with 18% in &amp;gt;75s. Conclusion The frailty pathway is an effective initiative in reducing unnecessary invasive investigations. Frail patients benefit from holistic geriatric assessment prior to invasive investigations, ensuring suitability and appropriateness.

SP9.3 - Introducing Frailty Assessment into The Suspected Lower GI Cancer Pathway – Results of a 2 Year Pilot

Abstract Introduction &amp; Aim An Increasing number of patients with suspected lowerGI cancer are being sent Straight-To-Test to achieve the 28 Day Faster Diagnosis Standards (FDS) following GP referral. This means that elderly frail patients may not get personalised care unique to their needs and undergo unnecessary investigations. Since 2022, we have been piloting a frailty pathway incorporated into the protocol for secondary care management of LowerGI 2ww referrals. Aiming to provide a holistic and personalised geriatric assessment to improve outcomes and reduce health inequality. This study analyses the outcomes. Methods A prospectively maintained database of all 2ww lowerGI cancer referrals between January2022-January2024 was analysed. Patients aged&amp;gt;75 with a frailty score of &amp;gt;=5 or performance status&amp;gt;=3, dementia, poly-pharmacy or from care home were referred straight to the frailty unit for assessment and discussion of the value of further investigation, based on a locally designed SOP. The patient journey was mapped and outcomes compared to the standard-pathway. Results Over a 24-month period, 228patients with suspected cancer were seen on the frailty pathway. 49.5%(113patients) were found to be unfit for further investigations or declined/self-discharged. The 2ww standard was met in80%of frail patients compared to55% in&amp;gt;75s who were sent straight-to-test on the standard pathway. The 28day-FDS standard was met in50%of frail patients compared with18%in the other&amp;gt;75s.The average number of investigations per referral was0.5for frail patients compared to 1 for patients on the standard-pathway. 5patients required optimisation prior to investigation. Only 1patient was diagnosed with cancer. Conclusion The frailty pathway is an effective initiative in reducing unnecessary invasive investigations, whilst providing timely investigations on the suspected cancer pathway.

Comparing the number-needed-to-biopsy ratio for melanoma diagnosis between teledermatology and face-to-face models ofcare.

The UK elective recovery plan has advocated that teledermatology (TD) should be available in every service receiving urgent suspected skin cancer referrals. Currently, TD plays an important role in some NHS dermatology services in triaging referrals on the skin cancer 2-week-wait (2WW) pathway, given the necessity for rapid lesion assessment and the ever-increasing volume of 2WW referrals received. However, evidence supporting the effectiveness of TD for the accurate diagnosis and triage of skin lesions remains insufficient, with further prospective and pragmatic evaluation required.

FTP2.8 The impact of implementation of a colon capsule endoscopy (CCE) service on demand for lower GI endoscopy: A retrospective analysis in a large district general hospital

Abstract Aims Demand on endoscopy services have increased due to higher numbers of 2WW referrals and the COVID-19 backlog. Alternatives to endoscopy including CT colonography and colon capsule endoscopy (CCE) have been seen as a way to reduce pressure on endoscopy services. Our centre implemented a CCE service, for patients referred via 2WW colorectal pathway with FIT of 10-100μg Hb/g, or undergoing surveillance. We analysed the impact of this service. Methods We retrospectively analysed patients referred for CCE, from initiation of the service in July 2021 to October 2022. We analysed presenting symptoms, findings at CCE, completion of CCE, and further investigations/treatment required. A total of 198 patients were included. Results 68% (134/198) of CCE were complete, defined as full visualisation of the large bowel through to the anus. 66% (89/134) of these required no further investigations. Of those patients requiring further investigations, 21 underwent flexible sigmoidoscopy, 15 underwent colonoscopy and 6 underwent CT-AP. Only 1 required an operation for malignancy. Of the 64 patients with incomplete CCEs, 63 underwent further investigations, mostly endoscopic (17 colonoscopies, 31 flexible sigmoidoscopies). Conclusions The implementation of a CCE service resulted in 94/198 patients not requiring endoscopic investigations over a 14 month period, highlighting the role for CCE in reducing endoscopy demand. However, there was a high rate of incomplete procedures (32%). With a higher rate of completion, a greater number of endoscopies could be avoided, further reducing the pressure on endoscopy departments.

SP10.15 Review of the Two-Week-Wait Suspected Lower GI Cancer Referral Process: Incomplete Information Delays Investigation

Abstract Aims With a rise in lower-GI2ww referrals compared to pre-pandemic levels, straight-to-test (STT)pathways in secondary-care are increasingly relied on to achieve the 28day faster diagnosis standard. Incomplete referral forms can delay the diagnosis. This study analyses lower-GI2ww referrals to a DGH to assess the impact on the straight to test pathway. Methods A prospectively maintained database of 2ww lower-GI cancer referrals between January2021to June2022, was analysed. Key referral criteria were identified as essential to make a STT decision (haemoglobin, renal function, ferritin, performance status/frailty index, FIT). With prior agreement with primary care partners, incomplete referrals were returned to GPs with request for further information, with patient remaining on the pathway. Results In an 18month period, 4740 2ww referrals were received. The cancer diagnosis rate was 3.1%. Assessing NG12 symptoms, 64.1%of patients were triaged STT. Incomplete referrals formed 22.6% of referrals. Upon requesting more information 4.1%of incomplete referrals were withdrawn from the 2ww pathway by GP. 10.4% of incomplete referrals were downgraded to routine pathways once more information was provided. 7.9% had no symptoms noted, 21.8% did not have blood tests and 73.7% lacked frailty score/performance-status. The median time to receive requested information was 7days. The median number of reminders required was 2. In those diagnosed with cancer, there was an average delay of 5 days in diagnosis when inadequate information provided. The proportion of patients requiring more information reduced over the 18month period from 25.7% in first 6months to 19.4% in final 6months. Conclusion Submission of complete referral forms facilitates faster diagnosis, enabling secondary care clinicians to make timely informed decisions about STT investigations for suspected cancer in accordance with BPTPs (BestPracticeTimedPathways) to achieve the Faster Diagnosis standard.

Pathways to cancer diagnosis: current state and recommendations.

Diagnosing cancer early is crucial in improving patient outcomes. Primary care networks are encouraged to audit routes to cancer diagnosis, as suggested by the Network Contract Directed Enhanced Service Early Cancer Diagnosis Guidance. We aim to measure how many patients were diagnosed with cancer in the period of April 2021 to March 2022 at an Essex GP practice, and for each of those patients, to ascertain the route of their diagnosis. We also conducted learning event analyses for patients whose diagnoses were not detected through 2-week wait (2WW) or screening. SystmOne Read codes were utilised to identify all patients coded with 'cancer', and 'fast-track cancer referral'. We measured the conversion rate of 2WW referrals to cancer diagnoses. For diagnoses not detected via 2WW or screening, we analysed patient notes for previous consultations and eventual route to diagnosis. In total, 160 2WW referrals were made with a 6.25% conversion rate to cancer diagnoses. In total, 26 patients were diagnosed with cancer. Seventeen patients were diagnosed through 2WW, three through national screening programmes, three through accident and emergency, two through routine referral, and one through incidental finding. For the six patients not diagnosed through 2WW or screening, reasons why included poor patient engagement with healthcare services, referrals requiring chasing, patients passed between specialties, and failure to detect pertinent clinical signs. It is promising that the majority of cancers are diagnosed through 2WW and screening; however, improving patient engagement, streamlining referrals, and thorough clinical examination and documentation will reduce delayed or missed diagnoses.

BT01 Taking pressure off the skin cancer service: impact of primary care dermoscopy pilot, medical photographer-led clinics and non-2-week-wait skin lesion advice and guidance pathway

Abstract Since the COVID-19 pandemic, we have struggled with similar pressures and capacity issues as most dermatology departments across the country. Our number of 2-week-wait (2WW) and general referrals have increased by 26%. To manage this, we have gradually introduced strategies based around a triaging system for 2WW referrals received with photographic images from the general practitioner (GP) via the National Health Service e-Referral Service (e-RS). We triage patients either to a face-to-face 2WW clinic, a spot clinic run by supervised junior members of the team or a photography/dermoscopy clinic. If we receive dermoscopic images with the GP referral, where appropriate, we can discharge or downgrade the patient to a routine clinic. Strategy 1: in September 2021, we set up a 1-year primary care 2WW dermoscopy pilot. Dermatoscopes were delivered to interested GP practices (appropriate technical training was provided), and the GPs attended skin lesion teaching sessions every 2 months. Thirteen per cent of all our 2WW referrals came through this dedicated pilot 2WW e-RS pathway. We discharged or downgraded 26% of those that were referred with both macroscopic and dermoscopic images. All GP practices (not just the pilot practices) in our region now have dermatoscopes. Strategy 2: in July 2022, we introduced secondary care photography/dermoscopy clinics run by both dermatology nurses and medical photographers using the Pathpoint/eDERMA platform. We triage patients from 2WW e-RS referrals with macroscopic images suggestive of benign lesions to these clinics. We can discharge or downgrade directly from the platform, which immediately sends patients’ information about their diagnosis and management plan via text message. Around 15% of 2WW referrals are booked to eDERMA clinics and around 60% are discharged. Strategy 3: in October 2022, we developed a non-2WW advice and guidance (A&amp;G) e-RS skin lesion pathway for lesions of diagnostic uncertainty and basal cell carcinomas. Dermatoscopic images are not an essential requirement as this is not a 2WW pathway. Referrals are triaged within 72 h, providing rapid advice to GPs. Initial data show that since introducing this service, 2WW referral numbers decreased by 32%. Of the A&amp;G referrals, 28% were discharged with advice and 17% were upgraded to 2WW. Within 3 months of starting this pathway, our department’s 2WW and Faster Diagnostic Standard 28-day cancer targets were no longer breaching. The combination of GP-based photography and dermoscopy, careful triage to a 2WW photography clinic in secondary care and a non-2WW lesion A&amp;G pathway has significantly improved our 2WW service.

DS26 Review of 2-week suspected skin cancer activity shows a large increase in number of patients with basal cell carcinoma: implications for designing services and workforce planning

Abstract The 2-week wait (2WW) suspected skin cancer referral pathway is for people with high-risk skin cancers in particular squamous cell carcinoma (SCC) and malignant melanoma (MM) but not for most basal cell carcinomas (BCC). Conversion rates reflecting the number of SCC and MM diagnosed via a 2WW pathway are around 8–12%. Prior to the COVID-19, pandemic people with straightforward low-risk BCCs would be referred on a routine pathway with an expectation that their management would be completed within 18 weeks. The postpandemic pressure on routine waiting lists has meant that managing patients with BCC in a timely fashion is challenging, and the impression is that these patients are now being referred on the 2WW pathway to avoid delays in treatment. The aim of this study was to review the 2WW referral activity between 2019 and 2022, particularly in relation to the number of patients with BCC. Data were obtained from the cancer team (Table 1). There has been a 68% increase in 2WW referral activity. The proportion of people discharged at first attendance and the MM and SCC conversion rate has remained fairly stable. Looking specifically at BCCs, there was an increase from 13.7% to 16.2%. The total number of tumours managed increased overall by 85% over the study period (Table 1). For BCC, the activity has doubled from 552 to 1108 patients (to the end of November 2022). These data confirm the large increase in the number of patients referred on the 2WW suspected skin cancer pathway. Although there is little change in the proportion of patients with different types of skin cancer being seen and managed, the total numbers reported here demonstrate a significant knock-on impact of additional workload for specialist teams, including the need for more skin surgery activity, histopathology and specialist skin cancer nursing services. This needs to be considered when developing skin lesion diagnostic and management pathways and confirms the importance of developing locally agreed BCC pathways and defining workforce requirements.Table 1Two-week wait (2WW) referral activity between 2019 and 2022Number of tumours managed2019202020212022 (to the end of November 2022)2WW referrals (n)4038480260636837Discharged at first attendance (%)56505454Melanoma (%)2.32.221.8SCC (%)5.98.47.65.8Conversion rate (SCC and MM) (%)8.210.69.69.6BCC (%)13.713.816.516.2Number of tumoursSCC237403461395Melanoma93104121124BCC5526629981108Total882116915801627

BT02 Use of teledermatology in the 2-week wait pathway: 5 years of positive data

Abstract Our teledermatology service was started in 2018 to facilitate the dermatology department’s move offsite and allow for the continuation of inpatient care digitally without the need for increasing staff levels or cross-site working. Its implementation also allowed for efficient adaptation and use throughout the COVID-19 pandemic and recovery following this period. Alongside these aspects, teledermatology has become integral in the department’s rapid-access 2-week wait (2WW) capacity. The pathway involves patients attending the department and undergoing a nurse-led review with upload of the history alongside macroscopic and dermoscopic photographs to the platform for consultant review and management. The platform conforms to all aspects of the British Association of Dermatologists’ teledermatology guidelines and is hosted on the National Health Service’s Health and Social Care Network. Of almost 4000 2WW referrals assessed by digital teledermatology between 2018 and the present, no referrals have been rejected for poor quality, only 1% required urgent face-to-face review with a consultant, 32% were discharged, 53% were booked in for a minor surgical procedure of which half were suspected to be cancer or precancer and performed urgently, and 14% were booked for routine review due to risk factors such a multiple moles and need for a full skin check. Our consultants can assess 40 patients on the digital platform in a 4-h period, and the overall cost is approximately half of a face-to-face clinic, including admin. Of all 2WW referrals, general practitioner diagnosis has remained quite constant, with 30% of lesions thought to be malignant melanoma (MM), 36% squamous cell carcinoma (SCC) and 3% basal cell carcinoma (BCC); in the remaining 31%, no diagnosis was made. Of those referred for surgery by the dermatology consultants, the clinical diagnosis was BCC in 20%, SCC in 22% and MM or MM in situ in 6%; the remainder was thought to be precancerous, atypical naevi or other. We have continued to demonstrate through audit that the clinicopathological correlation in the digital teledermatology clinic is as good as face-to-face clinics for lesion diagnosis because of the quality of the history and images. Our most recent satisfaction survey in 2022 showed 96% patient satisfaction with the initial teledermatology assessment; of those booked for a procedure, 88% strongly agreed that all concerns were addressed prior to surgery. All patients would recommend the service to friends and family. With nearly 5 years of data and continuous evaluation, we have shown the effectiveness of a well-designed, connected digital system in supporting our service without duplication of effort by clinicians or prolongation of the patient’s journey.

BT18 Evaluation of a teledermatology service for lesion monitoring

Abstract Teledermatology (TD) is an established diagnostic and triage tool for the initial assessment of skin lesions and is increasingly being used for monitoring. A previous study conducted at our trust found that 5% of our 2-week wait (2WW) referrals required follow-up for lesion monitoring. We therefore established a TD follow-up pathway to accommodate these patients and increase capacity for face-to-face (F2F) appointments. We retrospectively reviewed the outcomes of all TD follow-up patients seen from 1 April 2022 to 22 December 2022. The TD follow-up is usually requested 4 months after an initial assessment. We evaluated the proportion of benign lesions and those requiring further follow-up or surgery. In total, 3796 patients were assessed via TD, with 319 (8.4%) comprising TD follow-up. Altogether, 292 (91.5%) patients were initially reviewed via TD 2WW referral and 27 (8.5%) were referred from the clinic. Forty-eight (15.0%) did not attend (DNA) their follow-up and were discharged. Of the remaining 271 patients, seven (2.6%) who failed to attend their TD follow-up were rebooked, 179 (66%) were discharged after one TD follow-up assessment, 16 (5.9%) were booked for further TD follow-up, 19 (7.0%) were booked for routine F2F follow-up and five (1.8%) were booked for an urgent 2WW F2F appointment. Patients were also referred directly for excision, with 21 (7.7%) referred routinely and 24 (8.8%) referred urgently. From the 24 lesions excised urgently, five (21%) were dysplastic naevi, one (4%) was a moderately differentiated squamous cell carcinoma, 11 (46%) were benign (naevi, seborrhoeic keratoses or dermatofibroma) and for seven (29%), histology was unavailable (DNA appointment, sought private treatment or excision pending) at the time of data collection. No lesions were confirmed histologically as melanoma. Of the five dysplastic lesions, dermoscopic changes noted at follow-up included new atypical amorphous streaks, new and darker globules, loss of pigment and erythema. Our data suggest that TD for lesion monitoring may offer a suitable and time-efficient approach to follow-up, helping to alleviate pressure on services. Three to six months of follow-up has previously been considered an appropriate time period for short-term lesion monitoring; however, the optimal duration remains debatable. The low numbers of malignant lesions detected suggest an encouraging safety profile. However, with 66% of patients being discharged after TD follow-up, we plan to pilot a collaborative team approach to initial decision-making through mega processing clinics with the aim of improving specificity and ‘getting it right first time’ for patients. Longer-term data and cost-effectiveness analyses are required to further evaluate the sustained safety and efficacy of this service.

BT19 Teledermatology preserves the number needed to biopsy for diagnosis of skin cancer

Abstract In order to ensure a high sensitivity and prevent a missed skin cancer diagnosis, specificity is sacrificed. The number needed to biopsy (NNB) describes the number of benign lesions excised in order to diagnose one skin cancer. Published NNBs are highly variable, but a 2020 meta-analysis reported the overall NNB for melanoma to be 9.6 (Petty AJ, Ackerson B, Garza R et al. Meta-analysis of number needed to treat for diagnosis of melanoma by clinical setting. J Am Acad Dermatol 2020; 82:1158–65). The overall NNB is reported to be 3 for any skin cancer and 1.6 for nonmelanoma skin cancer (Matsumoto M, Secrest A, Anderson A et al. Estimating the cost of skin cancer detection by dermatology providers in a large health care system. J Am Acad Dermatol 2018; 78:701–9). The incidence of skin cancer is rising significantly in the UK, placing increased pressures on dermatology departments. A growing body of evidence suggests that the diagnostic accuracy of teledermatology is similar to that of face-to-face (F2F) care and many trusts now employ teledermatology for triage of 2-week wait (2WW) referrals. Our trust uses a teledermatology model where all patients referred via the 2WW pathway complete a digital form with details of the lesion. Both clinical and dermoscopic images are taken by a trained medical photographer and reviewed by a consultant dermatologist. Lesions felt to be suspicious for malignancy are triaged directly for biopsy. We aimed to evaluate the effectiveness of our teledermatology service by calculating the NNB, as well as the number of appointments where a biopsy was not performed following F2F assessment. Over a 2-month period, 251 lesions in 221 patients were triaged for biopsy via teledermatology, and 212 were biopsied following a F2F assessment. Of these, 54 (25.5%) were histologically diagnosed as skin cancer [11 melanoma, nine squamous cell carcinoma (SCC) and 33 basal cell carcinoma (BCC)]. When comparing the teledermatology diagnosis with the histological diagnosis, the overall NNB for skin cancer was 3.9. The NNB varied depending on the type of lesion suspected (7 for melanoma, 7.1 for SCC and 1.6 for BCC). When examining our NNB, it seems the accuracy of our teledermatology service is in keeping with data published from other centres. Furthermore, only a small proportion of lesions (10%) were not biopsied following a F2F assessment, demonstrating that teledermatology probably has a similar accuracy to F2F assessment. Although this is a small study from one centre, it further demonstrates that teledermatology is an efficient use of resources with no clear reduction in diagnostic accuracy.

BT10 Skin lesion triage teledermatology service: a review of secondary care 2-week wait upgrades

Abstract A teledermatology service for skin lesions was commenced in January 2021 initially as a pilot scheme with six general practices and one dermatology department in a metropolitan area; to date, 70% of the city practices have since been on-boarded. Many 2-week wait (2WW) referrals are made not just for suspected skin cancer, but also for cases where there is diagnostic uncertainty and secondary care opinion/reassurance sought. The aim of the service was to embed a fully integrated information technology solution to facilitate single skin lesion triage in an attempt to help to address the 2WW capacity issues in secondary care. The referring general practitioners (GPs) were provided with a mobile phone adaptor attachment and dermatoscope to obtain images of the index lesion in question. A proforma that includes a concise history of the lesion and clinical impression is completed. The GPs were encouraged to use this triage service but could also refer directly to the 2WW service if concerned. The consultant then provided advice and guidance with a menu of triage outcomes, including upgrade to a 2WW appointment. We reviewed the referrals received via this skin lesion pathway and numbers of cases converted to a 2WW appointment from 12 April to 1 December 2022 as a snapshot of the service. We aimed to determine factors from the referral that prompted the conversion. There were 1201 skin lesion referrals, and 299 cases were converted to 2WW (24.9% of the cohort). In 93 of 299 referrals, the GP’s impression was possible squamous cell carcinoma or melanoma. In 137 of 299 cases, the GP had not provided a clinical impression. In 70 of 299 referrals, the GP’s clinical impression correlated with the dermatology’s impression based on the dermatoscopic images. In 44 cases, the clinician’s impression based on the image was of a benign lesion; however, we noted that a more cautious approach was adopted by some clinicians who triaged to 2WW if there was any diagnostic uncertainty. After face-to-face review, 159 of 299 were listed for biopsy or excision. Some factors identified that limited diagnostic accuracy included poor image quality and some referrals contained multiple lesions, causing confusion. This skin lesion triage service appears to support the idea that photographic triage could reduce the burden of 2WW face-to-face referrals. Areas for improvement identified include ensuring that the referrer provides a concise history and clinical impression, the use of gel for dermatoscopic images and feedback when images are not of adequate quality. In the future, it may be necessary to consider photographic hubs to standardize referral photographic quality.

009 Comparing the number needed to biopsy (NNB) ratio for melanoma diagnosis between teledermatology and face-to-face models of care

Abstract The Elective Recovery Plan, published by NHS England (2022), has advocated that teledermatology (TD) should be available in every service receiving urgent suspected skin cancer referrals. However, evidence supporting the effectiveness of TD for the accurate diagnosis and triage of skin lesions remains limited. A 2018 Cochrane review found variable agreement between TD and face-to-face (FTF) assessment of lesions considered to be of low concern when seen FTF, with remote assessment more likely to recommend intervention (including excision) for low-risk lesions. The number needed to biopsy (NNB) ratio, calculated by dividing the total number of biopsies by the number of biopsied skin cancers, is increasingly used as a metric for the diagnostic accuracy for melanoma detection, with a low ratio suggesting high specificity and vice versa. We undertook a study to compare the NNB ratio for melanoma detection between TD and FTF models for assessing new 2-week-wait (2WW) skin cancer referrals within our service. Over 2019–2020, the service switched over from FTF to a full TD consultant-run model for 2WW referrals. Retrospective analysis of the FTF 2WW model between August and November 2018 identified 53 cases suspicious for melanoma referred for biopsy [30 women and 23 men; median age 44 years (range 27–90)]. Of these, six patients received a histopathological diagnosis of melanoma (NNB 8.8). Retrospective analysis of the TD model between August and November 2022 identified 62 cases suspicious for melanoma triaged directly to a biopsy appointment [37 women and 25 men; median age 49.5 years (range 18–90)]. Of these, three patients received a histopathological diagnosis of melanoma (NNB 20.7). NNB in the TD model was 2.3 times higher than in the FTF model. The NNB of 8.8 in our FTF 2WW model is comparable to a review of 46 studies, which generated an NNB of 7.5 for dermatologists worldwide. The higher NNB of 20.7 for TD indicates poorer diagnostic accuracy for melanoma in this model. The higher NNB in TD is consistent with previous findings that remote assessment is more likely to lead to the excision of low-risk lesions. Further large-scale studies are needed to compare NNB in teledermatology vs. FTF models of skin cancer assessment. TD brings considerable advantages of convenience and increased clinic capacity but may come at a cost of lower specificity for melanoma diagnosis and an increase in the number of biopsies of benign lesions.

Do two-week wait (2WW) referrals for breast pain alone correlate with cancer diagnosis? A departmental review and quality improvement project

Background/Introduction: Our department has an increasing caseload of two-week wait (2WW) referrals to the breast outpatient clinic. A proportion are referred with breast pain as their only symptom/clinical finding.

Faecal immunochemical testing reduces demand and improves yield of Leicester's 2-week pathway for change in bowel habit.

We look at the effect of introducing the faecal immunochemical test (FIT) in the straight-to-test 2-week pathway for change in bowel habit (CIBH). The FIT in primary care triages 2-week wait (2WW) colorectal referrals for patients aged 60 years and above for straight-to-test CT colonography (CTC). We compare the impact of the FIT on numbers of 2WW CTCs, in the year before and after FIT, in both colorectal cancer (CRC) detection and cost-effectiveness at both 4 μg Hb/g faeces and 10 μg Hb/g faeces. At a threshold of 4μg Hb/g faeces, the positive predictive value of the FIT for diagnosis of CRC is 5.0% with a negative predictive value of 99.8% and a polyp detection rate of 25.5%. The introduction of the FIT resulted in a reduction in the number of CTCs performed through the CIBH pathway from a mean of 143.9 per month prior to the FIT to 66.8 CTCs per month once the FIT was well established. Given a FIT threshold of 10μg Hb/g the number of CTCs would be predicted to fall by 70.4% to 42.6 CTCs per month resulting in higher CRC and polyp detection rate, and an estimated annual cost saving of £238 258 in our institution. The FIT use in primary care improves the yield of 2WW referrals for CIBH alone and reduces the burden and cost of investigations to exclude CRC. Improvements may be possible by increasing the cut-off employed, without adversely affecting the risk of missing a cancer.

100 Triaging Two Week Wait Referrals According to ABS Guidelines Established During the COVID-19 Pandemic Is Safe Practice

Abstract Aim CoVid-19 has affected healthcare globally, disrupting cancer care. Two weeks wait (2ww) breast cancer referrals were triaged according to Association of Breast Surgery (ABS) guidelines with patients with no red flag symptoms deemed low risk and able to be discharged back to their GP. This study aimed to assess the safety and efficacy of implementing these guidelines. Method A database was established to prospectively collect 2ww breast cancer referrals from the outset of CoVid-19. Two Consultants triaged the referrals and if there was disagreement, a third Consultant arbitrated. Data were recorded for patient age, gender, presenting complaint, assessment, investigations, diagnosis, and outcome and also time from initial referral to discharge letter to the GP. Results 188 patients were referred via the 2ww pathway to St Bartholomew's Hospital from 22/03/2020 to 08/04/2020. 43 (22.9%) were discharged with a median age of 34 (22–83 years) at the time of referral. The mean time from referral receipt to response was 12.1 (0 – 60 days). 15 (34.9%) patients were subsequently re-referred. Mean time from re-referral to one-stop clinic assessment was 9.1 (2 – 22 days), in keeping with NICE two week wait criteria. Of the patients re-referred, all patients underwent imaging in the form of mammogram and/or ultrasound scan. No patients were found to have pre-invasive or invasive disease. Conclusions Triaging patients based on GP referrals is a safe way of streamlining low risk patients. This has the potential to become standard practice worldwide but requires larger multi-centre studies prior to implementation.

SP9.2.2 Implementation of a straight to test colorectal cancer referral pathway significantly improves cancer targets and reduces outpatient requirements

Abstract Aims The main aim of this study is to determine the impact of the “Straight to Test” (STT) colorectal cancer pathway on the NHS England 28-day faster diagnosis and 62-day-treatment targets. The secondary aim is to evaluate the effect of the pathway on reducing outpatient clinic appointments and the proportion of colorectal cancers diagnosed within 2 week wait (2WW) referrals. Methods This case-controlled single-centre study included 1000 patients. Five-hundred consecutive patients were managed through the STT colorectal cancer pathway between February 2021 to May 2021 (study group), with a dedicated colorectal nurse triaging the referrals for straight to colonoscopy or outpatient clinic, for complex cases that do not fit the STT criteria. This group was compared with 500 consecutive patients referred on the 2WW colorectal cancer pathway prior to the implementation of the STT pathway and therefore all reviewed in outpatient clinic, between April 2019 to July 2019 (control group). Results The 28-day time-to-diagnosis and 62-day time-to-treatment targets improved after the introduction of STT pathway from 59% to 86% (p&amp;lt;0.0001) and from 35% to 60% (p=0.095), respectively. In the study group, 234/500 (47%) patients were triaged for straight to colonoscopy, freeing up an equal number of outpatient colorectal clinic appointments. The proportion of colorectal cancers diagnosed within the 2WW referrals was 5.2% in the study group and 4.2% in the control group. Conclusion Implementation of a STT 2WW colorectal cancer pathway has significantly improved our colorectal cancer targets and reduced outpatient clinic requirements.

SP9.1.7 The effect of the COVID-19 pandemic on Colorectal Cancer (CRC) diagnosis, management and outcomes

Abstract Aim We studied differences in stage, treatment modality, morbidity and mortality, two week wait referrals (2WW) and rate of 2WW cancer diagnosis. Method All 2WW referrals to the NHS trust colorectal department were analysed and their rate of diagnosis of any cancer. Using data extracted from the Somerset Cancer Database, we compared CRC patients diagnosed in the NHS trust 6 months prior to (Pre-PAN) and following (PAN) national lockdown on 23/02/2020. Outcome measures included: cancer stage, resection rate, stoma rate, Clavien-Dindo score and 90 day mortality. Statistical analyses included Chi-squared and Mann-Whitney-U tests. Results 2WW referrals dropped significantly during the pandemic (p=0.02). However, the rate of diagnosis of cancer of any kind was not significantly different (PAN=12.4%, Pre-PAN=11.4%,p=0.89). There were significantly fewer CRC diagnoses during the pandemic (Median monthly diagnoses: Pre-Pan=13.5, Pan=8.5 p=0.010). There was a significantly higher proportion of Dukes A cancers in Pre-Pan compared to Pan (Pre-PAN=31.3%, PAN=14.3%, p=0.036). There was a significantly higher proportion of Dukes B cancers in Pan compared to Pre-Pan (Pre-PAN=13.8%, PAN=33.9%, p=0.032). There was no excess morbidity or mortality between the two groups. Conclusion There was no excess mortality or morbidity, demonstrating the efficacy of COVID surgical protocols. PAN patients presented with advanced tumour stage. There were fewer 2WW referrals from GP and fewer diagnoses of CRC in the PAN group. However, the proportion of cancers picked up from 2WW referrals was not significantly different. Decreased diagnoses and stage migration may be due to loss of investigative resource or patient factors such as fear precipitating late presentation.