Two-week Wait Referrals Research Articles

Is a “straight to test” strategy a pragmatic alternative to the conventional two-week wait referral pathway for colorectal cancer in an ethnically diverse hospital catchment area? A single-centre case series

IntroductionIn a climate of rising pressure to ameliorate cancer services, a “straight to test” (STT) model whereby two-week wait (TWW) colorectal referrals undergo an investigative procedure prior to an outpatient assessment has been explored as a method to expedite the clinical pathway. We aim to evaluate the potential for its application in an ethnically diverse region and assess whether this model improves the time to diagnosis compared to the conventional route. Presentation of casesBetween September and October 2016, we performed a prospective comparative case series of 132 consecutive TWW colorectal referrals to a district general hospital. Following a two-stage triage process, 24 patients were allocated to a STT group and 108 patients were assessed in clinic first. The times to the first investigation, endoscopic procedure and established diagnosis were compared between the two groups. DiscussionThe median time to the first investigation was 13.5 days in the STT group versus 24 days in the non-STT group (p < 0.001). A diagnosis was established at a median time of 14 days for the STT group versus 25 days in the non-STT group (p < 0.001). 62/132 (47%) of all TWW referrals were excluded from STT owing to language barriers and medical grounds. ConclusionA STT approach minimises the time from TWW referral to investigations and diagnosis for patients with suspected colorectal cancer. Application of a STT model may be limited by local population factors including language issues and a high prevalence of medical comorbidity.

The impact of “Be Clear on Cancer” campaign on breast care services provided by a specialist oncoplastic unit – A retrospective case control study

Introduction“Be Clear on Cancer” (BCOC) was a national campaign to raise awareness of breast cancer in women over seventy years old. Cancer Research UK conducted this campaign from 03 February 2014 to 15 March 2014. This study assesses its impact on breast care services. MethodsBCOC campaign guidelines for hospital trusts were used as standard comparator for this retrospective case-control study. All new patients referred to breast clinic over four months from February 2014 were included, and compared to the same period in 2013. Information was recorded for referrals, biopsy rates and pathological diagnoses. Intra & inter-group comparisons were performed. Results1646 patients were included. An increase of 25.2%(n = 184) was observed in referrals in 2014(n = 915) compared to 2013(n = 731). Cancer detection rates went down significantly (P = 0.002,Chi-square) in 2014 (5.1%,n = 47) compared to 2013 (9.0%,n = 66) due to the increase in number of referrals.In the over 70s group, a higher than predicted increase of 64.2%(n = 52) in all referrals, and 8%(n = 44) in two-week wait referrals was observed. The number of biopsies and cancers detected remained stable although the proportions undergoing biopsies (2014–29.3%,n = 39/133 versus 2013–38.3%,n = 31/81) or being diagnosed with cancer (2014–19.5%,n = 26/133 versus 2013–30.9%,n = 25/81) declined significantly (P = 0.001,McNemar) during the campaign due to an inflation in the number of referrals. Despite the overall reduction, cancer detection rate for biopsies performed remained significantly high in the over 70s (66.7%,n = 26/39) when compared with the under 70s (23.9%,n = 21/88) during the campaign. ConclusionsAlthough “Be Clear on Cancer” campaign resulted in a significant increase in breast cancer referrals, it did not translate into an increase in biopsy rates or cancer detection rates. The amount of work generated for the hospital because of this campaign was far greater than the predicted increase from campaign pilots. Therefore, the overall effectiveness of this campaign is questionable.

Regonising Ear, Nose and Throat Conditions in the Dentist's Chair.

The dentist's chair presents an opportunity to pick up ear nose and throat lesions, by virtue of the close proximity of the anatomical areas. Urgent two-week wait referral can expedite assessment and management of head and neck malignancies, thereby improving the prognosis. In this paper, we attempt to highlight the ear, nose and throat (ENT) conditions that need a two week referral, as well as the benign head and neck lesions which can potentially be picked up in a dentist's chair.

Rate of positive diagnosis of skin cancer and its stage in two-week wait referrals in England according to age.

The incidence of skin cancer is increasing. The two-week wait conversion rate (TWWCR) is the percentage of urgent suspected skin cancer referrals that are confirmed as cancer. To examine the relationships between different epidemiological factors and TWWCR for malignant melanoma (MM) and cutaneous squamous cell carcinoma (SCC). We extracted data from the National Cancer Data Repository (NCDR) and National Cancer Waiting Times Monitoring Dataset between 2009 and 2010 for MM and SCC in England. We conducted partial correlation and stepwise multiple regression analysis on TWWCR, age, incidence, detection rate, tumour thickness (MM only), percentage MM/SCC and social deprivation. We also looked at the two-week wait referral rate (TWWRR) and incidence rate with respect to age. TWWCR was significantly correlated with age when partial correlation was used to control for the factors described above for MM (P < 0.05) and SCC (P < 0.001). Stepwise regression of these factors returned only age as significant in the final model for MM (P < 0.001) and SCC (P < 0.01). Incidence of MM and SCC increased with age. TWWRR also increase with age, but with higher rate in younger people relative to their incidence. Age is a predictor of TWWCR independent of the other factors measured, including thickness and incidence. This may be explained by the higher number of referrals for younger patients despite the lower incidence of skin cancer in this group. This may reflect a more appropriate rate of referral in order to achieve earlier diagnosis and better outcomes.

New NICE referral guidance for oral cancer: does it risk delay in diagnosis?

Changes to guidance about the two-week wait referrals for suspected cancer of the head and neck have created a new recommendation for a general medical practitioner to refer any patients to a dentist under certain criteria. The potential effect of this was assessed based on 91 referrals to an oral and maxillofacial unit. A total of 33 met the criteria for initial referral to a dentist; of these, one was later diagnosed with cancer. We outline the potential deleterious effects the new guidance might have on the rapid diagnosis of oral lesions.

P30. Two-week wait referrals of suspected head and neck cancer to maxillofacial surgery

P30. Two-week wait referrals of suspected head and neck cancer to maxillofacial surgery

PTH-318 Five-year trends in urgent referrals for suspected colorectal cancer – an increase in quantity but not in quality

Introduction Understanding the volume of incoming referrals to a colorectal cancer (CRC) service is essential for adequate service delivery. We aimed to determine the number of two-week wait (2WW) referrals and resulting cancer diagnoses at our centre, and to characterise trends over time. Method A retrospective review of all referrals from primary care with suspected malignancy to our institution over a five-year period (2009–2013) was performed. Annual numbers of colorectal cancer diagnoses were obtained from the trust database. Linear regression models were used to determine statistical significance of observed trends. Results The annual number of 2WW referrals for all cancers increased steadily from 14,031 to 22,912 during the study period (p = 0.02). Referrals for suspected CRC also increased from 1,706 to 3,278 (p = 0.03). The proportion of patients seen within 7 days of referral decreased from 23% in 2009 to 9% in 2013 (p Conclusion The number of referrals for suspected cancer from primary care to our institution is steadily increasing, which has significant implications for service provision. The rate of cancer diagnoses from these referrals is decreasing. Further investigation is required to determine the reasons underlying these trends. Disclosure of interest None Declared.

Efficacy of the Two-Week Wait Referral System for Head and Neck Cancer: A Systematic Review

The publication of the NHS Cancer Plan by the Department of Health in September 2000 led to an increase in the number of urgent referral clinics as the guidelines stipulated that cancer patients should not wait more than two months from referral to initiation of treatment. 1 following the implementation of these guidelines for head and neck cancer (HNC) referrals in December 2000, the National Institute for Health and Clinical Excellence (NICE) released an update as part of Clinical Guidance 27 in 2005 2 outlining eight key symptoms that should prompt urgent referral to secondary care.

The Effect of Increasing Two-Week Wait Referrals for Head and Neck Cancer in East Kent

In 1998 the UK government published its white paper The New NHS: Modern and Dependable, in which it first suggested that patients being referred with a suspicion of cancer should have a maximum wait of two weeks to see a specialist. The rationale for this was that outcomes for late-stage disease are significantly worse when compared with outcomes for early-stage disease (Table 1). It was assumed that reducing the wait to see a specialist would reduce the stage of disease at presentation.

Diagnostic performance of urgent referrals for suspected gynaecological malignancies

The objective of this study was to investigate the outcome of the urgent referrals with suspected gynaecological malignancy. Retrospective analysis of the data of the urgent referrals for suspected gynaecological cancers over a 12-month period at a gynaecological oncology cancer centre in the UK. A total of 233 patients (70.61%) were referred with suspected endometrial pathology, 59 patients (17.88%) with suspected ovarian, 25 patients (7.58%) with suspected cervical and 13 patients (3.94%) with suspected vulval malignancy. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulval malignancy was 11.6, 23.7, 12.0 and 15.4%, respectively. Amongst the indications for referral for suspected endometrial cancer, presence of postmenopausal vaginal bleeding had the higher odds for cancer (odds = 0.13; 95% CI 0.08-0.21). The odds for cancer for women referred with a pelvic mass was 0.17 (95% CI, 0.07-0.42) and for women referred with abdominal bloating was 0.66 (95% CI, 0.18-2.36). All the cases of malignancy were diagnosed in women referred with suspicious appearance of the cervix on clinical examination. The odds for cancer was 0.50 if the indication for referral was vulval itching. The majority of cases of gynaecological cancers during the study period were diagnosed following routine referrals. The overall predictive value of two-week wait referrals for suspected gynaecological malignancies is low. Refinement of the current referral guidelines is required with particular emphasis in the premenopausal women where the diagnostic performance of the urgent referrals is significantly poorer.

Two-week wait referral: should we persist with or should we scrap?

Two-week wait referral: should we persist with or should we scrap?

An Audit of Urology Two-Week Wait Referrals in a Large Teaching Hospital in England

Two week wait referral guidelines have been published by the UK Department of Health for suspected urological cancers. Concordance to these guidelines is variable. Our objectives were to assess the incidence of urological malignancy and the proportion of inappropriate referrals in the two-week wait pathway. Retrospective audit of all two-week wait referrals to the urology department over 6 months. Inappropriate referrals were those not satisfying the referral criteria, but referred under the two-week wait system. Detection rates were calculated for each referral criterion based on diagnosis obtained from histology, imaging reports and clinic letters. Incidence of cancer was 90 of 400 two-week wait referrals (23%). The cancer-detection rate based on reasons for referral ranged from 50 of 122 (41%) for elevated prostate-specific antigen levels to 2 of 56 (4%) for scrotal lumps; 42 (11%) referrals were inappropriate. The overall cancer-detection rate is acceptable. Most inappropriate referrals were for long-standing symptoms and non-specific testicular/scrotal symptoms. The testicular cancer detection rate raises questions about the two-week wait guidelines. Providing general practitioners with fast-track scrotal ultrasound and revising the guideline may reduce the disproportionately high number of patients referred with suspected testicular cancer. Other inappropriate referrals are a cause for concern as they add to the workload of the 'urgent-referral' pathway.

Straight to test. Results of a pilot study in a hospital serving an inner city population

The main aims of the study were to determine the frequency with which two-week wait (2ww) referrals for colorectal cancer (CRC) could proceed directly to straight to test (STT), and the potential improvement in time to diagnosis. A telephone interview was attempted in all 2ww referrals not requiring an advocate and under 80 years. Data were assessed according to a test protocol, and where indicated a potential slot for the appropriate investigation was recorded (virtual test). All patients proceeded to clinic, following which differences in time from GP referral to virtual compared with actual requested test, and any discrepancies between virtual and requested tests were analysed. Between 8th January and 16th February 2007, there were 42 2ww referrals. Twenty-one patients were contacted, of whom 14 were suitable for STT: 13 virtual colonoscopies and one CT scan were booked. Following out-patient consultation, eight colonoscopies; three flexible sigmoidoscopies, one barium enema, and two CT scans were actually booked. There was a difference of 15.5 days between the median times of the virtual and actual test. During this 6-week period a total of nine patients were diagnosed with CRC, of whom three were referred via the 2ww pathway, but none were suitable for STT. This 'straight to test' pilot study suggests a potential strategy for reducing the time to diagnosis and therefore first treatment of those identified with CRC, and offers a methodology for individual hospitals to assess their suitability to employ such a strategy.

Inter general practice variability in use of referral guidelines for colorectal cancer

The Two-Week Wait (TWW) referral system for suspected colorectal cancers has a low yield. To examine this, we assessed the referral pattern of general practices within four primary care trusts and looked at the variability of yield of colorectal cancer amongst all TWW referrals and assessed the reasons for variability. A prospectively collected database of all colorectal cancers was examined for new cases diagnosed in the 12 months from April 1st 2004. Patients were cross-referenced via general practitioner (GP) codes to identify the referral origin. Reasons for the variability in referral patterns from each general practice were assessed in relation to TWW referrals, population demographics and through postal questionnaire of GPs. A total of 175 patients diagnosed with colorectal cancer were referred from 49 general practices. Whilst there was a positive correlation between the number of TWW referrals and colorectal cancer per 1000-practice population (P = 0.001; Spearman correlation coefficient r(s=0.447,) two-tailed), there was a big discrepancy between referrals and cancer diagnosed in many general practices. Twenty-six general practices (53%) had no colorectal cancer diagnosed via the TWW route and these practices had significantly lower utilization of the TWW referral pathway. In the postal survey, 22% of GPs were unaware of TWW clinics or colorectal cancer referral guidelines and only 8% of GPs knew the number of referral criteria. This study demonstrates wide variability within primary care, in the appropriate use of colorectal cancer referral guidelines. General practices should be targeted for education.