Two-week Wait Research Articles

SP1.1.13Assessing quantitative FIT within the colorectal two-week wait pathway as a triage tool to focus endoscopy services

Abstract Aims Quantitative Faecal Immunochemical test (qFIT) is highly specific for luminal colonic pathology. This study models the potential impact on health care services of its introduction as a tool of triage for the 2-week wait referrals pathway. The Model utilises the recently published NICEFIT tudy. Methods All symptoms and results for patients within the colorectal two-week wait pathway are prospectively collated into a relational database. We modelled the impact of introducing targeted FIT testing to those patients without anaemia, rectal mass or overt rectal bleeding. Based on the recent NICEFIT Study, we set a population positivity value of 37% at 2µg/g with sensitivity of identifying colorectal cancer of 97%. Results 4240 patients were referred in 12 months up to till July 2019. 1333 referrals met the modelled criteria. These 1333 patient events generated 1619 investigations in 1227 patients. Malignancy was found in 4.3% of the investigated referrals (2.8% colorectal, 1.5% extracolonic). By applying FIT to the selected demographics with a positive value of 37%, the number of colonoscopies would fall by 63% (from 815 to 303) with estimated cost saving of £192,000. The FIT negative group would be investigated by selective cross-sectional imaging, with selected use of endoscopy as needed. Conclusion The high sensitivity of FIT permits its application as a screening tool in selected symptomatic patients. This can reduce the number of colonoscopies performed by almost 63% within a defined patient group. This would reduce the waiting time for positive high-risk patients as well as cutting overall costs.

Should National Institute for Clinical Excellence (NICE) Guidelines Remove Urine Cytology as a Suggested Adjunct in Suspected Bladder Cancer (haematuria) Investigations?

Background Despite National Institute for Clinical Excellence (NICE) guidelines suggesting the use of urine cytology (UC) for the diagnosis of bladder cancer, its use is variable. Reasons for this include sub-optimal sensitivity, financial cost, availability of alternative tests, and uncertainty over interpretation of results. Anecdotally, however, suspicious or malignant UC when other investigations are normal, occasionally leads to a cancer diagnosis. Therefore, we retrospectively assessed a cohort of our haematuria patients to determine the value of UC in cancer diagnosis and the clinical significance of atypical UC (graded as C3). Patients and methods We identified 3018 patients with haematuria referred on the suspected cancer pathway (“two-week wait”) in 2015. We retrospectively analysed clinical, demographic, and follow-up/outcome data in a random cohort of 500 cases. Results Median follow up was 58 months. Urological malignancy was diagnosed in 61/500 patients; all were identified by cystoscopy or imaging, i.e., irrespective of UC result. No cases of atypical UC re-presented with a ‘missed’ cancer diagnosis within the five-year follow-up period. However, suspicious and malignant cytology was associated with high-grade/aggressive tumours and subsequent tumour recurrence. Conclusion Urine cytology did not identify any cancers that were not already found by imaging or cystoscopy. Atypical UC in the presence of negative haematuria investigations does not appear to be associated with malignancy, and therefore should not alter patient management nor prompt further investigation. Suspicious and malignant UC was associated with higher risk cancers and could therefore be used to prioritise waiting lists for transurethral resection of bladder tumour (TURBT), however, it is unclear whether this might benefit patient outcomes. We conclude therefore that UC has no role in haematuria investigations.

1284 Comparison of British Association of Urological Surgeons (BAUS) 2008 and NICE 2015 Guidelines for Patients with Suspected Urinary Tract Cancer: An Audit of Haematuria Referrals

Abstract Introduction BAUS guidelines for the investigation of haematuria were replaced by NICE guidelines in 2015. However, both criteria are currently used to refer patients to our Haematuria Clinic. We audit the haematuria referrals made to our unit and compare cancer yield. Method A retrospective review of all two-week wait haematuria referrals to a single UK teaching hospital between October 2019 and April 2020 was performed. Referrals were stratified into two groups: BAUS 2008 and NICE 2015 referral criteria. The outcomes of haematuria investigations were analyzed and the incidence of urinary tract cancer (UTC) compared between groups. Results 316 referrals were analyzed. Of these, 123 (39%) and 193 (61%) referrals were made using BAUS and NICE criteria respectively. 233 (74%) patients were investigated for visible haematuria of which 68 (29%) were referred using BAUS criteria and 165 (71%) using NICE. UTC was identified in 20% of patients referred using NICE criteria and 4.4% using BAUS criteria. 83 (26%) patients were referred with non-visible haematuria. Of these, 55 (66%) were referred using BAUS criteria and 28 (34%) using NICE. UTC was identified in 2.5% of patients referred using BAUS criteria. No UTC was identified in referrals using NICE criteria. Conclusions Despite BAUS haematuria guidelines being superseded by NICE guidelines in 2015, these older guidelines still account for 40% of our two-week wait referrals. Furthermore, NICE guidelines have a higher cancer yield for visible haematuria compared to BAUS guidelines and should therefore take precedence to avoid subjecting patients to unnecessary and costly investigations.

704 An Audit of Marking of Cutaneous Lesions in A Two-Week Wait Skin Malignancy Service

Abstract Aim Clinical photography enhances a medical record and facilitates communication with other professionals involved in care. It is utilised frequently in the management of skin malignancy. The essence of good photography lies in accurate identification of the cutaneous lesion in question. National guidelines and local policy advise the use of circumferential marking to delineate a lesion of interest, and an alphabetical system for marking of multiple lesions. We audited compliance to standards for medical illustrations of cutaneous lesions in the two-week wait skin cancer clinic at University Hospital North Durham. Method Prospective audit of patients attending the clinic over a 7-day period (07/09/20-15/09/20). Data was collated from electronic records on a number of variables. Results 175 patients met inclusion criteria. The majority (n = 160, 89.9%) were referred for a single lesion, the rest for multiple lesions. Hospital clinical photography was obtained in 148 patients (83.2%). Marking was deemed inappropriate in 44.6% of those in which clinical photography was obtained. Of these 66 cases, 12 cases were multiple lesions marked without letters, 52 had an incorrect indicator for the lesion (such as arrows or dots, allowing more ambiguous interpretation), and 8 had no indicator at all. Incidentally, one patient was photographed with dressings covering the lesions. Conclusions Compliance with standards for demarcation of skin lesions for clinical photography was found to be poor. This permits the wrong identification of lesions in future treatment episodes and could potentially have a significant impact on care. We propose the introduction of a referral document illustrating correct marking guidelines.

Evaluation of women referred to the two-week wait gynaecology clinic with suspected ovarian cancer

ObjectivesOvarian cancer is the leading cause of death from gynaecological cancer in the UK, making early diagnosis key. The two-week wait pathway aims to facilitate rapid referrals from primary to secondary care for suspected cancer thus increasing rates of early diagnosis. The objective of this study was to evaluate referrals made via the two-week wait pathway for suspected ovarian cancer. Study DesignA retrospective analysis of 215 women referred on the two-week wait pathway to a tertiary centre in the United Kingdom with suspected ovarian cancer in 2018. ResultsOnly 16% of women referred were subsequently diagnosed with gynaecological malignancy. Of those diagnosed with ovarian cancer, 78% had late stage disease at diagnosis. Pre-menopausal women made up 29% of those referred, but only 6% of those diagnosed with cancer. ConclusionDespite its goal of increasing early stage diagnosis of cancer, the majority of women referred via the two-week wait pathway do not have cancer, and the majority of those who do are referred with late stage disease. These results highlight the need for an effective screening programme for ovarian cancer.

P-010: An economic model to establish the costs associated with routes of presentation for patients with Myeloma in the UK

<h3>Background</h3> Patients with myeloma often face significant diagnostic delay, with over a quarter of patients in the UK diagnosed following emergency presentation (EP) [1]. Compared with other presentation routes, patients presenting as an emergency have more advanced disease, increased complications and poorer prognosis. <h3>Methods</h3> An economic model was developed using a decision-tree framework and a lifetime time horizon to estimate costs related to presentation routes (EP, general practitioner [GP] suspected cancer referral with a maximum two-week wait [TWW], GP urgent, GP routine and consultant-to-consultant, categorised by Howell et al [2017] [1]) for patients diagnosed with myeloma in the UK. Following diagnosis, patients received one of three first-line management options (observation, active treatment with anti-myeloma drugs, or end-of-life [EOL] care). Those receiving observation were assumed to have a diagnosis of smouldering myeloma but could progress to active myeloma and receive active treatment. Inputs were derived from UK health technology assessments, targeted literature reviews, or based on authors' clinical experience where data were unavailable. Active treatment (drug acquisition, administration, adverse event and monitoring for several treatment lines), complication and EOL care costs were included. The model took a UK National Health Service and personal social service perspective. <h3>Results</h3> The average, undiscounted, per patient cost of treating myeloma (across all routes) was estimated at £168,000. The average per patient cost associated with EP (£174,987) was higher than for other routes (£151,370–£170,371). Complication and EOL care costs were higher for EP (£56,091) than other routes (£36,987–£49,844). Active treatment at diagnosis comprised 94% of total treatment costs for EP, versus 64–78% for other routes. For EP, 5% of total treatment costs were attributed to patients who received initial observation, but progressed to active disease and received treatment, whilst for other routes this ranged from 20–35%. In the absence of data, active treatment was modelled identically for patients receiving active treatment at diagnosis or after initial observation, thus total treatment costs were similar across routes. Should initial observation impact subsequent active treatment (e.g. duration of treatment-free intervals), total treatment costs may differ between EP and other routes. <h3>Conclusions</h3> An economic benefit may be associated with earlier diagnosis, gained via reduced complication and EOL care costs, with a difference of £19,104 per patient observed between EP and the GP routine route. The impact of initial observation on subsequent active treatment remains a key data gap. <h3>Acknowledgements</h3> This research was conducted free-of-charge on a pro bono basis by Costello Medical.

Patient Satisfaction With the Head and Neck Cancer Telephone Triage Service During the COVID-19 Pandemic.

BackgroundA telephone triage consultation, as part of the two-week wait head and neck cancer referral pathway, was implemented nationally in March 2020. This was in response to the COVID-19 pandemic to stream cancer referrals to minimize unnecessary interactions and appointments with health services. The aim of this study is to assess patient satisfaction with this novel telephone triage system in the setting of a district general hospital.MethodsA custom designed patient satisfaction questionnaire covering different facets of the patient experience was used. These questions were adapted from several internally validated questionnaires. A retrospective telephone survey was conducted by interviewers for all continuous new head and neck cancer referrals over two 4-week periods in 2020. Questionnaire responses to the initial modality of consult (either telephone triage or face to face) were collected, and data were analysed both qualitatively and quantitatively.ResultsSeventy-five responses were received, with 51 patients providing feedback on an initial telephone triage consultation. Patients rated the telephone triage consultation to be between satisfied and very satisfied across most domains, with an overall score of 4.29 out of 5. Accessibility and efficiency of the telephone triage were the domains with the least satisfaction. Fifty-five percent of patients would be happy to receive a similar telephone triage consultation beyond the pandemic. Qualitative analysis showed praise for the safety and convenience of the telephone triage consultation during the pandemic but highlighted a general preference for a face-to-face consultation and dissatisfaction regarding a lack of physical examination.ConclusionsOverall, patients are satisfied with the telephone triage consultation employed in the pandemic, with high satisfaction rates for multiple aspects of care. However, there were concerns regarding the accessibility and inefficiency associated with a lack of/delayed physical examination and inability to adequately address the fear and anxiety associated with the referral. A mixed response is obtained on whether the telephone triage system should stay for the long run.

COVID-19 pandemic-related impact on two-week wait window for clinic visits in dermatology departments-results of pre-visit image referrals.

COVID-19 pandemic-related impact on two-week wait window for clinic visits in dermatology departments-results of pre-visit image referrals.

O-194 Insights from smartphone app based emotional tracking data on the impact of the Covid-19 pandemic on IVF patients

Study questionIs the emotional experience of patients during IVF different since the start of the global Covid-19 pandemic?Summary answerTracking data since re-opening demonstrated patients lower positive challenge emotions but no significant change in harm, threat, or stress.What is known alreadyCovid-19 caused widespread shutdown of fertility centres, including in the UK, when the HFEA mandated closure from March until May 2020. Research shows clinic closure and an uncertain future were a significant psychological burden for patients anticipating treatment. However, emotional experiences before, during and after closure have not yet been compared, which is the aim of the study.Study design, size, durationRetrospective single-centre analysis of anonymised emotional tracking data entered by 707 patients using the MediEmo smartphone app alongside their IVF cycle, from May 2017-September 2020.MediEmo includes medication timeline/ notifications, coping tools and emotional tracking. Patients rate 2 questions daily in each emotion domain (challenge, threat, harm, e.g. ‘I am feeling tense’) on a 0-3 scale and indicate coping ability (‘I am unable to cope with the stress I am experiencing’) on a binary scale.Participants/materials, setting, methodsEgg donor, recipient and fertility preservation cycles were excluded. First, mood scores were analysed by 2020 month of entry to capture the emotional impact of closure. Second, “Pre-Covid” (May 2017-Feb 2020) and “After Re-opening” (May 2020–Sept 2020) emotional experiences were compared, using student t-tests. Mean and standard deviation of scores in each mood domain entered on each cycle day were calculated, centred on luteal day 0/ egg collection, from cycle day -14 to + 14.Main results and the role of chanceGraphical presentation of emotional data by month clearly demonstrates the significant increase in threat, harm and stress emotions and reduced positive emotions experienced immediately prior to and during mandatory clinic closure. Of patients entering emotional data during closure in March/April 2020, 40% (14/35) stated they felt unable to cope with the stress they were currently experiencing.From May 2020 after the clinic reopened, analysis of in-cycle emotional tracking data showed there are no significant differences in harm or threat emotion levels or numbers reporting intolerable stress during IVF, compared to cycles pre-pandemic (May17-Feb 2020). Patients undertaking IVF cycles since closure are logging lower challenge scores (confident, encouraged, positive, hopeful), demonstrating less optimism, particularly in the ‘two-week wait’ phase of the cycle. The mean (s.d) of challenge scores pre-Covid was 1.50 (1.07), compared to 1.38 (1.04) after re-opening, p = 0.00085.The women who had treatment cycles post re-opening from May 2020 onwards were older (33.4(5.2) vs 32.6(4.4)), which may reflect clinical treatment prioritisation decisions. There was no significant differences in number of eggs collected (mean(s.d) Pre-Covid 12.08 (8.0) vs After re-opening 11.83 (9.4), p = 0.84) or live birth/ ongoing pregnancy rates for undelivered pregnancies (p = 0.69) between the groups.Limitations, reasons for cautionEmotional data was only available for those who chose to use MediEmo, entered emotional tracking data and who gave consent for use of their clinical data in research. As such, this analysis may not fully reflect all patients’ experiences. Most of the available data were entered prior to the pandemic.Wider implications of the findingsFor Covid-19 safety reasons, patients currently have less in-person staff contact when undertaking IVF. The findings reassuringly suggest emotional wellbeing was not markedly different in most domains. However, daily ratings did show the emotional fall-out of clinic closures which for most threatened attainability of parenthood goals (e.g., less hope).Trial registration numberNot applicable

What is the impact of CT colonography interpretation by advanced practitioner radiographers on delivery of the 28 day colorectal cancer target?

IntroductionCT Colonography (CTC) is an indicated test to assess the colon and rectum for evidence of polyps and neoplasms. The advanced practitioner radiographer (APR) is increasingly involved with the entirety of the radiology pathway including procedural modification, preliminary clinical evaluation (PCE) and multi-disciplinary team (MDT) meeting notification of high risk colonic pathologies. MethodsA retrospective audit of the Radiology Information System (RIS) was undertaken at a large secondary care centre, 12 months of data of 119 consecutive patients who had undergone CTC with summary coded reports of high risk pathology were included for analysis. Analysis of accuracy of procedural modification, PCE and impact of hypothesised earlier full radiological staging data being available for MDT discussions were measured and evaluated. ResultsFor high risk C4b studies, just 16.67% of colonic pathology was observed during the CTC study, rising to 79% during radiographer PCE. For likely colonic neoplasm C5a studies 86% of colonic pathology was observed during the CTC study, rising to 93% during radiographer PCE. Where subsequent CT chest staging was deemed necessary following CTC by the referring team, patients had a median wait of 34 days for completion CT chest scan staging. ConclusionThis study supports the integration of the advanced practitioner radiographer into the entire radiological processes of a CTC, with time advantages apparent for both diagnostics, but also the decision to treat. Implications for practiceAppropriately trained radiographers are able to support CTC services to ensure delivery of an effective two-week wait diagnostic service with direct MDT liaison.

Impact of COVID-19 on referrals for physical and mental health care

AimsTo determine the effect of the COVID-19 pandemic on referrals to mental health and physical health services.MethodWe analysed referral data from three psychiatric services in the boroughs of Camden and Islington across 2018-2020: Early Intervention Services (for patients with a 1st episode of psychosis), Crisis Resolution Teams and inpatient admissions. We also analysed GP referral data to Cancer Services (two-week wait referrals) to Whittington Hospital, Royal Free Hospital and University College Hospital (all of North Central London). We examined the impact of the COVID-19 pandemic on these referrals and compared the findings between physical and mental health. We chose to use EIS and Cancer services as comparable services since they both operate with the two-week target of achieving diagnosis of psychosis and cancer respectively.ResultThe number of referrals to EIS and CRT both decreased to 61% in April 2020 with respect to their baseline; EIS referrals continued to decrease to 48% in May before starting to recover. Inpatient admissions saw a smaller reduction to 87% in April 2020. The number of cancer two-week wait referrals similarly decreased and reached a trough of 37% in April 2020. The rate of recovery back to the baseline number of referrals and admissions relative to previous years differed between services, with acute care recovering faster. Referrals to CRT and inpatient admissions recovered by 98% and 115% respectively by June 2020; comparatively, referrals to EIS recovered to 102% by December 2020. In contrast, cancer two-week wait referrals returned to 106% by September 2020, a rate faster than EIS, but slower than CRT and inpatient admissions.ConclusionThe reduction in the number of referrals across all examined services correlated with the first wave of the COVID-19 pandemic. The rate of decrease was similar across all services, coinciding with the peak of COVID-19 infections. However, the ultimate degree of decrease and following rate of recovery in numbers differed across both psychiatric and non-psychiatric services. These differences likely have multifactorial origins. The authors discuss contributing factors, such as changes in health seeking behaviours observed during the pandemic, potential impact of reduction in face to face consultations in primary care, as well as temporary changes in the population demographic of Camden and Islington resulting in absent target groups (i.e. students who make up a large proportion of referrals to EIS opting to return home). It remains important to not neglect mental health and face a hidden epidemic once COVID-19 pandemic settles.

651 Can Two Week Wait Breast Cancer Referrals Be Triaged to Prioritise High Risk Patients for Early Diagnosis and Treatment?

Abstract Introduction NHS England state there should be a maximum 62-day wait from urgent GP referral to first definitive treatment in 95% of patients. Within this timeframe is the two-week wait (TWW) target from urgent GP referral to first outpatient appointment. This audit aims to identify those at higher risk of a cancer diagnosis and prioritise their outpatient appointment. Method A retrospective analysis was conducted of patients on a 62-day breast cancer pathway treated at the Royal Surrey County Hospital (RSCH), from February to July 2019. TWW was identified as a common rate-limiting step. Further analysis of September 2019 allowed the contents of GP referrals to be correlated with subsequent diagnoses. Results 40% of breast cancer patients breached the 62-day target in this 6-month period; the mean TWW was 11.5 days. In September, 266 referrals were received with a cancer detection rate of 3.95%. The most specific referral characteristic was personal history of a breast cancer. Breast lumps in the &amp;gt;30s are more specific than in the &amp;lt;30s (6.8% versus 0%). Conclusions Designated clinics for breast pain and lumps for &amp;lt;30s, would relieve pressure on the high volume of referrals made to TWW clinics, reducing delay to diagnosis and treatment for those most at risk

Stage of ovarian cancer at diagnosis. Does presentation as an emergency make a difference?

ObjectivesThe purpose of this study is to evaluate whether presentation of ovarian cancer as an emergency compared to presentation via referral to diagnostic clinic has an impact on stage of disease at diagnosis. Secondary outcomes include the relationship between stage of diagnosis and age as well as socioeconomic status and type of presentation (emergency or clinic referral). Study designData were obtained from the central database for all new diagnoses of ovarian, fallopian tube or primary peritoneal malignancy at a tertiary teaching hospital for 2016–2018 (n = 147). The electronic patient records were manually reviewed to determine the patient’s presentation. Age and stage at diagnosis were from the central records. Socioeconomic status was determined by the multiple deprivation index deciles obtained from patient postcode data. Non parametric chi squared analysis was used to assess for any significant results. Results51 % of women presented through a gynaecology two-week wait service; 27 % presented as an emergency admission; 12 % through a routine gynaecology outpatient clinic and 10 % after initial referral to a non-gynaecological two-week wait service. There was a significant (p = 0.008) association with later stage disease and emergency presentation. Increased age was also strongly linked to later stage at diagnosis (p = 0.00001). There was no association between stage at diagnosis and socioeconomic status. ConclusionsEmergency presentations account for just over a quarter of new diagnoses and are significantly associated with later stage disease with increased morbidity and mortality. Older women were also more likely to present at an advanced stage. Socioeconomic status did not impact on staging at diagnosis.

Telephone triage of suspected head and neck cancer patients during the coronavirus disease 2019 pandemic using the Head and Neck Cancer Risk Calculator version 2.

Utilisation of the Head and Neck Cancer Risk Calculator version 2 has been recommended during the coronavirus disease 2019 pandemic for the assessment of head and neck cancer referrals. As limited data were available, this study was conducted to analyse the use of the Head and Neck Cancer Risk Calculator version 2 in clinical practice. Patients undergoing telephone triage in a two-week wait referral clinic were included. Data were collected and analysed using appropriate methods. Sixty-four patients in the study were risk-stratified into low-risk (51.6 per cent, 33 of 64), moderate-risk (14.1 per cent, 9 of 64) and high-risk (34.4 per cent, 22 of 64) groups. Of the patients, 53.1 per cent (34 of 64) avoided an urgent hospital visit, and 96.9 per cent (62 of 64) were cancer free, while 3.1 per cent (2 of 64) were found to have a head and neck malignancy. The sensitivity, specificity, negative predictive value and accuracy were 50.00 per cent, 66.13 per cent, 99.92 per cent and 66.11 per cent, respectively. It is reasonable to use the calculator for triaging purposes, but it must always be accompanied by a meticulous clinical thought process.

Supraclavicular lymphadenopathy following COVID-19 vaccination: an increasing presentation to the two-week wait neck lump clinic?

The first COVID-19 vaccination was given in December 2020 and there is an effort to vaccinate the international population on a massive scale. Common side effects from the vaccine include headache and tiredness. Regional lymphadenopathy has been described in relation to other vaccines. We describe two cases of supraclavicular reactive lymphadenopathy presenting in patients who had the COVID vaccination in the ipsilateral arm. Awareness of this diagnosis is important for patients presenting to the neck lump clinic.

Effect of coronavirus disease 2019 on urological surgery services and training up to the peak of the pandemic in South East England

Introduction: The coronavirus disease 2019 (COVID-19) pandemic is having significant effects on health services globally, including on urological surgery for which the British Association of Urological Surgeons (BAUS) has provided national guidance. Kent, Surrey and Sussex (KSS) is one of the regions most affected by COVID-19 in the UK to date. Methods: An anonymous online survey of all KSS urology trainees was conducted. The primary outcome was to assess the effects on urology services, both malignant and benign, across the region in the acceleration phase and at the peak of the pandemic compared to standard care. The second was to quantify the effects on urology training, especially regarding operative exposure. Results: There were significant decreases in urological services provided at the peak of the pandemic across KSS compared to standard care ( p&lt;0.0001). Only 22% of urology units were able to continue operating for low-risk cancer and to continue cystoscopy for two-week wait non-visible haematuria referrals in line with BAUS escalation guidelines. A third (33%) did not complete any prostate biopsies at the peak. The majority of urology units continued clinics by telephone. Urology trainees reported completing substantially fewer operating procedures and workplace-based assessments. A third (33%) had moved to consultant-only operating by the peak. Conclusions: The COVID-19 pandemic has caused significant changes to urological surgery services and training in KSS, with heterogeneity across the region. We suggest further work to quantify the effects nationally. Level of evidence: 4.

Tracking cancer occurrence in the 5years after referral for suspected head and neck cancer.

Very little is known about those who receive a negative (benign) result after referral for suspected cancer, including their risk for future cancer. This service evaluation aimed to track the occurrence of cancer (of any type) in the 5years after an appointment for suspected head and neck cancer (HNC) and compare to those referred to hospital for routine ear nose and throat reasons. Patient identifiers of referrals to one hospital Trust with either a) suspected HNC cancer on a two week wait (TWW) pathway, or b) routine ear, nose & throat problems, were linked with the National Cancer Registry data to determine the occurrence, site and stage of subsequent cancer. 10,314 patients were referred between 2009 and 2011. Cancer occurrence in the 5years after their appointment for those who had initially received a negative diagnosis, was 4.0% for those referred via TWW and 2.1% for those routinely referred. Lung cancer was the most common subsequent cancer site in the TWW group. Those in higher age groups, those with previous cancer, and those referred via the TWW pathway were significantly more likely be diagnosed with subsequent cancer. Given the increased risk of subsequent cancer, it could be beneficial to improve the service provision (e.g. advice on screening attendance, ways to reduce risk, advice on timely help-seeking for symptoms of cancer) at the point of a negative diagnosis on the TWW pathway, especially in older patients and those with a previous diagnosis of cancer.

North East London coronavirus disease 2019 protocol for diagnostics in two-week wait head and neck cancer patients.

The coronavirus disease 2019 pandemic requires urgent modification to existing head and neck cancer diagnosis and management practices. A protocol was established that utilises risk stratification, early investigation prior to clinical review and a reduction in aerosol generating procedures to lessen the risk of coronavirus disease 2019 spread. Two-week wait referrals were stratified into low, intermediate and high risk. Low risk patients were referred back to primary care with advice; intermediate and high risk patients underwent investigation. Clinical encounters and aerosol generating procedures were minimised. A combined diagnostic and therapeutic surgical approach was undertaken where possible. Forty-one patients were used to assess feasibility. Thirty-one per cent were low risk, 35 per cent were intermediate and 33 per cent were high risk. Thirty-three per cent were discharged with no imaging. Implementing this protocol reduces the future burden on tertiary services, by empowering primary care physicians to re-refer low risk patients. The protocol is applicable across the UK and avoids diagnostic delay.

Patients undergoing primary surgery for oral and oropharyngeal cancer: how many are referred on the two-week wait pathway and by whom?

Available data suggest that the two-week wait referral pathway is ineffective at expediting diagnosis of cancer due to large numbers of inappropriate referrals. This study aimed to compare the referral pathway of 125 patients who had undergone primary surgery for oral and oropharyngeal cancer with 100 who had been two-week wait referrals. This was a case note review. Of the 125 patients who underwent surgery; 47 (38%) were referred via the 2WW pathway. GPs had referred 25 (53%) of the 47 patients and general dental practitioners 22 (47%). The tumour stage was similar regardless of referral pathway (two-week wait or routine). GPs recognised that the two-week wait pathway was needed in 49% of the patients they had referred, whereas the equivalent figure for GDPs was 40%. Of the 100 2WW patients, 52 were biopsied. Of these, nine (9%) were diagnosed with a malignancy. GPs referred 61% of the 100 two-week wait patients and accurately diagnosed five of the cancers (although two were basal cell carcinomas), general dental practitioners the remainder (including one basal cell carcinoma). Overall, 41% of the patients referred on the two-week wait pathway by GPs needed a biopsy, compared with 69% of those referred by general dental practitioners. While the criteria for referral on the two-week wait pathway lack discrimination and the majority of referrals proved benign, nearly 40% of surgically treated patients were referred via this pathway, suggesting that it does serve a useful purpose. More patients with cancer were referred by GPs, but more two-week wait referrals by general dental practitioners warranted biopsy.

P029: Can two week wait breast cancer referrals be triaged to prioritise high risk patients for early diagnosis and treatment?

NHS England state in 'Everyone Counts: Planning for Patients 2014/15 to 2018/19' there should be a maximum 62-day wait from urgent GP referral to first definitive treatment in 95% of patients. Within this timeframe is the two-week wait (TWW) target from urgent GP referral to first outpatient appointment. This audit aims to identify those at higher risk of a cancer diagnosis and prioritise their outpatient appointment. A retrospective analysis was conducted of patients on a 62-day breast cancer pathway treated at the Royal Surrey County Hospital (RSCH), from February to July 2019.