BMJ  2007;335:361 (25 August), doi:10.1136/bmj.39311.468183.3A

Letters

Two week rule

Breast cancer growth rates favour abolition of rule

Potter et al highlight the failure of the two week wait initiative to discriminate between patients with breast cancer and those with benign disease.¹

However, what is more important is whether earlier diagnosis provided by a fast track system improves outcomes for patients. Evidence for this is lacking. This is likely to be due to the underlying biology and kinetics of tumour growth. Most breast cancers are relatively slow growing, with an average tumour volume doubling time of 280 days. Assuming that each cancer develops from a single cell and assuming a constant doubling time of 280 days, a tumour of 2 mm (the lowest mammographically detectable level) will have been present for more than 18 years.² A clinically detectable tumour will have been present for even longer.

Moreover, the development of metastases, which ultimately affects the potential for curative treatment, is likely to have occurred even before the primary tumour is clinically detectable.³ Therefore, the importance of whether a patient is seen by a breast specialist within two weeks of referral is largely down to psychosocial issues such as patients' anxiety.

Despite evidence that most referred breast lumps will be benign, most patients who find a lump will fear that they have cancer. A patient referred routinely with a lump may well have the same degree of anxiety as a patient referred urgently, but will have longer to endure the uncertainty of knowing whether she has cancer or not.

By abolishing the two week wait, resources could be directed towards reducing waiting times for all patients and help ensure timely diagnosis and reduction of anxiety for all.

¹ Bristol Royal Infirmary, Bristol BS1 3NU, ² Southmead Hospital, Bristol BS10 5NB

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Competing interests: None declared.

References

1. Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, et al. Referral patterns, cancer diagnoses, and waiting times after introduction of the two week wait rule for breast cancer: prospective cohort study. BMJ 2007;335:288-90. (11 August.)[Abstract/Free Full Text]
2. Friberg S, Mattson S. On the growth rates of human malignant tumors: implications for medical decision making. J Surgical Oncol 1997;65:284-97.[CrossRef][ISI][Medline]
3. Fournier DV, Hoeffken W, Junkermann H, et al. Growth rate of primary mammary carcinoma and its metastases. In: Zander J, Baltzer J, eds. Early breast cancer. Berlin: Springer, 1985.

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Relevant Article

Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study

Shelley Potter, Sasi Govindarajulu, Mike Shere, Fiona Braddon, Geoffrey Curran, Rosemary Greenwood, Ajay K Sahu, and Simon J Cawthorn
BMJ 2007 335: 288. [Abstract] [Full Text] [PDF]