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Rapid Responses: Rapid Responses published:
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Breast cancer referral waiting times
- Andrew J Maville (15 July 2007)
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What changed in 2003?
- Emma P M Holcroft (16 July 2007)
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Breast cancer referrals: two week wait for all patients.
- Gordon C Wishart, Peter D Britton, Dawn Chapman, Carlos Caldas (18 July 2007)
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Delay of Breast Cancer Referral
- Jeannie Erskine (20 July 2007)
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More questions than answers, but let's not scrap the urgent referral guidance
- Richard D Neal (20 July 2007)
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Equity and justice: should mammographic resources primarily be used for diagnosis or screening?
- Hazel Thornton (20 July 2007)
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Two week referral rule
- David P Jones (22 July 2007)
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Breast cancer growth rates favour abolition of two week wait
- Emma J Helm, Edward Nash (12 August 2007)
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Long live the 2 week wait
- Rupert A Gude (14 August 2007)
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Does longer wait improve cancer outcomes?
- Christian P Subbe (14 August 2007)
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Two week wait for all patients
- David P Levy (14 August 2007)
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No suprise there, then!
- Graham Kyle (15 August 2007)
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'Two-week rule' fails lung cancer patients also!
- Philip P SUTTON (15 August 2007)
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Is the 2WR a failure or are we failing the 2WR protocol?
- Russell J Thorpe (17 August 2007)
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Referral patterns after the introduction of the two week wait rule
- Joanne Morrison, Ian Z. MacKenzie (30 August 2007)
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Why's it the two weeks rule's fault?
- Aidan F Magrath, Alex Keenan (17 September 2007)
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Andrew J Maville, senior researcher Project North East, NE1 5DW
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Something is happening in the non-urgent group. Either GPs are using the wrong assessment criteria, or there is increased prevalence of a type of tumour which presents as benign but which is malignant. Having limited personal experience of this, my conclusions are suspect, but I think that the issue is with tumours which present as mobile across the breast. My 30 year-old wife's grade 3 tumour was assessed as mobile and seemingly innocent by both GP and consultant, each well experienced in breast examination. If you want more detail, I just posted on my blog about this at: http://her2.blogspot.com/2007/07/breast-cancer-referral-waiting-times.html Competing interests: None declared |
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Emma P M Holcroft, Business analyst GU2 7YP
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Looking at the data in terms of the percentage of total cancers detected in the two week wait group versus the routine group, the numbers were actually better (i.e. a greater percentage of the cancers were referred as urgent) in each of 2000, 2001 and 2002 than in 1999. It is only from 2003 onwards that this measure falls below 1999 levels and continues to decline. I would be interested to know if a reason behind this trend could be identified. Competing interests: None declared |
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Gordon C Wishart, Consultant Breast & Endocrine Surgeon Cambridge Breast Unit, Box 97, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2QQ, Peter D Britton, Dawn Chapman, Carlos Caldas
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We welcome the recent article by Potter at al(1) (BMJ 2007; 0: bmj.39258.688553.55v1) regarding the impact of the two week wait for breast cancer on referral patterns, cancer diagnoses and waiting times. It confirms much anecdotal evidence to suggest that a disproportionate resource has been directed to the two week wait referrals, where only 1 in 13 patients turn out to have breast cancer, with a resulting increased waiting time for non-urgent referrals, where 1 in 19 will have breast cancer. Their conclusion that the two week wait requires urgent review has already been recognised. In April 2005 the current government made a commitment that all breast referrals would be seen within two weeks by the end of 2008. By working closely with Breakthrough Breast Cancer, who’s Left in the Dark campaign highlighted the long waiting times for non-urgent breast referrals, the Department of Health (DOH) has recently examined a number of initiatives that may help deliver this pledge. The Cambridge Breast Unit has a similar workload to the Bristol Unit with approximately 4000 new referrals and 400 cancers treated per annum. We have implemented a number of strategies to reduce waiting times for all breast referrals. In 1999 we discharged over 1200 patients with benign disease who attended for annual surveillance in order to implement the two week wait. We then developed a model to train nurse practitioners (NP)(2)in breast examination and have championed this role as a way of managing an increasing referral workload. A new advanced clinical nurse practitioner course has been established in Cambridge, with funding from the Cancer Services Collaborative & DOH, to support a national NP training programme at Masters level starting in September 2007. In addition, we have critically examined our breast cancer follow up and have now implemented a patient led follow up protocol for women at low risk of recurrence or death (defined objectively using the Nottingham Prognostic Index–NPI)(3) following breast cancer surgery. These patients undergo routine mammographic surveillance but do not have routine breast examination. This has released valuable clinical resource that can be redirected to new patient referrals and early feedback documents high patient satisfaction. By working closely with our Trust management team a capacity and demand survey supported the implementation of an additional weekly rapid diagnostic clinic and since early 2007 we have been able to see all breast referrals within two weeks. All of these strategies can be replicated in other units and with payment by results additional resources can be allocated to cope with the increased referrals and shorter waiting times. The two week wait has been divisive but it has focused our attention on patient pathways and the diagnostic journey. It is now time to implement changes that will allow us to provide this same level of service for all our patients with new breast symptoms. (1)Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007; 0: bmj.39258.688553.55v1 (2)Chapman D, Purushotham AD, Wishart GC. An audit of nurse practitioner training in breast and axillary examination. Nursing Standard 2002; 17: 33 -36. (3)Haybittle JL, Blamey RW, Elston CW, et al. A prognostic index in primary breast cancer. Br J Cancer 1982; 45: 361-6. Competing interests: None declared |
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Jeannie Erskine, Breast Cancer Patient FK21 8TY
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I particularly refer to Andrew Maville’s response whereupon his wife’s breast cancer was wrongly assessed. I, however, didn’t even manage to get into the system despite three attempts over a four year period. My GPs refused me a mammogram (my way for asking for further investigation) on the grounds that swelling, thickening and armpit lumps were nothing to worry about despite these symptoms being mentioned in all breast cancer awareness leaflets as something to look out for. I went four times (first time with Practice Nurse who said if I was concerned I should see my GP) from 2001 with symptoms, anxiety and a request for a mammogram, but the GPs said there was nothing to worry about. I did try to self-refer but this was not an option. I also tried to go privately but was told I needed a doctor’s referral. As soon as I reached 50, I referred myself for tests and within a few weeks in 2005 I was diagnosed with advanced invasive lobular breast cancer. My life fell apart. I complained to the local Health Board, the Scottish Public Services Ombudsman and the General Medical Council. Total rejection. The Scottish Public Services Ombudsman holds the power. She says the GPs were working to the Guidelines that were available at the time and cannot uphold my complaint. My GPs did not use their clinical acumen, ignored my anxiety and my request for a mammogram. All they could say was I couldn’t go for a mammogram as I was under 50 – under age for the NHS screening programme. This was more important than listening to the patient or even my symptoms. GPs are not getting it right. They need continuous compulsory training. I truly hope the system gets a shake-up. Competing interests: None declared |
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Richard D Neal, Senior Lecturer in General Practice Department of Primary Care & Public Health, North Wales Clinical School, Cardiff University, LL137YP
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Dear Editor Any system change designed to improve the diagnosis of cancer is important, and the place of the urgent referral guidance for suspected cancer is very much still open to debate; the paper by Potter and colleagues adds considerably to this in breast cancer, but raises more questions than it answers.(1) The urgent referral guidance, as it stands, creates a two-tier system whereby patients with certain symptoms and registered with certain GPs, (and perhaps patients with different health responses or personality traits) get their cancers diagnosed quicker than others. The difference that the guidance has made in terms of cancer outcomes is debatable but is at the crux of the design of the service. Data from a systematic review has demonstrated that for breast cancer, longer time to diagnosis is associated with poorer survival (although amongst other cancers, this is almost unique).(2) However, whether the reduction in time to diagnosis in patients referred urgently through the guidelines is sufficient to lead to improved survival is unclear. Survival data from Potter and colleagues will be welcome in due course. Any impact is likely to be small given the relatively short referral delay in this study (mean of about 30 days, which compares favourably to other studies); and because referral delays contribute relatively little to overall time to diagnosis.(3) It is therefore questionable how ‘disadvantaged’ non-urgent patients really are. Two other issues are unclear. First, whether one effect of the guidance is to identify as urgent those with least to gain; for lung cancer those fulfilling criteria for urgent referral are those with potentially least to gain and poorer survival.(4) Secondly, any potential psychological advantages or disadvantages of faster or slower diagnosis remain unknown. This paper is not the first, nor will or be the last to demonstrate modest compliance by GPs with the guidance.(5) There are no checks on GPs’ use of the guidance, and perhaps more poignantly, no QoF points. Cynically, it may facilitate a process enabling GPs to be able to get their own patients seen within two weeks, simply by ticking the right boxes. The lack of emphasis on implementation in primary care is in stark contrast to the investment in secondary care, which has resulted in vast resources being allocated to ensure targets are reached despite the fact that secondary care delays account for a very small proportion of total time to diagnosis.(3) In conclusion, all women need their breast cancer diagnosed quickly; and the NHS needs women diagnosed quickly, but within the context of variable symptoms, and variable responses to those symptoms. Data on outcomes are needed from different referral and diagnostic routes, and if these show that they don’t make a difference to clinical or psychological outcomes the NHS can stop worrying about the mechanism and continue to rely on primary care referral of symptomatic patients to secondary care. We also need more data on the meaning and predictive value of symptoms and clusters of symptoms, and risk factors from primary care populations; this will inform further refinement of the guidance. And, perhaps most importantly, we need women to present their breast symptoms early. In the meantime, maybe the urgent referrals guidance remains the preferred system; it has certainly focused thoughts, and systems, in both primary and secondary care, putting cancer diagnosis higher up the agenda and in the forefront of clinician's minds. Scrapping it now may take the emphasis away from early symptomatic diagnosis of cancers in primary care which would be detrimental to all. Better the devil we know? Richard D Neal.
References 1. Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Grenwood R, Sahu AK, Cawthorn SJ. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ doi:10.1136/bmj.39258.688553.55 2. Richards MA, Westcombe AM, Love SB, Littlejohn P, Ramirez AJ. Influence of delay on survival in patients with breast cancer: systematic review. Lancet 1999;353:1119-26. 3. Allgar VL, Neal RD. Delays in the diagnosis of six cancers: analysis of data from the National Survey of NHS Patients: Cancer. Br J Cancer 2005;92:1959-1970. 4. Neal RD, Allgar VL, Ali N, Leese B, Heywood PL, Proctor G, Evans J. Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes. Br J Gen Pract 2007;57:212- 19. 5. Allgar V, Neal RD, Ali N, Leese B, Heywood P, Proctor G, Evans J. Urgent general practitioner referrals for suspected lung, colorectal, prostate and ovarian cancer. Br J Gen Pract 2006;56:355-362. Competing interests: None declared |
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Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester "Saionara", 31 Regent Street, Rowhedge, Colchester. CO5 7EA
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The need for a woman with breast symptoms to have access to mammography should surely be judged as greater than that for a healthy woman? Yet they can often find it difficult to get the necessary prompt referrals. [1] [2] But the NHS Breast Screening Programme Annual Review for 2006 shows that 2,074,572 women aged 50 - 70 were invited for screening; 1,713,897 were screened (1,584,695 (74.6%) through the screening programme, 129,202 self/GP referral). 13,812 cancers (0.0081%) were detected, of which 2,872 (21%) were in situ cancers. This means that for 1,700,085 of the women who were screened, (more than 99%), no cancer or in situ cancer was detected. In consequence, 99 out of 100 women (99%) will be likely to affirm that they feel `reassured` on receiving a negative finding. Is it equitable, or right and proper, that resources should be expended on providing 1,700,085 `healthy` women with reassurance that they have no evidence of disease, when so many women with symptoms are unable to get the rapid referral, diagnosis and treatment that they need? Particularly as those `reassured` women have so little understanding of their underlying risk, or of their tiny potential for benefit? This is because they have not been given “the facts” [3] i.e. the evidence, [4] about what screening can and cannot do for them, or a balanced presentation of benefits and harms, or decision aids to help them arrive at a reasoned decision. [5] When women are told “…for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily” [3] it can cause them to stop and think. References: [1] Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, Sahu AK, Cawthorn SJ. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ published online 13 July 2007: doi:10.1136/bmj.39258.688553.55v1 Accessed 14th July 2007 [2] Jeannie Erskine. Delay of breast cancer referral. Bmj.com rapid response 20th July 2007. http://www.bmj.com/cgi/eletters?lookup=by_date&days=1#172543 accessed 20th July 2007. [3] NHS Breast Screening Programme. The Facts. http://www.cancerscreening.nhs.uk/breastscreen/publications/ia-02.html [4] Goetzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2006. Issue 4, Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub.2. [5] Barratt A, Trevena L, Davey HM, McCaffrey K. Use of deicison aids to support informed choice about screening. BMJ 2004; 329:507-510 Competing interests: None declared |
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David P Jones, General Practitioner Bangor, Gwynedd. LL57 2BQ
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The experience of Jennie Erskine should concentrate all our minds. Whether her cancer was present at the beginning or not, it has clearly left her with serious misgivings of the system and with her doctor in particular. But her comments that GP's are not getting it right and that they need compulsory training is not right either.
The two week rule is not just applied to breast disease - it is applied wherever a GP feels that a diagnosis of cancer is "likely". In areas of the country where there is NO access to exclude cancers (primary or metastatic) then GP's have to rely on clinical skills. The popular press and politicians have created an environment where the public have no confidence in their GP's clinical skills therefore "forcing" our hands to refer for further investigations. This invariably then produces the bottleneck and the statistics of low yield from the "cancer line" referral. It also does not help when the referral on the "Cancer line" is then downgraded to non urgent by the consultant, and ultimately the patient seen and cancer diagnosed. It appears to the patient that the delay has been in primary care and once again, confidence lost. This happens and has happened in our practice within the last 4 weeks. The upshot of this diatribe is that the system has to be patient centered. If a "two week" rule is written into the policy of the Trusts, then it has to be adhered to and all clinicians, GP's and secondary care doctors alike, have to treat it with respect and not interfere or abuse the system. Cynical comments about linking it to QoF likewise does little to create an atmosphere of trust. Whilst the NHS is funded the way it is there will be constraints and these have to be managed with mutual co-operation. Competing interests: None declared |
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Emma J Helm, Specialist Registrar in Radiology Bristol Royal Infirmary, Marlborough St, Bristol BS1 3NU, Edward Nash
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We read with interest the article by Potter et al highlighting the failure of the two- week wait initiative to discriminate between patients with breast cancer and those with benign disease.1 However, what is surely more important, is whether earlier diagnosis provided by a fast-track system improves patient outcome. Evidence for this is lacking. This is likely 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 2mm (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 detectable3. Therefore, the importance of whether a patient is seen by a breast specialist within 2 weeks of referral is largely down to psychosocial issues such as patient anxiety. Despite evidence that the majority of 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 they will have longer to endure the uncertainty of knowing whether they have 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. 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. doi:10.1136/bmj.39258.688553.55 2. Friberg S and Mattson S. On the growth rates of Human Malignant Tumors: Implications for medical decision making. Journal of Surgical Oncology 1997; 65: 284-297 3. Fournier D v, 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-Verlag, 1985 Competing interests: None declared |
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Rupert A Gude, Retired General Practitioner Tavistock, Devon, PL19 9EL
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The Bristol Breast Team have taken a good history, left some questions unanswered, come to the wrong diagnosis and left out the management. The problem lies in that of the 260 odd cancers referred annually 43 were in the nonurgent group in 1999 and 70 in 2005. So why were the General Practitioners not referring them as urgent? Why did Griffiths et al (1) find no difference in symptoms in those patients with breast cancer despite different routes of referral? They need to enquire if there is a fundamental lack of appropriate management by a subgroup of General Practitioners. The 2 week wait for cancer has been a fantastic innovation for the British public and the work of General Practitioners. When I was in General Practice in the 1980s and 1990s patients with an obvious breast cancer often had to wait 3, 4 or 5 weeks to be seen. Many patients were not willing to wait this long and sought a private consultation. The 2 week wait initiative - one of the major initiatives of the Labour Party in an attempt to improve the NHS - gave everyone with a suspect cancer a chance to be seen in 2 weeks. What doctor or doctors wife with a breast lump would wait more than two weeks to be seen? So why should the British public have to wait longer? There is a general tone in the article that seems to disapprove of the 2 week wait. First there is the assertion that there is "little scientific foundation". Surely I do not need "a scientific foundation" to be seen urgently if I have a 12.8% chance of having cancer or even a 7.7% chance. What is the scientific foundation for the assertion that there is a "low number of cancers detected in this group" (the 2 week wait group).Who decides the level that is acceptable? Surely not those who have instant access to professional colleagues if they or their families fall ill. Why have the effectiveness of the 2 week wait initiative been so frequently questioned? Is it related to the fact that now I can guarantee that a patient will be seen in 2 weeks that they do not need to seek a private appointment? As to the management, there is a need for all the nonurgent referrals to be looked at by a clinician for the appropriatenes of the referrals and to address not necessarily the diagnostic skills of General Practitioners but their referral behaviour. However let us praise the initiative oulined by Mr Gordon Wishart of Addenbrookes (rapid resonse). I refer to an excellent Personal View(2)by the French Orthopaedic Surgeon John Petri who had to explain to his wife what a 'liste d'attente' (waiting list) was. She was horrified.By good management and hard work he demolished his waiting list. His private practice was halved. The ultimate in Britain is to follow Mr Wisharts plan with sufficient resources so that everyone can be seen in 2 weeks. Even that is 13 days longer than patients are seen in France or other European countries. 1. Griffiths C,et al. Patients with breast cancer present with identical symptoms in the 2 week wait stream and the routine stream. Eur J Surg Oncol 2006;32:1042 2.Petri J. Liste d'attente? Pourquoi? Personal view, BMJ 2007:335.210 Competing interests: None declared |
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Christian P Subbe, Consultant Physician Wrexham Maelor Hospital
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I have to admit that I read the paper by Potter at al with great interest. I have however got concerns about some of the underlying assumptions of the study. 1. It is likely that the implementation of an algrorithm that involves a screening test will imperfect sensitivity and specificity does not alter outcomes. Should we therefore scrap the two week wait? 2. What is the hypothesis of the study: That waiting longer could be better for patients? Does the underlying philosophy of care suggest that it is perfectly acceptable to wait for an appointment if the change of prognosis brought by faster processing is statistically non-significant. This is a recurrent theme in health care discussions in many areas and an argument for rigid scheduling arrangements. Are there improved outcomes? What do we mean by this in 2007? Have patients anxieties, quality of life, time off work, reduced productivity at the work place, strain on relation ships etc been assessed? As physicians our philosophy should not be "What is lost by delaying an appointment?", but "What is gained by delaying it?". If there is no gain for the patient: see them today and let them get on with their life! Competing interests: None declared |
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David P Levy, Consultant Oncologist Weston Park Hospital, Whitham Road, Sheffield S10 2SJ
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Dear Sir The article from Potter et al (1) serves to remind us that it is difficult to accurately predict which patients may or may not have symptoms of breast cancer. The National Institue for Clinical Excellence guidance of criteria for two week wait referral (2), illustrated within the article, was drawn up after a consultation where breast surgeons could have responded. It would have been usful to know the characteristics of those patients being referred routinely, with a final diagnosis of breast cancer - did they have an unusual tumour? or did their symptoms lie outside the current guidance. Finally the solution is simply that the two week wait rule should apply to all referrals, rather than those who may have cancer. Some breast units have already achieved this and patients and their families will benefit from a more rapid diagnostic service. 1. Potter et al BMJ 2007;335:288-90 2. NICE Guidance-referral for suspected cancer. June 2005. www.nice.org.uk/CG027 Competing interests: None declared |
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Graham Kyle, Consultant Ophthalmologist University Hospital Aintree, Liverpool,L9 1AE
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The Summary Box for this article claims this study 'adds' to knowledge by showing that 'The two week rule has led to increased waiting times for routine appointments.' No 'research', other than observation of a supermarket check-out queue was required to reach this conclusion. If some customers in the queue are given preferential attention, without another check-out being opened for the purpose, then inevitably, those customers who are not cherry-picked for favourable treatment will have to wait longer. Those of us managing patients who require imaging for serious, but 'non-cancerous' conditions have been aware of this for years. Competing interests: None declared |
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Philip P SUTTON, Consultant Physician University Hospital of Hartlepool, TS24 9AH
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I wholeheartedly support the enquiry by Potter et al(1)to search for objective evidence to assess the two-week rule - after all, this is the age of Evidence Based Medicine! My experience is taken from eighteen years heading up a lung cancer service; for the first nine years my surgical referral rate was 59/1032 ie 5.7% (most will recognise this measure as a reliable surrogate measure of the efficacy of lung cancer care ).Since the introduction of the two-week rule this rate remains stubbornly around 7% - the european rate is three or four times this (2). It is true that some patients with very serious illness appreciate being dealt with swiftly (weren't they always?), but this should be set against those patients with benign disease who are filled with terror while awaiting their appointment at the 'cancer clinic'.Previously they might have been treated individually, perhaps following a conversation between GP and consultant, which seldom happens now. Meanwhile up to half of all new cases of lung cancer present as emergency admissions - a catalogue of advanced diease and missed oportunities, and their interests certainly are not being served by the two-week rule..they have been ignored! 1.Shelley Potter, Sasi Govindarajulu, Mike Shere, Fiona Braddon, Geoffrey Curran et al.Referral paterns, cancer diagnoses, and waiting times after of two week wait rule for breast cancer. BMJ 2007;335:288-90. 2. A.Imperatori,RN harrison, DN Leitch, F Rovera, P Sutton et al. Lung cancer in Teesside (UK) and Varese (Italy): a comparison of management and survival. Thorax 2006;61:232-239. Competing interests: None declared |
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Russell J Thorpe, GP. Primary Care Cancer Lead North Lancs PCT The Old Links Surgery St Annes FY8 2LY
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Sir; As a primary care cancer lead I have been involved with the introduction and monitoring of the fast track referral system since its introduction. As you can imagine the introduction of a protocol that was not evidence based and led to a significant increase in work load almost overnight was not welcomed with open arms by our colleagues in secondary care. We have now seen several papers published that decry the system however I have yet to see one that analyses whether or not those patients that were referred routinely and subsequently found to have cancer met the criteria for a fast track referral. In other words is the perceived failure of the system due to a deficiency in the fast track criteria or their implementation by primary care? The most recent paper by Shelly Potter et all BMJ 2007;335:228-90 is highly critical of the fast track referral system but yet makes no attempt to compare the patient experience before and after the introduction of the system. It makes no mention of the significant funding that came with the initiative and how it was used. At Blackpool Victoria Hospital, Breast Cancer Nurse Specialists were trained and employed to increase capacity in the breast clinic to help ensure that patients referred as non fast track were not disadvantaged compared to the situation pre fast track. I note the high number of cancers fast tracked to the Frenchay Breast Care Centre in the early years of the initiative, 84% of the cancers found as a result of a primary care referral were the result of a fast track referral with a hit rate of 12.8%. These are exceptional figures and I commend the primary care practitioners referring to the Bristol unit for their rapid uptake of the then new system. I note that the clinic used "robust diagnostic and outcome data" "to generate letters to primary care on almost 25000 referrals" It would have been helpful to see examples of the content of these letters, did they encourage the use of the referral criteria or seek to dissuade the use of a fast track referral if the individual primary care physician did not suspect the patient had a breast cancer even when their presenting clinical features matched one of the fast track referral criteria? At Blackpool Victoria Hospital our audited outcome data reveals a hit rate of around 15% with around 50% of breast cancers being identified as a result of fast track referrals. This is at odds with the assumption by the Frenchay Centre that other cancer units will not better their current figures. The most recent audit of outcome data for the whole of the Lancashire and South Cumbria Cancer Network (Oct - Dec 2006) demonstrates that for our network the present situation is 11.9% of breast fast track referrals are found to have cancer with 57% of all breast cancers being initialy fast tracked. Interestingly these figures arnt far away from those of the Frenchay Centre in 1999. Finally the discussion of their results identifies that waiting for investigation of a potentially malignant condition causes "considerable psychological impact" and this is precisely why the fast track system was introduced, along with the HMG desire to demonstrate a "genuine sense of commitment to improving cancer services in the UK" and their perceived impact on the UK cancer treatment outcomes by delayed referrals from primary care. I feel the fast tracking of patients with potential breast cancer has been of "benefit" even if not improved outcomes, other tumour sites however such as lower bowel are more tricky. Dr Russell Thorpe
Competing interests: None declared |
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Joanne Morrison, clinical lecturer and subspecialist trainee in gynaecological oncology John Radcliffe Hospital, Oxford, OX2 6HE, Ian Z. MacKenzie
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It is depressing to read the results of the study reported by Potter et al (1), assessing the impact of the two-week wait rule on the diagnosis and treatment of breast cancer. In 2003, we published our results of a similar study examining the impact of the two-week wait rule on referrals for gynaecological cancer during the first three years following the introduction of the system in 2000(2) . Our results were very similar to those reported by Potter et al (1). We observed a rapid increase in referral numbers via the two-week wait system, a reduced efficiency with consequent delay in referrals to routine gynaecological clinics, because appointment slots were commandeered for two-week wait referrals, and a disappointingly low proportion of cases of endometrial (26%), ovarian (44%) and vulvar (56%) cancers diagnosed via the two-week wait system compared with routine outpatient referrals. Referrals for suspected cervical cancer were generally directed through the colposcopy service. While it is obviously desirable to have people with suspected cancer seen quickly, the identification of high risk patients is best left to clinicians, rather than the blunt tools of government targets and criteria. In addition, the waiting time targets for diagnosis and treatment do not exercise any clinical distinction between the obviously unwell cancer patient and those with a suspicious symptom ultimately shown to have a benign condition; this can lead to conflict between clinicians, keen to treat patients requiring urgent treatment rapidly, and managers,who focus more on the overall 'breaches'. The current ‘target’ system also has a detrimental impact on those patients requiring hospital referral for presumed non-malignant conditions, and as we and the study by Potter and colleagues have shown, those patients with a malignancy referred to routine clinics (27% in their study) are having a potential for delayed diagnosis. The compromise to the care that ‘other’ patients receive is perhaps more obvious in those specialties, such as gynaecology, which encompass a broad spectrum of symptoms and non-malignant conditions. There would appear to be few reports extolling the virtues of the two -week wait system for the referral of patients with suspected cancer and it is hoped that this latest publication might prompt a re-think on this issue by health care strategists. (1)Potter S, et al. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 335:288, 2007. (2) Morrison J, Gillespie S, and MacKenzie IZ. Two week wait standards for suspected gynaecological malignancy. On target, but missing the point? Journal of the British Menopause Society December:170-172, 2003. Competing interests: None declared |
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Aidan F Magrath, F2 Countess of Chester Hospital, CH2 1UL, Alex Keenan
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Following the article by Potter et al, I would congratulate them on a thorough 6 year assessment on the two week rule. One also has to agree with them as to the change in referral patterns in the time since the two week wait. I would point out however, no comparison is made to prior to this date, and as such this is not really a fair assessment of what influence the two week rule has had. This article finds that the two week rule is failing patients, however the figures shown indicate that for the first 4 years waiting times decreased every year, with the percentage of patients with cancers diagnosed remaining similar in each of these years. Even in 2005 waiting times are overall shorter than for 1999 and 2000. Following 2002 there does seem to be a change, but this could be attributed to far more than just the two week rule. Changing disease profile, increasing public awareness and fears of disease (and therefore presentation of cases, particularly in the highly publicised vocal middle class), the General Practitioners skills, or simply a few years of abnormal referrals could all be responsible at least in part. One makes the assumption that they have the luxury of more advanced screening methods available than a GP i.e. consultant examination, mammography and biopsy if necessary. As such it would be useful to compare GPs findings on examination with those of the breast clinic, and also whether the breast clinics findings placed the patient in the same referral category as the GPs. I would also like to ask what the author deems to be a failure of the two week rule. As on average women referred as urgent are seen in less than two weeks (specific data on waiting times not offered by author), surely the two week rule is working well. Whether it is the right rule is open to debate. As mentioned previously, a proposed plan of action could have proved valuable; however, this is not needed as all women should be seen in less than two weeks by 2009. Competing interests: None declared |
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