Breast cancer referrals: two week wait for all patients.
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
Competing interests:
No competing interests
18 July 2007
Gordon C Wishart
Consultant Breast & Endocrine Surgeon
Peter D Britton, Dawn Chapman, Carlos Caldas
Cambridge Breast Unit, Box 97, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2QQ
Rapid Response:
Breast cancer referrals: two week wait for all patients.
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
Competing interests: No competing interests