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

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.

Senior Lecturer in General Practice, North Wales Clinical School, Cardiff
University. nealrd@cf.ac.uk

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