Waiting lists are putting patients' lives in jeopardy

EDITOR—Spurgeon et al's findings on waiting times in England for patients with cancer are worrying to say the least.1 Nevertheless, the authors understate the problem because they take no account of delays before referrals by general practitioners.

In my experience the main cause of delay in patients with cancer receiving the treatment they need is delay in obtaining the necessary investigations, even when they are marked “urgent.” For example, in my area, suspected cases of bowel cancer take about four months to investigate—a four week wait for a sigmoidoscopy and a 12 week wait for an “urgent” barium enema. If patients need a colonoscopy the wait is longer still. By contrast, once these cases are diagnosed, they are usually seen by general surgeons within two weeks and wait no more than another two weeks for surgery.

More worrying still are patients with cancer who present with apparently benign symptoms and physical signs and who have to wait many months because they go on the non-urgent waiting list for investigation. I can recall one patient who clinically seemed to have gall stones but who eventually proved to have a primary hepatoma, and another patient who had persistent heartburn while taking low dose aspirin who had carcinoma of the stomach.

The mere fact that a clinician requests an investigation usually implies a degree of diagnostic uncertainty. Therefore, it follows that it is unsafe to put patients on waiting lists for investigations until a definitive diagnosis has been made.

It is high time that our profession impressed on government that waiting lists for investigations are putting patients' lives in jeopardy. We should be aiming to abolish waiting lists for all investigations. I can think of no better way of spending the £2bn of extra funding that the government has promised the NHS.

Applying conclusions from a selected sample is dangerous

EDITOR—The government has acknowledged that cancer care in Britain needs substantial improvement. It has focused on removing delays in access to cancer specialists and says this will improve outcomes. Spurgeon et al's study reports on data collected from 98% of NHS trusts in England.1 Yet the total number of patients detailed is less than half the number expected to present with cancer in a single month. Furthermore, the data indicate that the incidence of breast cancer is twice that of lung cancer. We are concerned that this is a selected sample and that applying any conclusions widely is dangerous.

Spurgeon et al show, but do not comment on, the far more important delay in the time to first definitive treatment. Solving this will require a far more radical overhaul of the cancer patient's journey through investigation and treatment. Substantial resources are clearly needed to bring our cancer services up to the standards of our European neighbours. We hope that the national cancer director puts appropriate emphasis on treating patients—knowing you have cancer will not cure you.

Meeting the two week target for breast cancer

EDITOR—Spurgeon et al's paper mentions the government's initiative to speed the time from referral to first appointment.1 The initiative has been the subject of much criticism and debate. The reasons for setting these targets may be ultimately to affect mortality by early treatment. On our unit, however, we have maintained this practice for nearly three years. We have managed to see not only suspected cancers but also all new patients within two weeks of referral. More than 2000 new patients were seen in the past year.

My reasons for giving early appointments are mainly patient driven. General practitioners, under pressure from the patient, may prefer to refer rather than risk a missed diagnosis. Patients with symptoms are anxious and fear that they have cancer until reassured by a specialist. It is unreasonable to keep patients waiting 13 weeks before they are told that they have benign breast disease.

Our cancer unit is in a district general hospital but is situated in a designated area with mammography, scanning facilities, consulting rooms, a counselling room, a minor procedure room, and an appliance room all housed together to help patients. This is how I envisage all breast units will be in the future. To meet our objective we relied on innovation and on improving communication with general practitioners and patients. Liberal use of standard forms, patient history questionnaires that are filled in by patients themselves before arriving in clinic, a one stop diagnostic service, patient information leaflets on every conceivable breast condition, and same day communication to the GP has helped us achieve our unit targets.

We have achieved these results in a singlehanded surgical practice with a skeleton staff. Meticulous planning, hard work, and commitment by staff have made this possible without any help from the government or the trust. We have addressed the issue of quality using patient and GP surveys that assess satisfaction with the service. Patients and GPs both have a high degree of satisfaction.

Women need to be educated about the risks of breast cancer

EDITOR—The introduction of the two week rule for the referral of patients with a possible diagnosis of cancer, introduced for breast cancer in April 1999, has had a considerable impact on clinics dealing with patients with symptoms. 1 2 The pick up rate of breast cancer in a clinic for patients with symptoms varies with the symptoms the patient is experiencing and the age of the patient. Overall it is well documented at 10%. When pain is the only symptom there is a 2% rate of cancer.

We applaud the fact that information and health education have improved patients' awareness of the disease, but women grossly overestimate the risk of developing breast cancer.3 This anxiety is real and is something that the primary care doctor finds hard to deal with. In many cases it is impossible to exclude breast cancer on the basis of a simple clinical episode in the general practitioner's surgery.

We have audited the impact of the two week rule on the referral pattern to our breast clinic for patients with symptoms over the six months May to October 1999. The overall pick up rate for cancer has averaged 8% over the six months (table).

Of the 231 requests made by general practitioners for an urgent appointment, only 15 carried the specific annotation “two week rule must apply,” which is supposed to give the primary care doctor rapid access to the hospital for patients with cancer. Of these 15 requests, only six patients actually had cancer. Substantially more referrals are made requesting urgent attention because of the patient's anxiety (table). In our clinic, consultants regrade the referral letters on receipt using the British Association of Surgical Oncologists guidelines. Substantially more cancers are diagnosed in the “urgent” and “soon” groups using these guidelines than using the two week rule. In the small percentage of breast cancers that pose a difficult diagnostic problem, referral under the two week rule does not speed up the diagnosis.

We would strongly advise appropriate health education for the public about the risk of breast cancer and education on the use of recommended British Association of Surgical Oncologists guidelines for doctors making referrals. Requests for urgent appointments on the basis of anxiety alone usurps finite resources, taking valuable quality time from patients with cancer.