Intended for healthcare professionals


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

BMJ 2007; 335 doi: (Published 09 August 2007) Cite this as: BMJ 2007;335:288
  1. Shelley Potter, clinical fellow1,
  2. Sasi Govindarajulu, staff grade breast surgeon1,
  3. Mike Shere, associate specialist breast physician1,
  4. Fiona Braddon, clinical information systems manager2,
  5. Geoffrey Curran, cancer analyst3,
  6. Rosemary Greenwood, medical statistician4,
  7. Ajay K Sahu, consultant surgeon1,
  8. Simon J Cawthorn, consultant surgeon1
  1. 1Breast Care Centre, Frenchay Hospital, Bristol BS16 1JE
  2. 2Administration Building, Frenchay Hospital
  3. 3Southmead Hospital, Bristol
  4. 4Research and Development Unit, United Bristol Healthcare Trust, Bristol
  1. Correspondence to: S J Cawthorn Simon.Cawthorn{at}
  • Accepted 14 June 2007


Objective To investigate the long term impact of the two week wait rule for breast cancer on referral patterns, cancer diagnoses, and waiting times.

Design Prospective cohort study.

Setting A specialist breast clinic in a teaching hospital in Bristol.

Participants All patients referred to breast clinic from primary care between 1999 and 2005.

Main outcome measures Number, route, and outcome of referrals from primary care and waiting times for urgent and routine appointments.

Results The annual number of referrals increased by 9% over the seven years from 3499 in 1999 to 3821 in 2005. Routine referrals decreased by 24% (from 1748 to 1331), but two week wait referrals increased by 42% (from 1751 to 2490) during this time. The percentage of patients diagnosed with cancer in the two week wait group decreased from 12.8% (224/1751) in 1999 to 7.7% (191/2490) in 2005 (P<0.001), while the number of cancers detected in the “routine” group increased from 2.5% (43/1748) to 5.3% (70/1331) (P<0.001) over the same period. About 27% (70/261) of people with cancer are currently referred in the non-urgent group. Waiting times for routine referrals have increased with time.

Conclusion The two week wait rule for breast cancer is failing patients. The number of cancers detected in the two week wait population is decreasing, and an unacceptable proportion is now being referred via the routine route. If breast cancer services are to be improved, the two week wait rule should be reviewed urgently.


  • Contributors: SP performed the literature search, collected and analysed the data, and wrote the paper. SG, MS, and AKS were involved in data collection and writing. FB and GC were involved in data collation and analysis. Helen Cooke analysed the demographics of the hospital catchment area to ensure this has remained stable. RG performed the statistical analysis. SJC was responsible for the design and conception of the study, assisted in writing, and is guarantor.

  • Funding: None.

  • Competing interests: None declared.

  • Ethical approval: Not required.

  • Accepted 14 June 2007
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