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. 2001 Oct 13;323(7317):864.

Two week rule for cancer referrals

Reducing waiting times from diagnosis to treatment might be more effective

Simon Thomas 1,2, Neil Burnet 1,2
PMCID: PMC1121397  PMID: 11683154

Editor—In their editorial on the two week rule for cancer referrals Jones et al discuss the fact that steps to meet the target for “urgent” referrals have led to a doubling of waiting time for “routine” cases.1 This is exactly the result we would expect from our calculations modelling waiting times with a Monte Carlo model based on Poisson fluctuations in demand.2

To sustain a waiting time below two weeks, capacity needs to exceed mean demand by approximately two patients a week for a wide range of values of mean demand. This applies to any appointment, including those for diagnostic and staging procedures, as well as for treatment. Applying this excess capacity to a subgroup of urgent referrals is inherently less efficient than applying it to reduce the waits for all patients. If a fast track for urgent referrals is created by transferring resources from routine cases, this is likely to lead to demand exceeding capacity for routine cases and hence to ever increasing waiting times.

These calculations assume that variations are due to random fluctuations in a constant demand, which is an effective model for oncology referrals.2 There is some evidence from dermatology that reductions in waiting times lead to increase in demand, negating the benefit of increased resources.3

It might also apply to referrals for suspected cancer, in which case the extra capacity required will exceed our calculations. This effect should not apply to the number of cases of diagnosed cancer, which will be limited by the incidence of the disease. This suggests that resources may be more effectively targeted at reducing the waiting times from diagnosis to treatment than on reducing the time from referral by a general practitioner to diagnosis.

References

  • 1.Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ. 2001;322:1555–1556. doi: 10.1136/bmj.322.7302.1555. . (30 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Thomas SJ, Williams MV, Burnet NG, Baker CR. How much surplus capacity is required to maintain low waiting times? Clin Oncol. 2001;13:24–28. doi: 10.1053/clon.2001.9210. [DOI] [PubMed] [Google Scholar]
  • 3.Smethurst DP, Williams HC. Are hospital waiting lists self-regulating? Nature. 2001;410:652–653. doi: 10.1038/35070647. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Oct 13;323(7317):864.

All stages of care pathway need speeding up

M D Oliver 1

Editor—I and a colleague from East Yorkshire spoke against the two week rule for cancer referrals1-1 a few years ago at the local medical committee conference. We thought that the deadline was a diversion from the important point: that what mattered in cancer care was not the delay at one point at the start of the path but total delay.

I was reminded of this recently when I saw one of my patients, who has just been diagnosed with probable colorectal cancer 15 months after a referral with rectal bleeding and iron deficiency anaemia. In this case the wait for colonoscopy dwarfed any delay in the initial appointment. All stages of the care pathway need speeding up: anything else is window dressing.

References

  • 1-1.Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ. 2001;322:1555–1556. doi: 10.1136/bmj.322.7302.1555. . (30 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Oct 13;323(7317):864.

Specialists, not GPs, may be best qualified to assess urgency

Paul Sauven 1

Editor—In their editorial on the two week rule for cancer referrals Jones et al cite evidence that the standard is only being met for colorectal cancer at the expense of routine referrals.2-1 The breast group of the British Association of Surgical Oncology undertook a prospective study last year, with participating breast units auditing all breast referrals from general practitioners over a minimum of three months. Units recorded the number of referrals, the degree of urgency stated by the referring doctor, and the number of cancers subsequently diagnosed. Referrals were also graded according to how they complied with the published guidelines for general practitioners for referral of patients with breast problems.2-2

Table.

Numbers (percentages) of breast cancers diagnosed by urgency of referral

Unit Total referrals Urgent referrals Referrals outside guidelines Total cancers diagnosed Cancers diagnosed after non-urgent referral Cancers per 100 referrals
1  115 34 (30) 24 (21) 11  3 (27) 9.6
2  428 210 (49) 64 (15) 33 2 (6) 7.7
3  445 139 (31) 71 (16) 28  3 (11) 6.3
4  455 111 (24) 36 (8) 34  5 (15) 7.5
5  341 43 (15) 55 (16) 28 15 (54) 8.2
6  958 211 (22) 62 19 (30) 6.5
7  845 566 (67) 60 15 (25) 7.1
8  321 112 (35) 119 (37) 32 10 (31) 10.0
9 1680 215 (13) 164 99 (60) 9.8
10 1310 460 (35) 126 34 (27) 9.6
11  406 260 (64) 207 (51) 19 4.7
12  253 80 (32) 36  8 (22) 14.2
13 2522 749 (30) 285 98 (34) 11.3
14 1103 208 (19) 88 34 (39) 8.0
15 1176 54 (21) 115 61 (53) 9.8
Total 12358 3452 (28) 576 (23) 1121 406 (36) 9.1
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Altogether 12 358 referrals were received by 15 breast units, of which 3452 were graded as urgent by the general practitioner. A total of 1121 cancers were diagnosed, but 406 of these were not referred urgently (table). The numbers of both urgent referrals and patients with cancer who were not referred urgently varied widely among units. In seven units that were able to assess referrals almost a quarter (576 of 2511) did not comply with the agreed national guidelines. Most breast units were not able to see all breast referrals within two weeks, and the delay in seeing the non-urgent cancers ranged from 2 to 14 weeks.

These results, and other studies, show that general practitioners may not suspect breast cancer in many cases. The diagnosis may be delayed in women referred to breast units non-urgently, particularly in those units that cannot recruit specialist staff. These problems need urgent attention. Only 1% of breast cancers are found in women under 30, and breast cancer charities have a responsibility to ensure that breast awareness is focused on an appropriate age group without causing distress to younger women.

Evidence based guidelines must be agreed with general practitioners, who need to be reassured that they are unlikely to miss breast cancers and will not face unfair criticism. Until additional resources are in place breast units should be given authority to defer urgent referrals that do not comply with agreed guidelines to enable them to expedite non-urgent referrals for women who seem to be at greater risk.

There is no evidence that a 14 day delay influences survival. All patients with suspected cancer are entitled to a minimum delay, but evidence suggests that the specialist, and not the family doctor, may be best qualified to assess the degree of urgency.2-3

Footnotes

The following surgeons at breast units participated in this study or made available data from their own audits: R M Watkins, C Teasdale, L Campbell (Derriford Hospital, Plymouth); G T Layer (St Peter's Hospital, Chertsey); N Rothnie (Southend Hospital, Southend); P Cant (Rotherham General Hospital, Rotherham); I Reid, D C Smith (Victoria Infirmary, Glasgow); M Lee (City Hospital, Birmingham); M Perry (Queen Alexandra Hospital, Portsmouth); B Isgar (New Cross Hospital, Wolverhampton); E J Duggan (Royal Victoria Infirmary, Newcastle upon Tyne); M J Higgs (Queen Elizabeth Hospital, Gateshead); T Archer, C Mortimer (Ipswich Hospital, Ipswich); P Armitstead (Kidderminster General Hospital, Kidderminster); R D Leach (Kingston Hospital, Kingston upon Thames); and T Bates (William Harvey Hospital, Ashford).

References

  • 2-1.Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ. 2001;322:1555–1556. doi: 10.1136/bmj.322.7302.1555. . (30 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Austoker J, Mansel R, Baum M, Sainsbury R, Hobbs R. Revised guidelines for referral of patients with breast problems. Sheffield: NHS Breast Screening Programme on behalf of Department of Health Advisory Committee on Breast Screening; 1999. [Google Scholar]
  • 2-3.Roshan Lall C, Leinster S, Mitchell S, Holcombe C. Current patterns of referral in breast disease. Breast. 2000;9:334–337. doi: 10.1054/brst.1999.0151. [DOI] [PubMed] [Google Scholar]

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