Editor—We were surprised at the amount of media interest in the data given by Thrush et al in their letter on grading referrals to a specialist breast unit.1 We have two main concerns. Firstly, the data presented do not support their conclusions. Secondly, the issue is not simply about the inappropriateness of general practitioners to determine urgency, but more about the development of evidence based guidance and general practitioners' adherence to this guidance.
The authors say that the two week wait initiative is not ensuring that most patients with symptomatic cancer are seen within two weeks of referral. This is not supported by the data presented in that over half of patients (56%) found to have breast cancer were in fact referred as urgent cases. No data are presented concerning delays experienced by the non-urgent group. Their data show that 9.3% of urgent referrals were diagnosed with cancer compared with 1.7% of non-urgent referrals. This equates to a diagnosis of cancer being six times more likely in urgent compared with non-urgent referrals. Hence it may be valid to conclude that general practitioners' use of the guidance is working to some extent.
Thrush et al do not differentiate according to whether patients fulfilled the urgent referral criteria; this makes it impossible to distinguish between the effectiveness of the guidance and the adherence of general practitioners to the guidance. It is well established that the two week referral guidance overall lacks an evidence base, especially as there is a lack of good quality data on the predictive value of symptoms.2
Longer delays for breast cancer patients have been found to be associated with worse survival rates.3 However, the delay between referral by the general practitioner and first appointment in secondary care is only one component of the total diagnostic delay. Evidence is lacking on the association of individual components of delay (patient delay, primary care delay, and secondary care delays) with stage at diagnosis and survival.
High quality research is clearly needed to investigate diagnostic delay and clinical outcome to produce evidence based referral guidance and develop effective strategies to ensure that such guidance is adhered to.
References
- 1.Thrush S, Sayer G, Scott-Coombes D, Roberts JV. Grading referrals to specialist breast unit may be ineffective. BMJ. 2002;324:1279. doi: 10.1136/bmj.324.7348.1279/a. . (25 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
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