Referral Letters

Whether the paper by Webb and Khanna with its confusing numbers and contradictions contributes to an evaluation of the rapid referral scheme for suspected cancer is doubtful.

When a two-week referral proforma is used, there is an obligation on the part of the hospital clinician to at least see the patient within two weeks of the receipt of the referral. There is no need, as implied in the paper, to mark such a referral as urgent. Likewise, it is superfluous to indicate urgency in a referral letter that suggests that a patient has malignant melanoma!

Of the 204 referrals received, 56 patients were discharged, leaving 148 patients, but we are told of only 133 patients who were recommended to have surgery. No mention is made of the four patients out of ten in the benign group. Further along, there are 69 patients where the GP thought the lesion was benign and 123 patients where the GP considered malignancy, making a total of 192.

However, of the 69 patients with a presenting diagnosis of a benign condition, surgery was performed in 43 (62%) with histology showing malignant/premalignant lesions in 5 (7%).

Of 123 patients that the GP thought had malignancy, surgery was planned in 80 (65%). Histology showed malignant/premalignant lesions in 33 (41%). Therefore, there is also 93% accuracy by the GP in the diagnosis of non-malignant conditions.

Additionally, there has not been a significant increase in workload from 1999 to 2003. The two-week rule has not always affected routine waiting times, which in some instances have improved.¹

That a GP needs to use the referral proforma appropriately is important. It is unfortunate that this paper contains confusing information while seeking to imply that there is abuse by GPs of the referral system. Primary care personnel, like those in secondary care, are under increasing pressure to investigate/refer patients partly fuelled by public concern about cancer and from the risk of litigation. Coupled with this is the considerable uncertainty with which primary care physicians have to work.

Referral guidelines are there to identify the majority of patients with cancer. There will always be patients who fall outside guidelines but who are a source of concern in primary care and who, nevertheless, need to be seen urgently. It is this group in whom it is vital to mark the referral letter as ‘urgent’ or even to speak to the relevant consultant prior to dispatch of the letter. It is imperative that hospital personnel look at work patterns and lobby for increase in resources while supporting a reasonable and safe shift from secondary to primary care. Patient education should remain an integral part of any scheme to improve the care of patients with cancer.²