Managing the 2-Week Wait for Breast Patients

Abstract

Ann R Coll Surg Engl 2008; 90: 69-71 69The 2-week wait for breast cancer was introduced by the UK Government on 1 April 1999. 1 This initiative was recognised in the NHS Cancer Plan and further targets were subsequently incorporated. 2Ever since the inception of 2-week wait, numerous studies have been conducted looking at various aspects of this service. [3][4][5][6][7][8][9][10][11][12][13][14] Published data suggest that the 2-week wait system and triple assessment at one fast-track clinic visit is an out-dated method of identifying disease in a referral population. These studies report up to 32% of the breast cancer coming from routine referrals. 11It has been concluded, therefore, that all patients should be seen within 2 weeks by 2008. 15 Patients and MethodsThe Birmingham Heartlands and Solihull fast-track clinics were set up in 1999 with a prospective audit system. The data collected in this audit included mode of referral ( i.e. routine versus fast-track) and adherence to the referral criteria (appropriateness). These data were retrospectively analysed and cross-referenced with the cancer data base to obtain the final diagnosis ( i.e. cancer versus non-cancer).Referral criteria for the fast-track breast clinics are available to general practitioners (GPs) referring breast patients to our hospital. The appropriateness of the referral was adjudged by the examining clinician in view of the referral criteria.Data were collected from November 1999 to February 2005. Statistical analysis was performed using the chisquared test and significance accepted if P < 0.05. ResultsA total of 14,303 patients were seen over this period. Out of these, 46.7% ( n = 6678) of the referrals originated from fasttrack and the remainder 53.3% ( n = 7625) came via routine referrals.The median age for referrals was 48 years and 40 years for fast-track and routine referrals, respectively. Published data suggest that the 2-week wait system and triple assessment at one fast-track clinic visit is an out-dated method of capturing disease from a referral population. These studies report up to 32% of breast cancer coming from routine referrals. It has been recommended, therefore, that all breast referrals should be seen within 2 weeks. The sheer volume of referrals are likely to prevent this target being achieved. The aim of this study was to analyse the performance of our fast-track system. BREAST CANCER Ann R Coll Surg Engl

Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study

“…Our study registered data which were significantly higher in terms of GP referral (around 60%) and cancer detection rates (around 30%), and similar in terms of adherence to referral guidelines. In breast cancer, the 5-year study (period 1999–2005) conducted by Singhal et al (2008) covered 6678 patients, 46.7% of the total seen in the period. The cancer detection rate was 16.4%, and guideline adherence was 71.9%.…”

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“…[7][8][9][10][11] However, for common tumours, the incidence within primary care is reasonably high so there is an a priori reason to assume that urgent referrals will result in a diagnosis of malignancy in a significant proportion of cases. Table 2 Summary of referred and observed criteria…”

“…Similar strategies have been adopted in other malignancies, and recent published reviews of workload changes and outcome data relating to the 2-week wait criteria of these cancers have shown a wide range of diagnostic efficiency. In breast cancer, approximately 10-20% of these urgent referrals are shown to have malignancy, [7][8][9] with a similar rate of 10% for colorectal cancer. 10,11 Some authors have indicated a decrease in 'standard' referrals since the introduction of the system, with a commensurate rise in urgent referrals, which has necessitated a shift in practice towards making more clinical appointments available for suspected cancer referrals at the expense of routine work.…”

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“…The diagnostic yield of malignancy has also varied widely from 9.4% to 16.4% for bowel and breast cancer, respectively, [2, 3]. One study looking into urological malignancies [4] found that 11 out of 35 patients (31.4%) referred with a high PSA had prostate cancer, but most cases were beyond cure.…”

“…There has been considerable controversy about the benefits of two-week wait clinics with some claiming that they will not improve the diagnosis of patients with malignancy and others that they will delay diagnosis and management of other nonmalignant conditions. The diagnostic yield of malignancy has also varied widely from 9.4% to 16.4% for bowel and breast cancer, respectively, [ 2 , 3 ]. One study looking into urological malignancies [ 4 ] found that 11 out of 35 patients (31.4%) referred with a high PSA had prostate cancer, but most cases were beyond cure.…”