Suspected childhood cancer fast track: increasing referrals, diminishing returns

Delphi method to identify expert opinion to support children’s cancer referral guidelines

“…Of particular note, the original statement ‘the 2-week wait is an effective referral route for ensuring the prompt diagnosis of childhood malignancies’ was rejected outright with just 12% support. This is consistent with other reports which show it is not useful for paediatric cancer, with at most 1%–3% of referred patients ultimately being diagnosed via this route9–11 and, conversely, over 95% of children with cancer not reaching the paediatric haematology/oncology service through the 2-week wait system 12 13…”

“…The updated guidance retained the ‘2-week wait’ referral pathway, introduced in 2000. Since only 1%–3% of children referred via this route are ultimately diagnosed with malignancy,9–11 this inevitably leads to unnecessary parental anxiety for the vast majority. Conversely, more than 95% of children with cancer do not reach the oncology service through the 2-week wait system 12 13…”

The importance of “early diagnosis” to improve the prognosis in children with cancer: a prevalent concept for 50 years with little scientific support

“…In addition to the above, age can both limit and facilitate diagnosis, since very young children compared to older ones show a smaller repertoire of signs. Given this non-specificity of clinical symptomatology and its high variability, a proposed premise to suspect pediatric cancer is that any patient with one or more persistent or progressive symptoms should raise cancer suspicion; 15,20 uncertainty can translate into an erroneous opinion; even in developed countries, 52 % of pediatric patients with cancer had an incorrect initial diagnosis at first assessment. 13,21 Definition of time to diagnosis TTD has been defined as the elapsed period since cancer-associated symptoms initiation until its diagnostic confirmation, either histopathological or by other incontrovertible evidence (bone marrow cytomorphological study in children with leukemia).…”

“…19 The problem is data subtleness, which 90 % of the time are due to trivial pathology, and owing to their persistence or progression neoplasm is suspected. The United Kingdom tried a strategy known as "Two strike and go": 49 if a patient was assessed more than twice for the same reason and there was no improvement or there was worsening, authorization was given for immediate consultation at a cancer center. At 5 years of implementation of this strategy, unnecessary consultations increased and the rate of oncological diagnoses decreased, without the stages at solid tumors diagnosis being modified.…”

Towards evidence-based medicine for paediatricians

“…(There’s a similar issue with referrals with lymphadenopathy in particular for suspected lymphoma, with the ‘two week wait’ systems being shown repeatedly3–5 to have a very low positive predictive value. In this instance, the National Institute for Health and Care Excellence guideline6 states explicitly that in adults it’s working with a 2% pickup threshold and that in children it should be considerably lower.…”