Abstract
Introduction The two-week rule (2WR) for referring suspected malignancies aims to improve access and outcomes for cancer patients. However, there has been criticism of the rule in the literature. GDPs have an important role in spotting head and neck cancer (HNC) and using the 2WR appropriately to ensure their patients get fast and effective treatment.
Aims 1) To evaluate adherence to guidelines of electronic 2WR referrals for HNC sent to Western Sussex Hospitals Trust from GDPs in Sussex; 2) to determine the detection rate of oral malignancies from these referrals; 3) to determine the success of the maxillofacial unit in seeing referred patients within two weeks.
Materials and methods Two hundred and nineteen randomised electronic 2WR referrals were analysed for adherence to the guidelines for referral of suspected oral cancer. Patient waiting times, subsequent correspondence and pathology results were analysed.
Results One hundred and thirty-five referrals (62%) were deemed to be compliant with the NICE NG12 guidelines, while 186 referred patients (85%) were seen within the two-week time frame. Six referrals (2%) resulted in a positive detection of malignancy (a lower rate compared to similar previous studies).
Discussion There are several possible reasons for the poor rate of guideline adherence from GDPs, such as pressure to refer defensively and a lack of knowledge of referral guidelines or oral pathology. This may contribute to a poor detection rate, although there may be other contributing factors.
Conclusions Thirty-eight percent of electronic 2WR referrals from GDPs were deemed inappropriate; ongoing education is required to minimise these inappropriate referrals. Patients must be made aware of the reason for their referral to promote attendance. Further studies are required to identify the reasons for such a low detection rate.
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References
Department of Health. The new NHS: modern, dependable. London: The Stationary Office, 1997. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/266003/newnhs.pdf (accessed August 2019).
Department of Health. Referral Guidelines for Suspected Cancer. London: Department of Health, 2000. Available at https://webarchive.nationalarchives.gov.uk/20100412085623/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4014421.pdf (accessed August 2019).
National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. 2015. Available at https://www.nice.org.uk/guidance/ng12 (accessed August 2019).
Marur S M, D'Souza G, Westra W H, Forastiere A A. HPV-associated head and neck cancer: a virus-related cancer epidemic. Lancet Oncol 2010; 11: 781-789.
Cancer Research UK. Head and neck cancers diagnosis and treatment statistics. Available at https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/head-and-neck-cancers/diagnosis-and-treatment#heading-One (accessed August 2019).
Parkin D M. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer 2011; 105 (Spec Iss): S2-S5.
Gandini S, Botteri E, Iodice S et al. Tobacco smoking and cancer: a meta-analysis. Int J Cancer 2008; 122: 155-164.
Mehanna H, Beech T, Nicholson T et al. Prevalence of human papillomavirus in oropharyngeal and nonoropharyngeal head and neck cancer - systematic review and meta-analysis of trends by time and region. Head Neck 2013; 35: 747-755.
Chuang S C, Jenab M, Heck J E et al. Diet and the risk of head and neck cancer: a pooled analysis in the INHANCE consortium. Cancer Causes Control 2012; 23: 69-88.
Shiels M S, Cole S R, Kirk G D, Poole C. A meta-analysis of the incidence of non-AIDS cancers in HIV-infected individuals. J Acquir Immune Defic Syndr 2009; 52: 611-622.
National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. 2005. Available at https://webarchive.nationalarchives.gov.uk/20080611175222/http://www.nice.org.uk/nicemedia/pdf/cg027niceguideline.pdf (accessed August 2019).
East S C, Stocker J L, Avery B S. Is the two-week rule of any benefit to patients with oral cancer? Br J Oral Maxillofac Surg 2005; 43: 511-512.
Shah H V, Williams R W, Irvine G H. Fast-track referrals for oral lesions: a prospective study. Br J Oral Maxillofac Surg 2006; 44: 207-208.
Singh P, Warnakulasuriya S. The two-week wait cancer initiative on oral cancer; the predictive value of urgent referrals to an oral medicine unit. Br Dent J 2006; 201: 717-720.
McKie C, Ahmad U A, Fellows S et al. The 2-week rule for suspected head and neck cancer in the United Kingdom: referral patterns, diagnostic efficacy of the guidelines and compliance. Oral Oncol 2008; 44: 851-856.
Hobson J C, Malla J V, Sinha J, Kay N J, Ramamurthy L. Outcomes for patients referred urgently with suspected head and neck cancer. J Laryngol Otol 2008; 122: 1241-1244.
Miller C C, Hierons R J. Two audits of the diagnosis of oral cancer and the two-week rule following referrals from primary care practitioners in Newcastle. Prim Dent Care 2012; 19: 63-68.
Rimmer J, Watson J, O'Flynn P, Vaz F. A head and neck 'two-week wait' clinic: cancer referrals or the worried well? Ann R Coll Surg Engl 2012; 94: 1-4.
Pracy P, Prichard L S, Whitehead I J, Moorthy R. The 2-week wait head & neck cancer referrals: is this system working? Otorhinolaryngol 2013; 6: 182-186.
Begum J, Davies M, Lawson J, Burke E. 0770: Two audits on the two-week wait head and neck suspected cancer referrals: Is the referral form being filled in correctly and is this contributing to inappropriate referrals? Int J Surg 2015; 23: S67.
Hong B, Shaikh Z, Adcock S, Aldallal S N. Two-week wait false alarms? A prospective investigation of 2WW head and neck cancer referrals. Br Dent J 2016; 220: 521-526.
Tikka T, Pracy P, Paleri V. Refining the head and neck cancer referral guidelines: a twocentre analysis of 4715 referrals. Br J Oral Maxillofac Surg 2016; 54: 141-150.
Roy S, Anjum K. The two-week wait - a qualitative analysis of suspected head and neck cancer referrals. Br Dent J 2018; 225: 159-163.
Warnakulasuriya S, Johnson N W, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med 2007; 36: 575-580.
Bagan J, Sarrion G, Jimenez Y. Oral cancer: clinical features. Oral Oncol 2010; 46: 414-417.
Brocklehurst P R, Baker S R, Speight P M. Factors which determine the referral of potentially malignant disorders by primary care dentists. J Dent 2010; 38: 569-578.
Pulleyblank A M, Silavant M, Cook T A. Failure to recognize high-risk symptoms of colorectal cancer in standard referral letters leads to a delay in initiation of treatment. Br J Surg 2003; 90 (Spec Iss): 133.
Potter S, Govindarajulu S, Shere M et al. Referral patterns, cancer diagnoses and waiting times after the introduction of the two week wait rule for breast cancer: a prospective cohort study. BMJ 2007; 335: 288.
Rai S, Kelly M J. Prioritization of colorectal referrals: a review of the 2-week wait referral system. Colorectal Dis 2007; 9: 195-202.
NHS England. Consultant-led referral to treatment waiting times. Available at https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/ (accessed August 2019).
Langton S, Siau D, Bankhead C. Two-week rule in head and neck cancer 2000-14: a systematic review. Br J Oral Maxillofac Surg 2016; 54: 120-131.
Thorne K, Hutchings H A, Elwyn G. The two-week rule for NHS gastrointestinal cancer referrals: a systematic review of effectiveness. The Open Colorectal Cancer Journal 2009; 2: 27-33.
Rodgers J, Macpherson L M, Smith G L, Crighton A J, Carton A T, Conway D I. Characteristics of patients attending rapid access clinics during the West of Scotland Cancer Awareness Programme oral cancer campaign. Br Dent J 2007; 202: 680-681.
Oral Health Foundation. Mouth Cancer Action Month. Available at https://www.dentalhealth.org/Pages/Category/mouth-cancer-action-month (accessed August 2019).
Acknowledgements
I would like to thank Stephen Walsh for his continuing support and advice during the process of this project.
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Grey, R., Walsh, S. A review of the electronic two-week rule referrals for head and neck cancer to Western Sussex Hospitals NHS Foundation Trust. Br Dent J 227, 403–409 (2019). https://doi.org/10.1038/s41415-019-0668-x
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DOI: https://doi.org/10.1038/s41415-019-0668-x
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