Following the 1999 implementation of the “two week wait” initiative for Breast Cancer, concerns have been expressed on the number of breast cancers which came through the routine referral route as some studies have suggested that almost a third of cancers in a referral population have not come through the rapid referral service.
Aims.
The aims of the audit were to analyse the performance of fast-track two week wait system for breast cancer in Birmingham NHS Foundation Trust, measure the compliance to the guidelines and evaluate the effectiveness of urgent referrals (cancer detection rates).
Methods.
All patients who were referred to the Birmingham Heartlands and Solihull fast-track breast clinics were included. The data were collected from November 1999 to February 2005. The data collected in this audit included mode of referral (routine versus fast-track) and appropriateness of the referral (adherence to the referral criteria). These data were retrospectively analysed and cross-referenced with the cancer data base to obtain the subsequent diagnosis (cancer versus non-cancer).
Audit data were examined on waiting times, the number of urgent and routine referrals, the use of referral criteria and outcome of patients referred from primary care (number of cancers subsequently diagnosed) in urgent and non-urgent stream.
Results.
A total of 14,303 patients were seen over a 5-year period. Out of these, 46.7% (n = 6678) of the referrals originated from urgent fast-track and the remainder 53.3% (n = 7625) came via routine referrals. 100% of urgent referrals were seen by a specialist within two weeks. A total of 1193 breast cancers were detected during this period with 1095 (91.8% of the total) from fast-track clinics and 98 (8.2% of the total) from routine referrals. As a proportion of the total number of cases seen via each mode of referral, 16.4% of the patients seen in the fast-track clinic were detected with breast cancer compared to only 1.3% from routine referrals.
The appropriateness data of urgent referral were available on 3178 patients with 2280 (71.7%) meeting the referral criteria. Further analysis showed that 14.4% of the appropriate referrals were cancers compared to only 0.55% of the inappropriate referrals.
The results show that 8.2% of the cancers were not referred through the fast-track system. Of the total cancers detected via routine referrals, 5% fit criteria for urgent 2-week wait referral. So, in effect, they should have been fast-track patients if the referring GP had stuck rigidly to the referral criteria. The accuracy of GP referrals was shown to be improving with time (69.9% in 2003, 71.1% in 2004 and 72.1% in 2005) and thus was only a reflection of learning curve problems.
Conclusion.
This audit of two week wait for breast cancer showed that Birmingham breast clinics complied with the national guidelines and all women referred urgently by their GPs with suspected breast cancer saw a specialist within a fortnight. The cancer detection rate among two week wait referrals was high and the percentage of breast cancers diagnosed outside the 2-week referral route was not significant. The audit provides evidence that urgent two week referrals are efficient in identifying patients with breast cancer.
Reference: Singhal R., Marudanayagam R., Balasubramaniam B., Paterson I. (2008). Managing the 2-week wait for breast patients Ann R Coll Surg Engl 90(1): 69-71.