Are upper gastrointestinal cancer two week referrals an appropriate use of National Health Service resources?
The UK Department of Health NHS Cancer Plan set out targets to improve clinical care of patients with cancer in response to poor UK survival rates compared with other developed European countries.1 One focus was the ‘two week rule’ (TWR) system for patients with suspected cancer. Primary care physicians who suspect a patient of having cancer are encouraged to refer the patient using a standardised proforma (specific to each speciality) with an obligation for the hospital to see the patient within two weeks. This TWR puts enormous pressure on trusts to accommodate these patients, and hospital managers will take extraordinary steps to meet this target. However there is a paucity of data on outcomes for upper gastrointestinal cancer referrals using the TWR.
We undertook a review of the final diagnosis of patients referred to Barnet Hospital, a district general hospital serving a population of 250,000, using the upper gastrointestinal (GI) North London Cancer Network (NLCN) two week proforma. All upper GI NLCN referral forms received at our institution from April 2006 to October 2007 were analysed for age, sex, presenting symptoms, final diagnosis and treatment. In total 345 referrals were received with complete outcome data available in 91.6% cases (n=316; female = 55.7%; mean age = 66.9 years). Forty three cancers were diagnosed, of which 36 (11.4%) were upper GI cancers. The types of cancer were oesophageal (n=14), pancreatic (n=13), gastric (n=8) and cholangiocarcinoma (n=1). The major presenting symptoms were: oesophageal cancer - dysphagia (85%), weight loss (50%) or both (43%); pancreatic cancer - weight loss (61.5%), abdominal pain (38.5%) or obstructive jaundice (38.5%); gastric cancer - weight loss (75%). However only 1.9% of patients had curative treatment (n=6), the remainder receiving palliation with stents, radiotherapy or supportive care.
Patients with suspected upper GI cancer are fast tracked into out patient clinics or endoscopy in an attempt to improve the quality of care and mortality rates in the UK. It is often difficult for GPs to differentiate those patients who could harbour a serious illness from the majority who are likely to have benign disease. Only one in 10 referrals using a proforma with stringent guidelines actually proved to be an upper GI cancer. This detection rate is similar to lower GI cancer yields in the literature.2 Furthermore, curative surgery was only possible in less than 2% of all referrals. Given the pressures on specialty managers and clinicians to accommodate TWR, we would suggest that this represents a poor use of limited resources and cannot be considered a success story for the upper GI cancer referral guidelines.
Footnotes
Letters not directly related to articles published in Clinical Medicine and presenting unpublished original data should be submitted for publication in this section. Clinical and scientific letters should not exceed 500 words and may include one table and up to five references.
- © 2011 Royal College of Physicians
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