Cancer is a progressive illness. It is a disease that can alter rapidly, a disease that is difficult to treat, a disease that most of us will become familiar and that many of us will develop. Although the United States of America declared war on cancer in 1971, it was not until relatively recently that the UK began to methodically target cancer.
The NHS Cancer Plan1 was an attempt at a radical comprehensive strategy for reducing the disease burden of cancer on the country, which at inception in 2000 were causing 120,000 deaths per year; a figure that has increased to the this day. The plan was to tackle a wide variety of issues, from awareness, to prevention, to increased palliative care funding. Among the commitments was the following:
The ultimate goal is that no one should wait longer than one month from an urgent referral for suspected cancer to the beginning of treatment except for a good clinical reason or through patient choice.
Regrettably the cancer patient’s pathway is not necessarily straight and smooth. In the process of fulfilling the commitment the pathway can be abstracted and broken into key relevant phases.
Targeting any one of these phases has the potential to hasten the end goal, early and effective treatment. In the public health domain, much has been done to inform people about early warning signs. From Breast Cancer awareness month, to Public Health England’s Be Clear on Cancer campaign, the aim of these measures is to give people the information they need to reduce the time between the symptoms presenting and raising them with their GP.
The Two Week Wait (TWW) referral system was one of the key measures implemented. It provides a way for GPs to rapidly refer patients they suspect may have cancer on to specialists. These specialist must in turn provide the necessary clinics for these patients to be seen within 2 weeks. By and large the operating standard of 93% has been achieved across Clinical Commissioning Groups.
The original plan makes no reference to the yield associated with rapid access clinics, however, a common complaint of the TWW program has been that the diagnostic yield for urgently referred patients has typically been low. A meta-analysis across cancer types found that detection rates in two week wait clinics is typically around 10%2. Further meta-analyses restricted to type have supported this figure, with 11.1% for head and neck cancers3, and 10.3% for colorectal cancers4. This figure also persists across geographical region.
In response to the reservations of the medical community towards the urgent referrals process, new criteria were released by NICE in 2005 as Referral Guidelines for Suspected Cancer5 and 2015 under the title \textitSuspected Cancer: Recognition and Referral6. These introduced strict criteria dependent on cancer type, restricting the use of urgent referrals. As well as tightening requirements, expectations were revised down to a pragmatic positive predictive value of 5%. In a pointed remark, NICE refer to their ‘more systematic method’ as one of the key differences to the Department of Health’s Cancer Plan, perhaps referring to the lack of pilot studies prior to implementation4.
One of the few exceptions to the low diagnostic rates could be in the area of lung cancer2. In this field 48.8% of urgent referrals resulted in a cancer diagnosis. The researchers point to high levels of compliance with NICE guideline criteria, and the practice of performing chest x-rays before referral, allowing for a greater certainty in the mind of the referrer. This raises the notion of making more diagnostic services available in a primary care setting, thus easing the reliance on specialists.
There is doubt cast into how well the NICE guidelines are being applied on a broader basis. Many researchers report poor compliance with criteria, although the extent is difficult to gauge, figures in the range 30-75%732 have been quoted. In support of NICE recommendations, compliance was found to be associated with a higher cancer detection rate7.
It’s important to remember that although these patients may have been incorrectly referred via the urgent cancer pathway, they have presented with symptoms, and may have potential disease. There remains a duty of care, and these patients still need to been seen.
Finally in the age of evidence-based medicine, it’s important to keep an eye on the key outcome. Does it increase patient survival or quality of life? While this is a difficult point to prove, the consensus is that the two week wait system is unlikely to improve survival432. Largely this is assigned to the fact that the time to first specialist consultation is not the longest or most limiting factor in a patient’s journey to treatment. Nevertheless, there is likely a psychological benefit from being seen for rapidly.
In conclusion, the two week wait system was hastily implemented, and the lack of proper prior investigation reduced its usefulness. The idea that it was instituted out of political motivation is also hard to put aside. More recent, systematic, and evidence-based approaches have improved matters, but more education and resources need to be available in the primary care setting and other areas for improvement need to be targeted.
Department of Health. “The NHS Cancer Plan”. In: Department of Health September (2000), pp. 1–98. url:https://www.thh.nhs.uk/documents/_departments/cancer/nhscancerplan.pdf ↩
S. J. Hanna, A. Muneer, and K. H. Khalil. “The 2-week wait for suspected cancer: Time for a rethink?” In: International Journal of Clinical Practice 59.11 (2005), pp. 1334–1339. issn: 13685031. doi: 10.1111/j.1368-5031.2005.00687.x. ↩ ↩2 ↩3 ↩4
R Kumar et al. “Efficacy of the Two-Week Wait Referral System for Head and Neck Cancer: A Systematic Review”. In: The Bulletin of the Royal College of Surgeons of England 94.3 (2012), pp. 101–105. issn: 1473-6357. doi: 10.1308/147363512X13189526439917. url: http://publishing.rcseng.ac.uk/doi/10.1308/147363512X13189526439917. ↩ ↩2 ↩3
Kymberley Thorne, Hayley A Hutchings, and Glyn Elwyn. “The effects of the Two-Week Rule on NHS colorectal cancer diagnostic services: a systematic literature review.” In: BMC health services research 6 (2006), p. 43. issn: 1472-6963. doi: 10.1186/1472-6963-6-43. url: http://www.ncbi.nlm.nih.gov/pubmed/16584544%7B%5C%%7D5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC1479333. ↩ ↩2 ↩3
National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. June 2005. 2005, pp. 1–98. isbn: 1846290538. doi: 10.1016/S0140-6736(10)61376-1. arXiv: NBK45765 ↩
National Institute for Health and Clinical Excellence. “Suspected Cancer: Recognition and Referral”. In: NICE Guideline June (2015), pp. 1–378. ↩
D Debnath, N Dielehner, and K a Gunning. “Guidelines, compliance, and effectiveness: a 12 months’ audit in an acute district general healthcare trust on the two week rule for suspected colorectal cancer.” In: Postgraduate medical journal 78.926 (2002), pp. 748–51. issn: 0032-5473. doi: 10.1136/pmj.78.926.748. ↩ ↩2