GP two-week cancer referrals need 'root and branch' overhaul, say hospital doctors

The two-week wait cancer pathway is overwhelming hospitals with inappropriate referrals and delaying access to vital treatments, say surgeons who have called for an overhaul of the process.

Referral: hospital experts want overhaul of two-week cancer pathway
Referral: hospital experts want overhaul of two-week cancer pathway

Around one in 15 (6.6%) fast-track GP referrals placed through the two-week wait pathway for head and neck cancer come back positive, research published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) suggests.

The results have sparked calls from hospital doctors for a ‘root and branch examination’ of fast-track GP cancer referral targets and schemes. The British Association of Oral and Maxillofacial Surgery said large numbers of patients were being inappropriately referred through the NICE two-week wait pathway, overwhelming diagnostic services and delaying access to vital treatment for patients who actually have cancer.

But a senior London GP said the specialists' criticism of referrals was 'unhelpful', pointing out that patients present in primary care with a wide range of symptoms and it was unavoidable that many sent for tests would get the all-clear.

The findings come as separate research from Cancer Research UK showed a 12% rise in numbers of patients being diagnosed with cancer over the past two decades.

Two-week cancer referral

The two-week pathway debate follows NICE advice that lowered the threshold for GP referral to diagnostic tests last June, which recommended GPs refer patients with a 3% chance of having cancer, compared to 5% previously.

But these changes to the urgent suspected cancer (USC) pathway ‘do not work’, BJOMS editor Mr David Mitchell said.

Mr Mitchell, a facial surgeon, said: ‘I am surprised that the DH accepts a mere 3% rate of cancer detection using the USC pathway, despite the extra pressure this is putting on an already fractured health service. This is non-evidence based politics, not evidence based medicine.’

Researchers said the current criteria were not discerning enough, and they should be refined significantly to improve diagnostic efficacy. Cancer detection via the two-week wait pathway is low, they found, and criteria could be tightened without excluding high-risk symptoms.

GPs workload

But Londonwide LMCs medical director Dr Tony Grewal told GPonline: 'The problem is – and every GP has to do this – is balancing risk and need along with the other pressures that we’re under. No matter how good the system is, there will be people going through unnecessarily frightened and come out the other side clear. Because of the intense variation in individuals and presentations, people will get missed. The question is, where do you put that level of acceptable or unacceptable risk?'

Professor Mark Baker, clinical practice director at NICE, said: ‘The best way to successfully treat cancer is to make an early diagnosis, and this is what clinicians – including those specialising in oral cancers – have been keen to see reflected in NICE guidelines.

‘The sooner the disease is identified, the more likely treatment is to be effective. Earlier diagnoses have the potential to save thousands of lives each year.

‘NICE is committed to keeping guidelines current. When we develop guidelines we take into account all the evidence available at the time and then we regularly undertake surveillance reviews to ensure they are up to date in terms of changes to clinical practice, as well as new evidence that may impact on the recommendations, and a decision will be made as to whether any recommendations need updating. We welcome any new research that will help further develop our guidance.’

More than 352,000 people in the UK are diagnosed with cancer each year, according to Cancer Research UK figures. The rate of diagnosis has risen 12% over the past two decades, the charity's latest research says - from 540 per 100,000 people in 1993-1995 to 603 per 100,000 in 2011-2013.

Men are disproportionately affected, with 0.68% compared to 0.55% of women diagnosed each year.

But, despite this added pressure on NHS services, cancer death rates have fallen almost 10% in the last decade alone.

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