Two week wait referral criteria – heading in the right direction?

Abstract

ObjectivesThe National Institute for Health and Care Excellence referral guidelines prompting urgent two-week referrals were updated in 2015. Additional symptoms with a lower threshold of 3 per cent positive predictive values were integrated. This study aimed to examine whether current pan-London urgent referral guidelines for suspected head and neck cancer lead to efficient and accurate referrals by assessing frequency of presenting symptoms and risk factors, and examining their correlation with positive cancer diagnoses.MethodsThe risk factors and symptoms of 984 consecutive patients (over a six-month period in 2016) were collected retrospectively from urgent referral letters to University College London Hospital for suspected head and neck cancer.ResultsOnly 37 referrals (3.76 per cent) resulted in a head and neck cancer diagnosis. Four of the 23 recommended symptoms demonstrated statistically significant results. Nine of the 23 symptoms had a positive predictive value of over 3 per cent.ConclusionThe findings indicate that the current referral guidelines are not effective at detecting patients with cancer. Detection rates have decreased from 10–15 per cent to 3.76 per cent. A review of the current head and neck cancer referral guidelines is recommended, along with further data collection for comparison.

Outcome of two-week head and neck cancer pathway for the otolaryngology department in a tertiary centre

“…A recent retrospective study conducted in London also found the highest positive predictive values for oral swelling and neck lump. The most frequent reasons for referral were persistent hoarseness, neck lump, and unexplained throat discomfort or pain; 7 these were also the most common reasons for referral in our study, but with a different order of frequency.…”

“…They also recommended a review of the referral scheme in the current guidelines. 7 Tikka and colleagues’ study from Scotland showed a similar failure of the NICE 2015 guidelines to improve the early detection rate in the UK. 8…”

“…In this study, patients were risk-stratified after their first visit; those who were neither discharged nor scheduled for biopsy were classified as medium risk. 7 Of this group, 32 per cent were diagnosed with cancer, suggesting that they should remain on the two-week-wait pathway. The classification seemed more of academic value.…”

“…11 A recent study conducted in London showed a decrease in cancer detection rate, from 10 per cent to 3.76 per cent, with implementation of the 2015 NICE update; this could point to missing cases that are later diagnosed during routine referral. 7 However, the authors did not compare cancer pick-up rate with routine referrals. They also recommended a review of the referral scheme in the current guidelines.…”

Tracking cancer occurrence in the 5 years after referral for suspected head and neck cancer

“…low proportion of all TWW referrals resulting in a diagnosis of cancer). This is particularly the case in head and neck cancer (HNC) where the positive predictive value of TWW referrals resulting in a diagnosis is lower than 4% [8]. The TWW pathway for HNC has been reported to be 'overused', leading to funding strains and issues with capacity, with consultants spending more time with those without cancer rather than patients with HNC [8], [9].…”