Urgent 2-week Referrals for CNS/Brain Tumours: a Retrospective Audit

doi:10.1053/clon.2002.0133

Clinical Oncology

Volume 15, Issue 1, February 2003, Pages 7-9

https://doi.org/10.1053/clon.2002.0133 Get rights and content

Abstract

Objective: To assess the effectiveness of the 2-week referral system for CNS/brain tumours and to contrast this with the number of patients with neurological cancers identified independently of this system.

Method: Retrospective casenote review of patients referred to emergency neurology clinics pre-implementation of the 2-week referral system. Retrospective review of GP referral letters via this system and comparison to Department of Health referral guidelines. Review of corresponding casenotes to determine the actual neurological diagnosis. Identification of patients with CNS/brain tumours diagnosed independently of this system from a local CNS cancer register.

Results: Over a 3-month period pre-implementation of the referral system, of 12 patients referred as emergencies, none had CNS/brain cancer. Forty-three patients were referred via this system over a 9-month period to neurology departments of a teaching hospital and a district general hospital. Thirty per cent of the referrals did not follow the Department of Health guidelines. Only 9% actually had CNS tumours (two astrocytomas, two cerebral metastases). The remainder were diagnosed with chronic daily headache (10), epilepsy (5), migraine (3), demyelination (2), essential tremor (2), other (17). During this period at least 69 neurological cancers were identified independently of the 2-week system.

Conclusion: These guidelines may increase diagnostic precision if adhered to rigidly. Inappropriate referrals have extended already lengthy outpatient waiting times in other specialities. We suggest early re-consideration of these guidelines and further study for earlier identification of CNS cancer. Copyright 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.

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Cited by (16)

Referrals for head and neck cancer in England and The Netherlands: an international qualitative study of the views of secondary-care surgical specialists
2019, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
In both countries participants mentioned that a large proportion of patients referred did not have cancer. A systematic review by Langton et al21 reported that 8.8% of English “two-week” rule referrals for head and neck cancer were diagnosed with cancer, and positive predictive values of this order are typical for many types of cancer referred through the English “two-week” rule system, including gastrointestinal,22 breast,23 colorectal,24 central nervous system,25 and gynaecology.26 Similarly, in The Netherlands, van Boven et al27 reported low positive predictive values for symptoms of potential cancer in patients who presented to primary care, including haemoptysis (2.7%), rectal bleeding (2.6%), and haematuria (2.2%).
One-year survival after head and neck cancer in England has been reported to be worse than that in Europe, despite five-year conditional survival being similar, which implies that patients present later in England. One country with better rates is The Netherlands. There are many possible causes, one of which may be the system of referral from primary to secondary care. We have compared the views of secondary care specialists in the two countries about their systems for referral, and identified aspects that might have an impact on outcomes. We organised semistructured qualitative interviews of surgical specialists in head and neck cancer in England and The Netherlands (n = 12 in each). The most common theme was communication between primary care and specialists. Surgeons in England identified this as the aspect most lacking under the English “two-week” rule, while Dutch specialists felt that the good communication in their system was one of its best points. Other themes included the educational needs of primary care practitioners, criticism of “tick box” referrals in England, and too many patients referred who do not have cancer. Overall, specialists in both countries identified good aspects of their respective referral systems, but those in England felt strongly that the “two-week” rule/NICE guidance system could be improved with better direct communication between primary and secondary care, which might improve the speed and quality of referrals, reduce unnecessary ones, and assist in educating primary care physicians. It is not clear whether such improvements would improve survival, but further research and piloting of such a system should be considered in England.
Two-week rule in head and neck cancer 2000-14: A systematic review
2016, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The pooled conversion rate from the fixed effect meta-analysis was 10.6% (95% CI 9.4% to 11.8%) in the early group, and 6.6% (95% CI 4.2% to 9.6%) in the late group, and the difference is significant (p<0.0001) (Figs. 6-9). In this systematic review we found a pooled two-week referral conversion rate for head and neck cancer of 8.8% (95% CI 7.0% to 10.7%), which is similar to that reported in several other specialties including gastrointestinal,9,45,46 breast,8 colorectal,10 central nervous system,47 and gynaecology.48 The pooled detection rate of 40.8% (95% CI 26.7% to 55.8%) suggests that, for the studies included, roughly two-thirds of head and neck cancers in the UK were diagnosed after referral routes other than the two-week system, and rates of this order are often described as poor.5,6,11
The fast-track system in the UK for patients with suspected cancer – the two-week rule - states that if cancer is suspected there should be a maximum of 14 days between referral from primary care and consultation with a specialist. This approach is valued by patients, ensures a universal standard of diagnosis, and speeds up the overall management of cancer. However, some say that the rule has had little or no effect on survival, results in a diagnosis of cancer in only a small proportion of patients referred, and is expensive. We have made a systematic review of the effectiveness of the two-week rule in patients with head and neck cancer with the aid of electronic searches of databases. including MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews CINAHL, and CANCERLIT up to the end of 2014. This was supplemented by searching conference proceedings and contacting experts. Retrospective and prospective studies that included either conversion rate (proportion of two-week referrals who were diagnosed with cancer – positive predictive value), or detection rate (proportion of diagnosed cancers referred under the two-week rule - sensitivity), or both, were included. Two reviewers assessed studies for inclusion, and extracted data independently. Heterogeneity was assessed by inspection of the overlap of 95% CI in the forest plot and calculation of I². We made a random-effects meta-analysis of 17 studies. All reported the conversion rate, and 10 also reported the detection rate. Meta-analysis indicated an overall pooled conversion rate of 8.8% (95% CI 7.0% to 10.7%) and a pooled detection rate of 40.8% (95% CI 25.7% to 55.8%) Subgroups in which maxillofacial (OFMS) and otolaryngology (ENT) were assessed showed no significant difference in conversion rate (8.3% and 8.8%; p = 0.73). Subgroup analyses of early studies (before the end of 2008) and later studies (2009–14), showed a significant reduction in conversion rates from 10.6% to 6.6%, p = < 0.0001. These early and late subgroups showed a significant increase in detection rate (35.0% to 49.7%, p = 0.0008). The conversion and detection rates were similar to those for a number of other cancer sites that relied on a list of signs and symptoms for referral and were similar in both ENT and OMFS units. There is evidence that two-week referral conversion rates are falling, while detection rates are rising because of an increased number of referrals. The influence of the two-week referrral on outcomes, particularly survival, is not well known.
Determinants of clinical effectiveness and significant neurological diagnoses in an urgent brain cancer referral pathway in the United Kingdom
2015, Clinical Neurology and Neurosurgery
Citation Excerpt :
Such referrals are appropriate in patients in whom the symptoms could potentially be secondary to an underlying malignancy but there were also a high number of inappropriate referrals to the clinic which did not fulfil the referral criteria and did not result in diagnosis of cerebral tumours. This is consistent with limited previous studies of the 2-week wait brain cancer pathway [6], demonstrating a similar incidence of inappropriate referrals (29%) with a low rate of diagnosis of cerebral malignancy (9%), although this study only looked at 43 referrals. A more recent retrospective audit of 72 referrals at a tertiary referral centre [7] found a similar incidence of tumours (11%, 7% malignant), although 5 out of 8 of these patients already had a diagnosis, but there was an even higher incidence of inappropriate referrals (82%).
Cerebral tumours can rapidly progress to life-threatening complications yet referral pathways often result in non-significant diagnoses. We aimed to identify the determinants of referrals resulting in significant neurological diagnoses after specialist review.
We reviewed all urgent brain cancer referrals to the neurology service at a British district general hospital between January 2009 and September 2013. Time to appointment, frequency of significant neurological diagnoses, appropriateness of referrals and referral heterogeneity across GP practices were measured as determinants of non-significant diagnoses.
31/105 patients received significant neurological diagnoses (29.5%), including ten (9.5%) tumours (7 malignant), although 2 patients were admitted prior to clinic. There was significant heterogeneity between primary care physicians in referral frequency (p = 0.008) and significant diagnoses (p = 0.005). Non-significant diagnoses were more common in inappropriate referrals and if patients were unaware of the potential diagnosis. Seizures or subacute focal symptoms were more likely to result in a significant neurological diagnosis than isolated headache syndromes (odds ratio 3.45, 1.34–18.4, p = 0.008).
Despite a significant number of important neurological diagnoses and tumours, there were frequent inappropriate or low-risk referrals resulting in non-significant diagnoses, particularly if a headache syndrome was the sole reason for referral.
Central Nervous System/Brain Tumour 2-week Referral Guidelines: Prospective 3-year Audit
2008, Clinical Oncology
Referral guidelines for suspected cancer of the head and neck
2006, Auris Nasus Larynx
To identify the impact of referral guidelines for head and neck cancer on the economics and effectiveness of the delivery of care.
A retrospective review of the literature was performed to examine the current referral guidelines and referral models that have impacted the delivery of care.
Advances in technology and changes in the diagnostic work up of head and neck cancer require that common symptoms and presentations of head and neck cancer are made available to primary care physicians to improve the expeditious referral of head and neck cancer patients.
Physician awareness and symptom guidelines may prove effective in expediting the care of patients with head and neck cancer.
Impact of the updated NICE referral pathway for patients with suspected brain cancer on a neuroscience service
2022, British Journal of Neurosurgery

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^f1: correspondence: Dr AJ Wills, Consultant Neurologist, Department of Neurology, University Hospital, Queen's Medical Centre, Nottingham, NG7 2 UH, U.K. Tel: 0115-9709141; Fax: 0115-9709493; E-mail: [email protected]

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Original ArticlesUrgent 2-week Referrals for CNS/Brain Tumours: a Retrospective Audit

Abstract

Eur J Surg Oncol

Original Articles
Urgent 2-week Referrals for CNS/Brain Tumours: a Retrospective Audit