J R Soc Med 2003;96:398-399
doi:10.1258/jrsm.96.8.398
© 2003 Royal Society of Medicine
How will the two-weeks-wait rule affect delays in management of urological cancers?
K R Subramonian FRCS
S Puranik MBBS
G R Mufti MCh FRCS
Department of Urology, Medway Maritime Hospital, Windmill Road,
Gillingham ME7 5NY, UK
Correspondence to: Mr G R Mufti E-mail:
gr.mufti-urology{at}medway.nhs.uk
 |
SUMMARY
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The UK National Health Service has now specified a maximum interval
of two
weeks between general practitioner (GP) referral and
specialist assessment for
patients with suspected cancer. We
examined progress through the cancer
pathway in 160 patients
with potentially curable cancers of the prostate,
bladder, kidney
and testis before implementation of this rule. Median
intervals
with interquartile ranges were quantified from the first GP
consultation
to hospital referral, then to the first hospital consultation,
confirmation
of diagnosis and definitive surgery.
34% of patients were seen at the hospital within two weeks of referral. The
overall median interval from GP consultation to radical surgery was 137 days,
the longest being for prostate cancer (median 244). For prostate, bladder and
renal cancers the principal element of delay was from the time of diagnosis to
surgery (76, 73 and 26 days respectively).
These results indicate that, under the two-weeks-wait rule, 2 out of every
3 patients achieve earlier initial assessment. However, the overall delay will
not be substantially reduced without concomitant increases in diagnostic
facilities, theatre time and human resources.
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INTRODUCTION
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The journey of a patient with cancer starts with the first consultation
with
the general practitioner (GP) and finishes with definitive treatment,
in
many cases removal of the affected organ. The Government
White Paper entitled
The New NHS—Modern, Dependable declared
that ‘Everyone
with suspected cancer will be able to see
a specialist within 2 weeks of their
GP deciding that they need
to be seen urgently and requesting an
appointment’.
1
For
urological cancers this was implemented from December 2000.
To see how
this might affect the cancer care pathway overall
we examined the delays at
various stages in patients treated
before implementation of the rule.
|
METHODS
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The study group consisted of 160 patients—40 each who
underwent
radical prostatectomy, radical cystectomy, radical
nephrectomy or radical
orchidectomy before December 2000 for
‘potentially curable’
cancers. The case notes were
reviewed to quantify the intervals between the
various stages
in the patient pathway—namely, from the first GP
consultation
to hospital referral, then to the first hospital consultation,
confirmation
of diagnosis and definitive surgery. The statistical package
SPSS
was used to analyse the data. Median time intervals with
interquartile (IQ)
ranges were calculated, since the data were
not symmetrically distributed.
|
RESULTS
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One-third of the patients were seen at the hospital within two
weeks of
referral.
Figure 1 shows the
proportions in each category.
The interval from onset of symptoms to radical
surgery for the
whole series was 137 days
(
Table 1). The longest delay
was for
prostate cancer and the shortest for testicular cancer. Patients
with
prostate cancer had to wait longest at all stages of the
pathway—before
specialist assessment, before formal diagnosis
and before surgical treatment.
Some of the prostate cancer patients
had several attendances for biopsies
before cancer was diagnosed.
During the last leg of the journey (diagnosis to
radical surgery),
the waiting period was the shortest for testicular
cancer.
|
DISCUSSION
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Patient delay, clinician delay and most important hospital delays
have been
recognized as the factors responsible for protracted
patient pathways in
urological
cancers.
2-6
Before December 2000
only 34% of patients who eventually had radical cancer
surgery
were seen in the hospital clinic within two weeks from initial
GP
referral. Whatever the effect of the two-weeks-wait rule,
it will not have
improved other steps on the urological cancer
care pathway. Patients with
prostate and bladder cancer spent
much time waiting for staging (imaging)
investigations and then
for an operating theatre slot.
Do these long waits mean poorer outcomes? This question has been examined
particularly for bladder and testicular cancers, but the evidence is
conflicting.7,8
For bladder cancer, a recent prospective study suggests that delay is harmful
in patients with T1
tumours.9 For
testicular cancers some workers report an adverse influence of delay on
survival,10,11
others
not.12,13
An MRC working party found no effect of delay once stage and marker status
were taken into
account.14 The
matter is hard to resolve because of the mix of patient-related factors (such
as co-morbidity) and tumour-related factors. Nevertheless, early diagnosis and
treatment will certainly be helpful in alleviating anxiety and reducing
absence from work due to symptoms. To this end, cancer services are being
reconfigured, and local networks are playing an increasingly important role.
Centres and units staffed by experts in all aspects of cancer management are
being established, and the resulting improved organization should reduce delay
times at various stages. The next Government target is two months from urgent
referral to treatment for all cancers by the end of December 2005, and our
results indicate that this can be achieved only by broad-based investment in
diagnostic and operating facilities.
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REFERENCES
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