Transcript Slide 1

South West Cancer Intelligence Service
Two-week wait referrals for malignant
melanoma: A clinical audit carried out
across four UK Cancer Networks
K Ruth1 ([email protected]), J Milne2, S Keohane3, J Verne1, D de Berker4, V Poirier1,
on behalf of the SWCIS Skin Cancer Tumour Panel.
1 Cancer Intelligence Service, South West Public Health Observatory (SWCIS), 2 Gloucestershire
Hospitals NHS Foundation Trust, 3 Portsmouth Hospitals NHS Trust, 4 United Bristol Healthcare NHS Trust.
Background
Cancer waiting time standards (2):
Malignant melanoma was the sixth most common cause of cancer and the
eighteenth most common cause of cancer death in the South West of
England in 2000 (1). In the South West, the age standardised rate of
malignant melanoma is also higher than the average for England. Since
the implementation of the two-week wait referral pathway in 2000, all
cases of suspected malignant melanoma should be seen by a specialist
within 14 days of GP referral. Little is known about the effectiveness of
two-week wait referrals for skin cancer. This audit was conducted on
behalf of the SWCIS Skin Cancer Tumour Panel to investigate waiting
times for new cases of malignant melanoma in the South West. Data are
presented for four of the five Cancer Networks in the SWCIS region.
• First treatment: the first definitive treatment is the
first intervention designed to remove or shrink the
tumour, e.g. excision biopsy.
• To relate this to the national standard that urgently referred cases should
be seen by a specialist within 14 days of GP referral.
Participation
Methods
Data was provided for 168 patients from 14/17 Trusts:
• A proforma was circulated to the Skin Cancer Lead at each of the
17 Hospital Trusts in four of the Cancer Networks in the SWCIS region –
Avon, Somerset and Wiltshire Cancer Services, Dorset, Peninsula and
Three Counties.
• 45/168 (27%) cases had
excision biopsy at initial
appointment.
Referrals for malignant melanoma
Number of patients
160
• Excision biopsy was performed
by GP for 22/168 (13%) cases.
140
120
Receipt of GP's referral to hospital appointment
100
80
60
Initial hospital appointment to excision biopsy
40
20
Receipt of GP's referral to histological diagnosis
Receipt of GP's referral to decision to treat date
Excisional biopsy to definitive treatmenti
GP referral to definitive treatment
Decision to treat to definitive treatmentii
0
April
June
August
All months
Month
2-w eek w ait
Non 2-w eek w ait
Referral method unknow n
Referrals meeting waiting time targets
70/74 (95%) of two-week wait referrals met the 14-day target.
Two-week wait referrals
Number patients
60
40
20
0
31 day
Target
Did not meet target
Non two-week wait referrals
Number patients
80
60
40
20
0
62 day *
31 day
Target
Met target
• Royal Cornwall
• Royal Devon and Exeter
• Royal United Hospital
Bath
• South Devon
• Taunton and Somerset
• United Bristol
• Weston
East Somerset
Gloucestershire
Hereford
North Bristol
Northern Devon
Poole Hospital
Royal Bournemouth
and Christchurch
180
• Excision biopsy was definitive
treatment for 59/168 (35%)
cases.
80
•
•
•
•
•
•
•
Waiting times (all months combined)
• 76/168 (45%) of patients were
two-week wait referrals.
14 day *
Definitions:
• To establish numbers and waiting times of patients with malignant
melanoma referred through the two-week wait system in a defined period
compared with those who were not.
Referral characteristics
Met target
• Maximum 31 day wait from diagnosis (the
decision to treat date) to first treatment (from
end 2005).
Objectives
• Data were analysed with reference to the cancer waiting time standards
(above right).
62 day *
• Maximum 62 day wait from urgent GP referral to
first treatment (from end 2005).
• Decision to treat: date when the patient and
clinician agree the treatment plan for first
treatment.
• Data were collected for April, June and August 2004 for patients
diagnosed with a malignant melanoma.
14 day *
• Maximum 14 day wait from urgent GP referral to
hospital appointment (from 2000).
* The 14 and 62 day targets
apply to two-week wait referrals
only. Data for non two-week wait
referrals are shown for
comparison purposes.
Note: The 14-day waiting time
target applies to the time
difference between the date of the
GP’s referral and the date of the
hospital appointment. In this audit,
time from receipt of GPs referral is
used here as an approximation of
date of GP's referral.
Did not meet target
References:
1. South West Cancer Intelligence Service. Factsheet No 2: Malignant
Melanoma in the South West. ICD-10: C43.
2. The NHS Cancer Plan. A plan for investment. A plan for reform. Department
of Health, 2000.
3. Cox NH. Evaluation of the UK two-week wait referral rule for skin cancer.
Br J Derm 2004;150:291–98.
Two-week
Non two-week
wait
wait
Median
Median
(days)
n
(days)
n
7.5
74
28.5
56
0
63
8
54
17.5
14.5
34
41.5
18.5
64
68
56
58
58
42.5
47
32
79
31
54
56
74
47
47
Notes:
i Where
excision biopsy was definitive, waiting time was 0 days. Otherwise, definitive
treatment was defined as wide re-excision, sentinel lymph node biopsy, lymph node
dissection or radiotherapy.
Calculated by subtracting the ‘Number of days from receipt of GP’s referral to
decision to treat date’ from the ‘Number of days from GP referral to definitive
treatment’.
ii
Conclusions
• 45% of patients were two-week wait referrals. These results were broadly in line
with a survey of UK dermatologists that found this to be 10–66% (3). Reasons why
patients were not referred by the two-week wait route require further investigation.
• As expected, waiting time from referral to initial appointment was longer for non
two-week wait referrals. This appeared to cause most of the delays in the referral/
treatment pathway. Such delays may be clinically significant.
• Nearly all patients referred by the two-week wait had a hospital appointment within
14 days of receipt of GP’s referral.
• Although the 31 and 62 day targets were not in operation at the time of the audit,
the proportions meeting these targets were encouraging.
www.swpho.nhs.uk