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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