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Two-week rule fails to improve cancer care

By Lilian Anekwe

Rule 'overwhelms' clinics and does not increase colorectal cancer survival

The shortcomings of the two-week rule for referral of colorectal cancer have been demonstrated 'beyond doubt'.

A major review reveals the rule is 'overwhelming' hospitals with inappropriate referrals and failing to identify cancers effectively.

Fewer than a third of diagnoses come through the two-week route, the evaluation of all available evidence concluded.

An accompanying study revealed the two-week rule had failed to have any benefits on colorectal cancer survival. Both sets of researchers argued the rule was failing in its aim to streamline referrals and called for a fundamental overhaul.

Mr Sajal Rai, specialist registrar at Leicester General Hospital and author of the review, said 'a fresh approach to find a cost effective and viable alternative' was needed.

'The national implementation of referral guidelines in the form of the two-week rule has failed to achieve the goal it set itself – to improve the speed of diagnosis and the treatment of colorectal cancer.

'The guidelines, even if they are accurately applied, are insufficiently specific to identify most cases.'

Criticisms focussed on poor specificity, decreasing cancer detection rates and increasing hospital referrals (see box below). Lack of compliance meant most patients were diagnosed outside the two-week route – and these were now waiting longer.

The second study, a comparison of colorectal cancer patients diagnosed at the Luton and Dunstable hospital in the two years before and after introduction of the rule, found waiting times fell from 26 to 21 days – but 'there was no significant difference in two-year survival'.

Study leader Mr Richard Novell, a consultant in general surgery at the hospital, was also strong in his criticism.

He said: 'Given the low cancer detection rate in most two-week clinics and the lack of any medium-term survival advantage, the two-week rule should not influence the development of more effective screening and diagnostic pathways.'

The studies were published in the latest issue of Colorectal Disease.

Criticisms of the two-week-wait rule

• Compliance with guidelines by GP has been 'variable but generally poor'
• Low colorectal cancer detection rates
• Only a third of diagnoses come through two-week system
• Poor specificity and high number of inappropriate referrals
• Shorter waiting times under fast-track, but large number of referrals 'overwhelming the system'
• No matching improvement in outpatient or diagnostic services
• No significant improvement in cancer detection or medium-term survival

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