The Two-Week Rule for NHS Gastrointestinal Cancer Referrals: A Systematic Review of Diagnostic Effectiveness

Abstract

Aim: To systematically review the impact of the Two-Week Rule in increasing the pick-up rate of colorectal cancers and Upper Gastrointestinal (GI) cancers in the NHS. Materials and Methods: Data were combined for meta-analyses to determine (1) the Two-Week Rule pick-up rate for each cancer type and (2) the proportion of patients referred using the Two-Week Rule. Overall results were given as weighted averages. Results: There were 20 articles and 27 peer-reviewed abstracts included in this review. Colorectal Cancer: Only 9.5% of patients referred by the Two-Week Rule were eventually diagnosed with colorectal cancer (n = 24). When examining the referral origin of all colorectal cancer patients diagnosed during the time of 19 studies with this data, 32.2% had been re- ferred using the Two-Week Rule. Upper GI Cancer: Only 5.5% of patients referred by the Two-Week Rule were eventu- ally diagnosed with Upper GI cancer (n = 23). When examining the referral origin of all Upper GI cancer patients diag- nosed during the time of 17 studies with this data, 23.6% had been referred using the Two-Week Rule. Conclusion: The Two-Week Rule is not sufficiently effective in diagnosing neither upper GI nor colorectal cancers in pa- tients presenting to their General Practitioner. BACKGROUND The Two-Week Rule (TWR) referral (1) was introduced by the UK's New Labour government in 2000 as one of many initiatives tackling the increasing problem of patients presenting to their General Practitioner (GP) with symptoms indicative of a cancer who, although urgently referred, did not get a hospital appointment in sufficient time to signifi- cantly improve their health outcome. It was hoped that the TWR referral route would help to reduce the number of can- cer-related deaths by 20% in people under the age of 75 years by 2010, thereby saving approximately 130,000 lives (2). The scheme allowed GPs to "fast-track" these patients to shorten the length of time they waited for a diagnosis fol- lowed by potentially life saving treatment. TWR referrals were faxed to the relevant diagnostic unit using a dedicated number and an appointment was made for the patient within two weeks. Only delays due to patient choice were accept- able reasons to over-run the two week target. Disease-specific guidelines (3, 4) were published with the aim of helping GPs make decisions about when to refer people to specialists when they presented with symptoms that could have been caused by cancer. This would facilitate the appropriate referral of suspected cancer patients using the TWR. In the case of gastrointestinal (GI) cancers, the referral guidelines applied to upper GI cancers (UGCs) including oesophageal and gastric cancer, and colorectal cancers (CRCs).