The effects of the Two-Week Rule on NHS colorectal cancer diagnostic services: A systematic literature review

BMC Health Services Research BioMed Central Research article Open Access The effects of the Two-Week Rule on NHS colorectal cancer diagnostic services: A systematic literature review Kymberley Thorne*1, Hayley A Hutchings†1 and Glyn Elwyn†2 Address: 1School of Medicine, University of Wales, Swansea, UK and 2Centre for Health Services Research, Cardiff University, Cardiff, UK Email: Kymberley Thorne* - ; Hayley A Hutchings - ; Glyn Elwyn - * Corresponding author †Equal contributors Published: 03 April 2006 BMC Health Services Research 2006, 6:43 doi:10.1186/1472-6963-6-43 Received: 18 November 2005 Accepted: 03 April 2006 This article is available from: http://www.biomedcentral.com/1472-6963/6/43 © 2006 Thorne et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The Two-Week Rule (TWR) was introduced to ensure that all patients with a suspected colorectal cancer (CRC) saw a hospital specialist within 14 days of an urgent GP referral. Guidelines were available to GPs to facilitate the appropriate TWR referral of patients exhibiting high-risk CRC symptoms. Methods: We aimed to evaluate the TWR and its CRC detection rate on NHS CRC diagnostic services by performing a literature search and critically appraising the peer-reviewed studies. Only 12 studies were eligible for inclusion. Data was collected and overall results were given as weighted averages. Results: The studies identified indicated that only 10.3% of patients referred by the TWR were eventually diagnosed with CRC. When examining the referral origin of all CRC patients diagnosed during the time of the studies, 24% had been referred using the TWR, 24.1% were referred as emergency cases, and 52.4% were referred using alternative routes. No evidence was found to indicate that the TWR had resulted in identifying CRC patients at an earlier, more treatable stage of their disease. Conclusion: The TWR referral system needs to be improved to increase the number of CRC patients referred using this fast track method as they present to their GP. The TWR and new NICE Guidelines for the referral of patients with suspected cancer should be independently evaluated. Background The Government set targets to be achieved by 2000 for NHS Trusts in England and Wales to see patients with suspected cancer within two weeks of an urgent referral by their GP [1], where "suspected" was defined as either a perceived level of probability or a hunch [2]. This was achieved by the implementation of the Two-Week Rule (TWR) for fast tracking suspected cancer referrals from primary to secondary care [3]. To facilitate the appropriate use of the TWR, Guidelines were published by the Department of Health (DoH) detailing the high-risk criteria exhibited by patients with suspected cancer [4]. In the case of colorectal cancer (CRC), the Guidelines' list of high-risk symptoms aimed to "identify up to 90 per cent of patients with bowel cancer" to be urgently referred using the TWR. The Guidelines recommended that a patient needed to exhibit a combination of the high-risk symptoms to be appropriately referred using the TWR. Patients referred using the TWR Page 1 of 5 (page number not for citation purposes) BMC Health Services Research 2006, 6:43 http://www.biomedcentral.com/1472-6963/6/43 Table 1: Description of the studies used in this paper. First author & Reference Location of study Study Type Time period studied Chohan [6] Maruthachalam [7] Eccersley [8] Walsh [9] Debnath [10] Flashman [11] Barwick [12] Tricket [13] Addenbrookes Hospital, Cambridge Newcastle upon Tyne NHS Trust Luton & Dunstable NHS Trust Blackpool Victoria Hospital, Blackpool South Durham Healthcare Trust Queen Alexandra Hospital, Portsmouth St James' University Hospital, Leeds Ashford & St Peter's Hospital NHS Trust Retrospective observational study Prospective evaluative study Prospective audit Prospective audit Prospective audit Prospective audit Retrospective observational study Prospective observational study † Jul 2000 to Dec 2001 Jan to Dec 2003 Jan 2000 to March 2001 Aug to Oct 2000 Aug 2000 to Jul 2001 Jul 2000 to Jun 2001 Jan to Aug 2001 Nov 2000 to Oct 2001 Key: † Study looked at CRC patients only that did not exhibit at least two of the criteria would be considered inappropriate referrals. Since 2000, English NHS Trusts have reported their compliance with the TWR to the DoH on a quarterly basis. The report for the first Quarter of 2005/06 showed that 99.5% of all patients referred with a suspected lower gastrointestinal cancer via the TWR were seen within two weeks [5]. A recent publication by Chohan et al highlighted the success of the TWR in speeding up patients' access to clinics at their hospital but reported a low CRC detection rate of 27%. The CRC patients diagnosed via this route also tended to have more advanced stage of the disease [6]. In light of this, we performed a literature search to evaluate all peer-reviewed evidence reporting on the TWR and its CRC detection rate within NHS CRC diagnostic services to determine whether the TWR was effective in identifying suspected CRC patients, and whether they were diagnosed at an earlier stage of their disease. Methods A literature search was performed using Medline, the Cochrane Library, the National Library for Health (NLH), the Health Management Information Consortium (HMIC) and the Centre for Reviews and Dissemination (CRD), employing a text search for peer-reviewed research publications. The search terms used were "colorectal" or "CRC" in combination with "urgent referral*", "two week*", "2-week*" and "fourteen day*". in CRC patients. Data extracted were actual values. All studies with comparable datasets were combined to give overall results, given as weighted averages. Results During the initial search for literature, a total of 123 articles were retrieved. Of these, 103 were immediately excluded because they did not refer to TWR in any way. Of the remaining 20 articles, one did not relate directly to TWR efficiency, four studies were done prior to the official implementation on TWR in July 2000 and three were letters. This left 12 articles suitable for inclusion. Of these, only eight had comparable data reporting on the effect of the TWR in NHS CRC diagnostic services. These studies consisted of two retrospective studies and six prospective studies, four of which were based on audits (see Table 1). These studies were performed between 2000 and 2003. The studies identified showed that of the 2440 patients referred by their GP using the TWR, only 10.3 per cent were subsequently diagnosed with CRC (see Table 2). When determining the referral route of all CRC patients diagnosed during the time of the studies ident (...truncated)