2 week referrals for bone and soft

tissue tumoursRuth Varrall

Ruth BlackwellShona Murray

IntroductionO <1% adult and 15% paediatric new

cancersO Managed in tertiary centres such as

Northern Bone and Soft Tissue Tumour Service

O NICE guidelines (2005) + NHS Cancer Plan (2000)

O Referral rates increasing

BackgroundO NICE criteria

O >5cmO PainfulO Deep to fasciaO Increasing in sizeO Suspected recurrence

O Refer when x-ray suspicious of pathalogical fracture or bone cancer lesion

BackgroundO Taylor et al in 2010

O 27% TWW malignant, c/w 52% non-urgent

O Malik et al in 2007O 22% TWW did not meet criteriaO Higher % malignancy from other

referrals than TWW (48 v 25%)O Pencaval et al in 2010

O Increasing referrals but not increasing rate of sarcoma detection

MethodO Identify all patients referred to Northern Bone and

Soft Tissue Tumour Service under the two week rule between 1st October 2011 and 31st December 2011.

O Review notes, specifically original referral letter, initial clinic letter, investigations and ultimate diagnosis.

O Information recorded on data collection sheet.O Identify referral source for malignant diagnoses at

Bone and Soft Tissue Tumour MDT during same period, and why they were not two week rule referrals.

O Identify areas where referral process could improve

ResultsO 32 referrals under 2 week ruleO 6 malignancies (19%)

O Non-hodgkin’s lymphomaO ChondrosarcomaO Metastatic lung cancerO Myxoid liposarcomaO Sarcoma NOSO Follicular lymphoma

O All met criteria in clinic

ResultsO 26 benign diagnoses

O 13 lipomaO 5 NADO 2 schwannomaO 2 fat necrosisO 1 haemangioma, non-ossifying fibroma,

thrombosed vein, parameniscal cystO 4 referral letters stated probable

lipoma, included one confirmed on USS

ResultsO Investigations

O 9 patients already had IxO Chondrsarcoma pt – symptoms started in

Sept, had USS, CT and MRI, referred on 22/11

O Myxoid liposarcoma pt – MRIO Sarcoma NOS pt – USSO Metastatic lung cancer pt - USSO Lipoma pt – had USS + MRIO Lipoma pt – USS

ResultsO Referral form

O Variable use, often letter, ?where fromO No area for free textO 5 patients did not meet criteria with

GP or in clinicO 3 patients did not meet criteria with

GP but did in clinicO GP surgeries

O Only 3 practices made two referrals

ResultsO Delay in appointment

O All malignancies seen between 1 and 8 days

O 2 benign diagnoses >14 daysO Lipoma for 2 yrs = 28 daysO Schwannoma = 15 days

O Low specificityO 13 patients with benign lumps fulfilled

NICE criteria in GP and clinic

DiscussionO Need to find a way to make current

guidelines as workable as possibleO Referral form redesign with

O Criteria fulfilledO History of criteriaO PMH + DH or GP print outO Combination of tick box and free text

DiscussionO Update website

O www.newcastlesarcoma.org.ukO Referral forms to download, detailed

explanation of criteriaO Target GP practices

O What are their perceived difficulties?O Why are they referring lipomas?O GP / registrar teaching

O Poster for GP surgeriesO Referral pathway, USS + biopsy service

LimitationsO Small sample sizeO Unable to get data in time looking at

where other patients on MDT are referred from

ConclusionO Need to find ways of improving the 2

week referral processO Key areas are education of GPs and

development of referral process

ReferencesO B Shmookler, J Bickels, J Jelinek, P Sugarbaker, M Malawer.

Musculoskeletal Cancer Surgery. Oct 2001. Published by Springer. Bone and Soft Tissue Sarcomas: Epidemiology, Radiology, Pathology and Fundamentals of Surgical Treatment.

O W St J Taylor, R J Grimer, S R Carter, R M Tillman, A Abudu, L Jeys. Sarcoma 2010; article ID 312648. “Two-Week Waits” – Are They Leading to Earlier Diagnosis of Soft-Tissue Sarcomas?

O A Malik, L Wigney, S Murray, C H Gerrand. Sarcoma 2007; Article ID 23870. The Effectiveness of “Two-week” Referrals for Suspected Bone and Soft Tissue Sarcoma.

O T Pencavel, D Strauss, G Thomas, J Thomas, A Hayes. Ann R Coll Surg Engl 2010;92:417-421. Does the two-week rule pathway improve the diagnosis of soft tissue sarcoma? A retrospective review of referral patterns and outcomes over five years in a regional centre.