Introduction The 2 week wait (2WW) system implemented in 2000 sought to stratify patients exhibiting high-risk symptoms for cancer, thereby establishing a dedicated pathway for urgent referrals. We audited the quality of GI 2WW referrals and their cancer conversion rate against the published literature.

Method 1) All 2WW primary care referrals to BSUH gastroenterology over 3 weeks were prospectively analysed and followed up to diagnosis.

2) A 2009 systematic review¹was updated with more recent literature reports.

Inclusion Criteria: All patients referred to our Digestive Disease Department as “2WW”.

ResultsReasons for non-adherence:

• No PR performed (37, 34%)

• No duration of symptoms (38, 35%)

• GI history unanswered (52, 48%)

• Family history unanswered (56, 52%)

Additionally 5 (5%) were referred in an innapropriate age bracket.

For UGI:

• 29 (43%) were referred with >55 and dysphagia, 1 had cancer (3.4% risk from the symptom)

• 15 (22%) with dyspepsia, 0 had cancer

• 13 (19%) with unexplained weight loss, 0 had cancer

For LGI:

• 46 (43%) were referred with >60+BHC (bowel habit change), 2 had cancer (4.3% risk from the symptom)

• 26 (24%) with >40 PR bleed + BHC, 1 had cancer (3.8% risk)

• 4 (4%) with palp PR mass and 1 had cancer (25% risk)

Conclusion A published 2009 review¹indicated average cancer detection from 2WW referrals was 9.5% for LGI and 5.5% for UGI. A pubmed search for relevant GI 2WW articles combined with relevant GUT extracts found 26 later references. By combining total 2WW referrals and conversion rates from all studies, we found similar updated rates of 9.1% from 30237 referrals (LGI) and 6.7% from 10634 referrals (UGI).

Our study adds weight to the growing evidence that, despite 2WW guidance stems from level 5 evidence, cancer conversion rates from 2WW referral is poor. In both our data and the literature, no criteria accurately predict cancer.²

Additionally there is good evidence that lower quality referrals, lead to lower cancer detection rates^{3,4 and} a less effective service. The poor adherence to the referral criteria shown in our study may partly explain our particularly poor cancer conversion. We also suspect that historical underinvestment in the service, which led to long waiting times, may have tempted GPs to overstate the urgency of referrals, even though the endoscopy waits are now entirely within target.

In an attempt to improve things, we have presented this data to our local clinical reference groups, and are exploring the difficulties encountered with the 2WW process from both sides, alongside ways in which we could improve the service.

Disclosure of interest None Declared.

References

1. Thorne 2009

2. Padwick 2013

3. Amin 2009

4. Jani 2012