An Audit of Urology Two-Week Wait Referrals in a Large Teaching Hospital in England

Abstract

INTRODUCTION Two week wait referral guidelines have been published by the UK Department of Health for suspected urological cancers. Concordance to these guidelines is variable. Our objectives were to assess the incidence of urological malignancy and the proportion of inappropriate referrals in the two-week wait pathway. PATIENTS AND METHODS Retrospective audit of all two-week wait referrals to the urology department over 6 months. Inappropriate referrals were those not satisfying the referral criteria, but referred under the two-week wait system. Detection rates were calculated for each referral criterion based on diagnosis obtained from histology, imaging reports and clinic letters. RESULTS Incidence of cancer was 90 of 400 two-week wait referrals (23%). The cancer-detection rate based on reasons for referral ranged from 50 of 122 (41%) for elevated prostate-specific antigen levels to 2 of 56 (4%) for scrotal lumps; 42 (11%) referrals were inappropriate. CONCLUSIONS The overall cancer-detection rate is acceptable. Most inappropriate referrals were for long-standing symptoms and non-specific testicular/scrotal symptoms. The testicular cancer detection rate raises questions about the two-week wait guidelines. Providing general practitioners with fast-track scrotal ultrasound and revising the guideline may reduce the disproportionately high number of patients referred with suspected testicular cancer. Other inappropriate referrals are a cause for concern as they add to the workload of the ‘urgent-referral’ pathway. Urological cancers (those involving the prostate, testis, penis, urethra, bladder, ureters and kidneys) accounted for 15.4% of all new cancers in England, 1 and 12.1% of deaths from cancer, 2 in England and Wales, in 2004. The two-week wait referral guidelines published by the UK Department of Health for suspected urological cancers 3 are summarised in Table 1 . NHS trusts and SHAs are encouraged to carry out clinical audits of suspected cancer referrals to generate further information. 4 There is wide variation among various centres and regions in the concordance of general practitioner (GP) referrals based on these guidelines, and also the rate of cancers detected based on the two-week wait system. [Table: see text] The objectives of this audit were to calculate: (i) the rate of detection of cancers among the two-week wait referrals; (ii) the rate of detection of cancers based on the reason for referral; and (iii) the proportion of inappropriate referrals.