1. 2 week referrals for bone and soft tissue tumours
Ruth Varrall
Ruth Blackwell
Shona Murray

2. Introduction <1% adult and 15% paediatric new cancers
Managed in tertiary centres such as Northern Bone and Soft Tissue Tumour Service
NICE guidelines (2005) + NHS Cancer Plan (2000)
Referral rates increasing

3. Background NICE criteria >5cm Painful Deep to fascia
Increasing in size
Suspected recurrence
Refer when x-ray suspicious of pathalogical fracture or bone cancer lesion

4. Non tender!
>2cm
Regional lymph node

5. Background Taylor et al in 2010 Malik et al in 2007
27% TWW malignant, c/w 52% non-urgent
Malik et al in 2007
22% TWW did not meet criteria
Higher % malignancy from other referrals than TWW (48 v 25%)
Pencaval et al in 2010
Increasing referrals but not increasing rate of sarcoma detection
Taylor – Royal Orthopaedic Hospital Birmingham
Malik – North of England
Pencaval – Royal Marsden

6. Method
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.
Review notes, specifically original referral letter, initial clinic letter, investigations and ultimate diagnosis.
Information recorded on data collection sheet.
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.
Identify areas where referral process could improve

7. Results 32 referrals under 2 week rule 6 malignancies (19%)
Non-hodgkin’s lymphoma
Chondrosarcoma
Metastatic lung cancer
Myxoid liposarcoma
Sarcoma NOS
Follicular lymphoma
All met criteria in clinic

8. Results 26 benign diagnoses
13 lipoma
5 NAD
2 schwannoma
2 fat necrosis
1 haemangioma, non-ossifying fibroma, thrombosed vein, parameniscal cyst
4 referral letters stated probable lipoma, included one confirmed on USS

9. Results Investigations 9 patients already had Ix
Chondrsarcoma pt – symptoms started in Sept, had USS, CT and MRI, referred on 22/11
Myxoid liposarcoma pt – MRI
Sarcoma NOS pt – USS
Metastatic lung cancer pt - USS
Lipoma pt – had USS + MRI
Lipoma pt – USS

10. Results Referral form GP surgeries
Variable use, often letter, ?where from
No area for free text
5 patients did not meet criteria with GP or in clinic
3 patients did not meet criteria with GP but did in clinic
GP surgeries
Only 3 practices made two referrals

11. Results Delay in appointment Low specificity
All malignancies seen between 1 and 8 days
2 benign diagnoses >14 days
Lipoma for 2 yrs = 28 days
Schwannoma = 15 days
Low specificity
13 patients with benign lumps fulfilled NICE criteria in GP and clinic

12. Discussion
Need to find a way to make current guidelines as workable as possible
Referral form redesign with
Criteria fulfilled
History of criteria
PMH + DH or GP print out
Combination of tick box and free text

13. Discussion Update website Target GP practices Poster for GP surgeries
Referral forms to download, detailed explanation of criteria
Target GP practices
What are their perceived difficulties?
Why are they referring lipomas?
GP / registrar teaching
Poster for GP surgeries
Referral pathway, USS + biopsy service

14. Limitations Small sample size
Unable to get data in time looking at where other patients on MDT are referred from

15. Conclusion Need to find ways of improving the 2 week referral process
Key areas are education of GPs and development of referral process

16. References
B Shmookler, J Bickels, J Jelinek, P Sugarbaker, M Malawer. Musculoskeletal Cancer Surgery. Oct Published by Springer. Bone and Soft Tissue Sarcomas: Epidemiology, Radiology, Pathology and Fundamentals of Surgical Treatment.
W St J Taylor, R J Grimer, S R Carter, R M Tillman, A Abudu, L Jeys. Sarcoma 2010; article ID “Two-Week Waits” – Are They Leading to Earlier Diagnosis of Soft-Tissue Sarcomas?
A Malik, L Wigney, S Murray, C H Gerrand. Sarcoma 2007; Article ID The Effectiveness of “Two-week” Referrals for Suspected Bone and Soft Tissue Sarcoma.
T Pencavel, D Strauss, G Thomas, J Thomas, A Hayes. Ann R Coll Surg Engl 2010;92: 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.