1. Two-week wait referrals for malignant melanoma: A clinical audit carried out across four UK Cancer Networks South West Cancer Intelligence Service www.swpho.nhs.uk K Ruth 1 (kate.ruth@swpho.nhs.uk), J Milne 2, S Keohane 3, J Verne 1, D de Berker 4, V Poirier 1, on behalf of the SWCIS Skin Cancer Tumour Panel. 1 Cancer Intelligence Service, South West Public Health Observatory (SWCIS), 2 Gloucestershire Hospitals NHS Foundation Trust, 3 Portsmouth Hospitals NHS Trust, 4 United Bristol Healthcare NHS Trust. Background Malignant melanoma was the sixth most common cause of cancer and the eighteenth most common cause of cancer death in the South West of England in 2000 (1). In the South West, the age standardised rate of malignant melanoma is also higher than the average for England. Since the implementation of the two-week wait referral pathway in 2000, all cases of suspected malignant melanoma should be seen by a specialist within 14 days of GP referral. Little is known about the effectiveness of two-week wait referrals for skin cancer. This audit was conducted on behalf of the SWCIS Skin Cancer Tumour Panel to investigate waiting times for new cases of malignant melanoma in the South West. Data are presented for four of the five Cancer Networks in the SWCIS region. References: 1. South West Cancer Intelligence Service. Factsheet No 2: Malignant Melanoma in the South West. ICD-10: C43. 2. The NHS Cancer Plan. A plan for investment. A plan for reform. Department of Health, 2000. 3. Cox NH. Evaluation of the UK two-week wait referral rule for skin cancer. Br J Derm 2004;150:291–98. 76/168 (45%) of patients were two-week wait referrals. 45/168 (27%) cases had excision biopsy at initial appointment. Excision biopsy was definitive treatment for 59/168 (35%) cases. Excision biopsy was performed by GP for 22/168 (13%) cases. Methods A proforma was circulated to the Skin Cancer Lead at each of the 17 Hospital Trusts in four of the Cancer Networks in the SWCIS region – Avon, Somerset and Wiltshire Cancer Services, Dorset, Peninsula and Three Counties. Data were collected for April, June and August 2004 for patients diagnosed with a malignant melanoma. Data were analysed with reference to the cancer waiting time standards (above right). Referrals meeting waiting time targets * The 14 and 62 day targets apply to two-week wait referrals only. Data for non two-week wait referrals are shown for comparison purposes. Note: The 14-day waiting time target applies to the time difference between the date of the GP’s referral and the date of the hospital appointment. In this audit, time from receipt of GPs referral is used here as an approximation of date of GP's referral. Conclusions 45% of patients were two-week wait referrals. These results were broadly in line with a survey of UK dermatologists that found this to be 10–66% (3). Reasons why patients were not referred by the two-week wait route require further investigation. As expected, waiting time from referral to initial appointment was longer for non two-week wait referrals. This appeared to cause most of the delays in the referral/ treatment pathway. Such delays may be clinically significant. Nearly all patients referred by the two-week wait had a hospital appointment within 14 days of receipt of GP’s referral. Although the 31 and 62 day targets were not in operation at the time of the audit, the proportions meeting these targets were encouraging. Cancer waiting time standards (2): Maximum 14 day wait from urgent GP referral to hospital appointment (from 2000). Maximum 62 day wait from urgent GP referral to first treatment (from end 2005). Maximum 31 day wait from diagnosis (the decision to treat date) to first treatment (from end 2005). Notes: i Where excision biopsy was definitive, waiting time was 0 days. Otherwise, definitive treatment was defined as wide re-excision, sentinel lymph node biopsy, lymph node dissection or radiotherapy. ii Calculated by subtracting the ‘Number of days from receipt of GP’s referral to decision to treat date’ from the ‘Number of days from GP referral to definitive treatment’. Waiting times (all months combined) Definitions: Decision to treat: date when the patient and clinician agree the treatment plan for first treatment. First treatment: the first definitive treatment is the first intervention designed to remove or shrink the tumour, e.g. excision biopsy. Two-week wait Non two-week wait Median (days)n n Receipt of GP's referral to hospital appointment7.57428.556 Initial hospital appointment to excision biopsy063854 Receipt of GP's referral to histological diagnosis17.56442.554 Receipt of GP's referral to decision to treat date14.5684756 Excisional biopsy to definitive treatment i 34563274 GP referral to definitive treatment41.5587947 Decision to treat to definitive treatment ii 18.5583147 Participation Data was provided for 168 patients from 14/17 Trusts: East Somerset Gloucestershire Hereford North Bristol Northern Devon Poole Hospital Royal Bournemouth and Christchurch Royal Cornwall Royal Devon and Exeter Royal United Hospital Bath South Devon Taunton and Somerset United Bristol Weston Referral characteristics Objectives To establish numbers and waiting times of patients with malignant melanoma referred through the two-week wait system in a defined period compared with those who were not. To relate this to the national standard that urgently referred cases should be seen by a specialist within 14 days of GP referral. 70/74 (95%) of two-week wait referrals met the 14-day target.