Two-week rule: suspected head and neck cancer referrals from a general medical practice perspective

The two-week rule (2WR) referral system was designed to fast-track patients with suspected malignancies to secondary care services to facilitate prompt investigation and management, the ultimate goals being early detection and improved survival. Patients with symptoms of head and neck cancer primarily present to the general practitioner (GP) who has an important role in the identification of high-risk patients for prompt management. This paper reports urgent 2WR referrals from primary care to highlight difficulties in the referral process. Data were collected from three GP practices (16 GPs) in Merseyside that all used the EMIS Web system (EMIS Health). All patients who were referred on the 2WR pathway in a two-year period from January 2017 were identified (n=113). The conversion rate for malignant diagnosis was 5.5% (95% CI: 2.0 to 11.5%). Those with multiple symptoms had a higher rate of malignancy (16%, 3/19) than those with a single symptom (3%, 3/91) (p=0.06). In total, 76% of patients had had no treatment before referral. The duration of symptoms ranged from 1 - 208 weeks (median (IQR) 6 (4-12) weeks). Common benign symptoms included laryngopharyngeal reflux (n=27), thyroid lesion (n=9), and neck lymph node (n=7). The diagnosis of head and neck cancer in primary care is challenging. Initiatives to try to increase the cancer conversion rate are required, but they run the risk of missed diagnosis and increased delay. Sufficient resources are needed in secondary care to ensure the timely assessment of patients who are referred on the 2WR pathway.