Clinical Oncology (2006) 18: 152e160
Letters doi:10.1016/j.clon.2005.09.007
The 2-week Referral Rule for Colorectal Cancer: Bane or Boon? Sir d The poor survival rates for colorectal and other cancers led the government to introduce the National Health Service (NHS) Cancer Plan in 2000 [1]. The strategies of the NHS Cancer Plan 2000 were to reduce the risk of cancer, to detect early stage disease and to improve access to the cancer management team. To achieve these objectives, the Department of Health introduced the waiting time standards. The 2-week standard (TWR), which came into effect in July 2000, required all patients with suspected cancer to be seen by a specialist within 14 days of the referral by the general practitioner (GP) [2]. The aims of the TWR were to make diagnosis and treatment quicker for all cancers. We felt the need to audit our hospital’s results in achieving the above objectives. A prospective colorectal cancer (CRC) database has been maintained since 1997. The database includes all relevant patient data, including dates of clinics, investigations and operations, histopathology and follow-up data. The waiting times for consecutive patients undergoing surgery for CRC at matched time points before and after the introduction of the TWR were audited. Time periods were measured as time from GP referral to clinic, from clinic to diagnosis (radiological or colonoscopy findings), diagnosis to treatment and finally the time from referral to treatment was calculated. The data are presented in Table 1. We have consistently achieved the TWR target (100%) for the first clinic visit. In January 1999, the time from referral to treatment was 83 (30e228), whereas, in January 2004, it was 201 (40e1060); P ! 0.001 (ManneWhitney U Test). This study shows that the waiting times for the first clinic from GP referral has not significantly changed. The number of patients referred via the TWR has been increasing. Almost half (48%) of the patients with CRC present through routes other than the TWR, 25% of them presenting as acute Table 1 e Waiting times in days d median (range) for all colorectal cancers Referral to seen January 1999 (n Z 30) May 2000 (n Z 30) May 2003 (n Z 30) January 2004 (n Z 30)
22 (1e62)
Seen to diagnosis
Diagnosis to treatment
Referral to treatment
26 (2e161) 26 (3e104)
83 (30e228)
31 (2e177) 15 (2e150) 30 (2e92)
92 (49e227)
14 (1e148) 29 (9e124) 32 (2e111) 110 (37e219) 19 (1e255) 54 (1e970) 53 (5e307) 201 (40e1060)
0936-6555/06/180152C09 $35.00/0
emergencies. Other studies have also shown similar findings, reporting that around 50% of patients with CRC were not aware of the significance of their symptoms and delayed months before seeking medical advice [3,4]. Early stage disease would present more efficiently with improved publichealth education measures and a screening programme. The waiting times for diagnosis and treatment have been steadily increasing. With the need for more investigations, hospitals are hard pressed to meet the demand. Most of the patients with suspected CRC undergo a colonoscopy and a staging computed tomography, with rectal cancer patients also requiring a magnetic resonance imaging scan. This puts a huge burden on the available resources. This may adversely affect patients with diseases like inflammatory bowel disease, who may have to face increasing waiting times for appointments and investigations. The true effect of the 2-week referral rule on the long-term survival rates for patients with colorectal cancer remains to be seen. A. J. VALLIATTU K. B. HOSIE
Colorectal Unit, Derriford Hospital, Plymouth, UK
References 1 Department of Health. The NHS cancer plan. Department of Health Publication, 22 September 2000. 2 Department of Health. The New NHS d modern, dependable. London: HMSO, 1997. 3 Holliday H, Hardcastle J. Delay in the diagnosis and treatment of symptomatic colorectal cancer. Lancet 1979;1:309e311. 4 Baig K, Whatley P, Thompson M. Delays during stages of referral, diagnosis and treatment of colorectal cancer; their relationship to mortality. Gut 1999;44(suppl 1):A16. doi:10.1016/j.clon.2005.10.006
What Do Cancer Patients Need to Know About Follow-up? Sir d Most complaints from patients and proxies in clinical practice arise from the differences between expectations and reality. Most people fail to realise the limitations of clinical procedures (including cancer patients in follow-up), and consequently their optimistic expectations are not fulfilled [1,2]. For most of them, follow-up seems to be a protective cover that avoids future cancer damage. However, benefits of cancer patient follow-up after potentially curative treatments are only marginal and limited to those tumours in which rescue therapy can afford a second option of cure [3]. The different guides available for cancer patients in follow-up show evident limitations; most relapses are not diagnosed on scheduled visits [4,5], even in patients undergoing regular follow-up and routine diagnostic procedures [6,7]. Also, no differences have been found in clinical effect between patients undergoing
ª 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
LETTERS Table 1 e Decalogue for cancer patients under follow-up 2 1. Follow-up is a traditional procedure after potentially curative therapy, but, for most tumours, it is not necessarily integrated into cancer therapy. 2. Clinical benefit of follow-up for most tumours is dubious. However, it may provide psychological support to cancer patients. 3. Follow-up is not infallible as it shares the essential uncertainty of clinical procedures. 4. No standard intervals for follow-up visits or diagnostic procedures are determined. Intensity of follow-up has clinical effect in a few tumours. 5. Even in patients under regular follow-up, most relapses escape the programmed visits. 6. When there is no standard schedule, selection of diagnostic procedures for follow-up depends on clinical judgement of the attending physician. 7. For most tumours, symptom-directed follow-up achieves the same results of intensive follow-up. 8. The evidence that the doctor receives and the information that he or she gives during follow-up depends on sensitivity and specificity of diagnostic procedures. Non-specific complaints are prone to biased interpretations. 9. Suspicious data from different procedures may induce severe distress even when the data might eventually be interpreted as false positive results. 10. A system of open access for cancer patients’ follow-up is not yet available.
3
4
5
6
7
8
9
153 expectations from palliative radiotherapy for symptomatic metastases. Clin Oncol 2001;13:204e208. Kravitz RL, Callahan EJ, Paterniti D, Antonius D, Dunham M, Lewis CE. Prevalence and sources of patients’ unmet expectations for care. Ann Intern Med 1996;125:730e737. Rubiales AS, Centeno C, Martı´n Y, Baro ´n FJ, Arranz F, Fra J. Cancer patient follow-up: how and when? An Med Interna (Madrid) 1997;14:527e533. Pfister DG, Benson AB, Somerfield MR. Surveillance strategies after curative treatment of colorectal cancer. N Engl J Med 2004; 350:2375e2382. Expo ´sito Herna ´ndez J, Dadet A. What is the usefulness and who has to do the follow-up alter the treatment of cancer patients. Oncologia 2004;27:544e547. de Bock GH, Bonnema J, van Der Hage J, Kievit J, van de Velde CJH. Effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences after treatment for early-stage invasive breast cancer: a meta-analysis and systematic review. J Clin Oncol 2004;22:4010e4018. Adlard JW, Joseph J, Brammer CV, Gerrard GE. Open access follow-up for lung cancer: patient and staff satisfaction. Clin Oncol 2001;13:404e408. Rojas MP, Telaro E, Russo A, et al. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev 2005;(1):CD001768. Renehan AG, Egger M, Saunders MP, O’Dwyer ST. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002;324:1e8.
doi:10.1016/j.clon.2005.10.005
symptom-directed and intensive follow-up [8]. However, eventually, even when follow-up achieves early detection of relapses or treatment-related late side-effects, it rarely modifies prognosis [9]. Patients and doctors may be in collusion in the belief that fulfilling follow-up requirements may assure their future. However, the reality of relapse may affect confidence between patients, proxies and doctors; questions may be asked, such as: ‘why did this happen when you said that everything was OK?’; ‘why did you not detect it before?’; ‘why did you neglect all these complaints for all this time?’; or ‘why did you not do the best diagnostic procedures before?’. These situations, which we have experienced more than once, prompted us to propose a specific decalogue of information for every patient that completes their potentially curative treatment and enters a follow-up programme in order to prevent the painful disappointment between unfulfilled expectations and reality when disease relapses (Table 1). ´. S. RUBIALES A M. L. DEL VALLE L. A. FLORES S. HERNANSANZ ´RREZ C. GUTIE
Medical Oncology, Hospital Clı´nico Universitario, E-47005 Valladolid, Spain
References 1 Chow E, Andersson L, Wong R, et al. Patients with advanced cancer: a survey of the understanding of their illness and
Choledochal Cyst Carcinoma Treated with Stereotactic Radiotherapy Sir d Here we present a case of a classical choledochal cyst undergoing malignant transformation after 26 years. Choledochal cysts are uncommon congenital anomalies, with an incidence of one in one lakh live births. Choledochal cysts were first described by Vatero and Ezler in 1723 AD [1]. Todani et al. [2] and Sarris and Tsang [3] published a classification scheme with five types and several subtypes. A boy aged 4 years was diagnosed to have choledochal cyst and underwent by-pass surgery in the form of choledocho-duodenostomy. Although complete resection is now the treatment of choice, there is still an increased incidence of malignancy in biliary tract [4,5]. At the age of 30 years, he presented with gradually progressive postprandial upper abdominal pain and jaundice, and he was diagnosed to have papillary adenocarcinoma in pre-existing choledochal cyst. On exploration, the mass was inoperable; however, a partial resection of the tumour was achieved. He then received six cycles of cisplatin and gemcitabine combination chemotherapy followed by a repeat resection with staple transection of gastric antrum, Roux-en-Y and hepaticojejunostomy with T-tube drainage for bile. The histopathology report revealed a mucinous adenocarcinoma with pT 7 ! 5 cm. However, the resection was again incomplete with 4.3 ! 2.5 cm residual lesion. In view of the man’s poor response to treatment and progressive disease, he received palliative radiotherapy