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2 week referrals for bone and soft tissue tumours

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

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2 week referrals for bone and soft tissue tumours

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  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. Background • Taylor et al in 2010 • 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

  5. 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

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

  7. 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

  8. Results • Investigations • 9 patients already had Ix • Chondrsarcomapt – symptoms started in Sept, had USS, CT and MRI, referred on 22/11 • Myxoidliposarcomapt – MRI • Sarcoma NOS pt – USS • Metastatic lung cancer pt - USS • Lipomapt – had USS + MRI • Lipomapt – USS

  9. Results • Referral form • 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

  10. Results • Delay in appointment • 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

  11. 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

  12. Discussion • Update website • www.newcastlesarcoma.org.uk • 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

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

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

  15. References • B Shmookler, J Bickels, J Jelinek, P Sugarbaker, M Malawer. Musculoskeletal Cancer Surgery. Oct 2001. 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 312648. “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 23870. 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 CollSurgEngl 2010;92:417-421. 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.

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