Diagnostic Delays - Common & Upsetting

Getting a quick diagnosis when breast cancer is suspected makes a big difference.

The breast cancer version of Einstein's theory of relativity: From the minute that you are told you need a biopsy until you receive the results time changes. Each stress filled day that you wait is longer than any day before or after. The minutes become hours and the days seem like a eternity.

Even if you ultimately find out that you don't have breast cancer, those days - or weeks - of anxiety will have changed your life. If you are diagnosed with breast cancer, the time you waited may have changed your treatment outlook.

Findings in a study published in the April 15, 2002, issue of the journal Cancer indicate that a delay of more than 20 weeks in diagnosing asymptomatic breast cancer is associated with increasing tumor size and increasing risk of lymph node metastases. The researchers found that delays of greater than 20 weeks from an initial “suspicious” screening to actual confirmation of the cancer were significant for worsening prognosis.

Recognizing the need for speed, in 1999 the UK government announced a 2-week directive for breast cancer referral. The initiative was set up so that women with suspected breast cancer would be able to see a specialist within 2 weeks of an urgent referral from their general practitioner (GP). The GP in the British healthcare system is what American insurance companies call your Primary Care Physician. The GP sees you for all complaints and makes referrals to specialists when needed.

A letter published in the May 25th issue of the British Medical Journal reported that the initiative may not be working the way it was planned. Some women with breast cancer are waiting six times longer than they should be for diagnosis and treatment. Some wait for up to three months to see a specialist.

Dr. Jonathan Roberts is a consultant surgeon associated with King's College Hospital in London. His unit is part of a government initiative called the "Cancer Collaborative," which applies business management principles to cancer care. To see if the 2-week initiative was working, Roberts and his colleagues analysed information on nearly 3,600 GP referrals to King's College Breast Clinic between April 1999 and December 2000.

They found that 665 - only 18.5% - were marked as urgent and the remainder non-urgent. Remember, urgent means that a patient must be seen within two weeks.

The researchers found that 62 urgent patients and 49 non-urgent patients were eventually found to have breast cancer, suggesting that the distinction had little bearing on clinical outcome.

In another letter in the same journal, Paul Sauven, honorary treasurer, BASO (British Association of Surgical Oncology) Breast Group reported 12 358 referrals were received by 15 breast units. Only 3452 were graded as urgent by the general practitioner. A total of 1121 cancers were diagnosed, but 406 of these were not referred urgently (table).

"It is clear that the 2-week wait initiative is not working. We are artificially creating a two-tier system when there is no need for one," Roberts explained in an interview with Reuters. "Our earlier work has shown anxiety was the same regardless of whether patients were referred urgently or non-urgently," he added.

According to Dr. John Toy, Cancer Research UK's medical director, "Even best intentioned approaches to improving cancer patient outcomes will fail if they are too simplistic or flawed in design. The King's group is to be loudly applauded for finding ways of rapidly managing all women with the worry of suspected breast cancer, which are not dependent on finding extra money."

Delyth Morgan, chief executive of the charity Breakthrough Breast Cancer, asked the question that lies at the heart of the matter, "If some units can see all women referred in two weeks, then why not all?"

SOURCE: British Medical Journal 2002;324:1279.

Elsewhere on the Web:

Breast cancer delays 'put lives at risk'

Danger in delays

Two week rule for cancer referrals

May 25, 2002

Last Updated July 8, 2009