2 week referrals for bone and soft tissue tumours

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2 week referrals for bone and soft tissue tumours

• Ruth Varrall
• Ruth Blackwell
• Shona Murray

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Introduction

• lt1 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

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Background

• NICE criteria
• gt5cm
• Painful
• Deep to fascia
• Increasing in size
• Suspected recurrence
• Refer when x-ray suspicious of pathalogical
  fracture or bone cancer lesion

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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

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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

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Results

• 32 referrals under 2 week rule
• 6 malignancies (19)
• Non-hodgkins lymphoma
• Chondrosarcoma
• Metastatic lung cancer
• Myxoid liposarcoma
• Sarcoma NOS
• Follicular lymphoma
• All met criteria in clinic

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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

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Results

• Investigations
• 9 patients already had Ix
• Chondrsarcoma pt symptoms started in Sept, had
  USS, CT and MRI, referred on 22/11
• Myxoid liposarcoma pt MRI
• Sarcoma NOS pt USS
• Metastatic lung cancer pt - USS
• Lipoma pt had USS MRI
• Lipoma pt USS

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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

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Results

• Delay in appointment
• All malignancies seen between 1 and 8 days
• 2 benign diagnoses gt14 days
• Lipoma for 2 yrs 28 days
• Schwannoma 15 days
• Low specificity
• 13 patients with benign lumps fulfilled NICE
  criteria in GP and clinic

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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

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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

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Limitations

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

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Conclusion

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

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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 Coll Surg Engl 201092417-421. 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.