Two week waits: What are we waiting for?

OBJECTIVES: To evaluate the two-week referral system by analysing the 2-week wait (2WW) referrals to the rapid access gynaecology clinic over one year. We have also sought to identify the risk factors for endometrial cancer to help setting criteria that can be used to prioritise urgent appointments, refine subsequent management strategies.

STUDY DESIGN: Retrospective review of the data of all women referred for suspected gynaecological cancers over one year via the 2 WW office at Queen's Hospital, Romford, UK. Data of all other women in whom a diagnosis of a gynaecological malignancy was made during the same period following non-urgent (non-2WW) referrals were also collected.

RESULTS: Over one year, a total of 1105 women were referred under the 2WW for suspected gynaecological malignancy. A total of 765 patients (69.23%) were referred with suspected endometrial cancer and the main indication for referral was postmenopausal bleeding. Hundred-seventy nine women (16.20%) were referred with suspected ovarian cancer. A pelvic mass found in 62 of these women and this was the main indication of referral. The number of women referred with suspected cervical cancer was 117 (10.59%) and the main indication for referral was postcoital bleeding. Forty-four women (3.98%) referred with suspected vulvo-vaginal cancer and the main presentation was vulval lesion. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulvo-vaginal malignancy was 8.1%, 9.5%, 5.98% and 13.64% and the overall predictive value for diagnosing gynaecological malignancy was 8.33%. The predictive values of the 2WW referrals for diagnosing different types of gynaecological cancers in premenopausal women are low compared to postmenopausal women (1.86% and 9.89% respectively, p<0.001). The number of cancers diagnosed through non-urgent system was higher than the number diagnosed through urgent system (95 vs. 92). Presence of diabetes mellitus, increased endometrial thickness, prolonged bleeding and advancing age represent the best model for predicting endometrial cancer.

CONCLUSION: The overall predictive value of the 2WW system for suspected gynaecological malignancies is low particularly in premenopausal women. The current referral criteria need to be modified with a view to incorporating risk factors to prioritise urgent appointments and refine subsequent management plans.