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ADC Online First, published on May 18, 2015 as 10.1136/archdischild-2014-308085 PostScript

LETTER

Suspected childhood cancer fast track: increasing referrals, diminishing returns Concern has been expressed regarding the timely diagnosis of cancer in children and young people in this country.1 The 2 week fast track (2WFT) system is intended to help GPs identify features of childhood cancer, and mandates local hospital trusts with suitable specialists to see referred cases within 2 weeks. Other than a paper reporting fairly small numbers within a District General Hospital setting,2 and a follow-up letter from our institution reporting larger numbers,3 both published in this journal, there is a paucity of published data on the effectiveness of this system. Our initial letter3 reported figures over a 3 year period. We have continued to collect data, and have now analysed five consecutive years of activity, and have benchmarked our local figures against national data. Outcomes for all 2WFT cases referred to Bristol Royal Hospital for Children are kept on a trust database. We analysed all cases referred between 1 January 2009 and 31 December 2013, aged under 16 years at the time of referral, from GPs in the three Primary Care Trust (now Clinical Commissioning Group) areas served by the hospital—Bristol, North Somerset and South Gloucestershire. Six hundred and sixteen cases were identified. Since our previous letter, it came to light that a number of children under 16 years within the same catchment area had been referred on the 2WFT system to neighbouring hospitals over the years. These were usually children approaching their 16th birthday with dermatological problems (suspected melanoma) or surgical problems (breast lumps, other palpable masses), referred to dermatologists and

Table 1 Outcome of 2 week fast track referrals for suspected childhood malignancy in children under 16 years Number referred

Number in whom malignancy diagnosed

Proportion of referrals diagnosed with malignancy

Year

Bristol

England

Bristol

England

Bristol (%)

England (%)

2009 2010 2011 2012 2013

98 126 141 138 202

4328 4893 5320 5420 6120

2 2 1 0 0

46 44 51 34 30

2.0 1.6 0.7 0.0 0.0

1.1 0.9 1.1 0.6 0.5

surgeons, respectively, rather than paediatricians. Information was gathered for these cases over the same 5 year period (n=89) and included in our figures. National figures were obtained from Public Health England (personal communication, published with permission). Results are summarised in table 1. These show that during the 5 year period studied, numbers referred locally and nationally increased steadily. Meanwhile the ‘conversion rate’ ( proportion referred who end up with a diagnosis of cancer) which was low at the start, fell further. The 2WFT system does not appear to be an effective tool for identifying childhood cancers. Ensuring all 2WFT referrals are seen within the designated time limit entails keeping urgent clinic slots free and available at short notice, able to accommodate not just a steady stream of cases but also unpredictable short-term spikes in referrals. This has resource implications for hospitals. In order to achieve the twin ambitions of improving time-to-diagnosis for childhood cancers, and running a lean and efficient health service during a time of financial constraint, consideration should be given to revising the current 2WFT criteria, or discontinuing the system in favour of one with more evidence-based systems built in. The forthcoming National Institute for Clinical Excellence guidance on recognition of cancer (children and adult) is

Arch Dis Child Month 2015 Vol 0 No 0

currently in draft form, undergoing a period consultation. It is to be hoped that its recommendations will bring about the desired improvements in performance in this important area of paediatrics. Reg Bragonier, Elaine Cordey Department of General Paediatrics, Bristol Royal Hospital for Children, Bristol, UK Correspondence to Dr Reg Bragonier, Department of General Paediatrics, Bristol Royal Hospital for Children, Marlborough St, Bristol BS2 8BJ, UK; [email protected] Contributors EC extracted data from computer records. RB wrote main article. Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed. To cite Bragonier R, Cordey E. Arch Dis Child Published Online First: [ please include Day Month Year] doi:10.1136/archdischild-2014-308085 Accepted 10 April 2015 Arch Dis Child 2015;0:1. doi:10.1136/archdischild-2014-308085

REFERENCES 1

2

3

Fern LA, Birch R, Whelan J, et al. Why can’t we improve the timeliness of cancer diagnosis in children, teenagers, and young adults? BMJ 2013;347:f6493. Mant J, Nanduri V. Role of the 2-week urgent referral pathway in childhood cancer. Arch Dis Child 2012;97:23–235. Bragonier R, Kenyon C. Two-week urgent referrals for suspected childhood cancer: experience within a large tertiary centre. Arch Dis Child 2012;97:233–5.

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Suspected childhood cancer fast track: increasing referrals, diminishing returns Reg Bragonier and Elaine Cordey Arch Dis Child published online May 18, 2015

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Suspected childhood cancer fast track: increasing referrals, diminishing returns.

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