Evaluation of the U.K. 2-week referral rule for skin cancer

BACKGROUND: In 1997 the U.K. government introduced the target that all patients seen in primary care, and whose general practitioner suspected a possible diagnosis of any cancer, would be seen by a specialist within 2 weeks. Several individual departmental reports suggest that this has generated a high volume of 'urgent' referrals and has been unachievable without impact on other patients. OBJECTIVES: To determine the views of dermatologists, with audit and database information where possible, on the overall impact of the 2-week rule referral standard for suspected skin cancers. METHODS: A questionnaire was sent to consultant dermatologists in the U.K. requesting views and numerical data. RESULTS: There were 139 responses, some on a departmental basis, representing 272 individuals (nearly two-thirds of all consultant dermatologists in post in the U.K). Based on 52 formal audit studies or database information, the overall proportion of confirmed skin cancers among 2-week rule referrals was 12%, but only 42% of tumours were referred by this route. Correct suspicion of melanoma was generally better than that of squamous cell carcinoma. Information on standard referral proformas was only considered to be 'usually adequate' by 34% of departments. Considering all replies, only 27% of respondents felt that the 2-week rule works well; the major problems are an excess of benign lesions, the lack of opportunity to prioritize referrals and the displacement of other urgent problems. CONCLUSIONS: There are significant problems with the perception and application of the 2-week referral standard for possible skin cancers, including a high volume of nonrelevant lesions and displacement of other urgent conditions. Increasing the specificity of referral guidelines, and increased education regarding recognition of benign lesions, are the favoured options for improvement.