The ‘two week rule’ in head and neck cancer, 2000-2014; a systematic literature review

ABSTRACT Background: The UK fast-track system for suspected cancer – the ‘two-week rule’ (TWR) - states that for suspected cancer there should be a maximum of 14 days between primary care referral and secondary care specialist consultation. This approach is valued by patients, ensures a ‘universal standard’ of diagnosis and speeds up the overall cancer management pathway. However, it can be argued that the rule has had little or no effect on survival, diagnoses cancer in only a small proportion of referrals and is expensive. Objectives: To conduct a systematic review on the effectiveness of the TWR in head and neck cancer. Methods: Electronic searches of a several databases including: Medline, Embase, Cochrane Database of Systematic Reviews CINAHL and CANCERLIT were conducted up to the end of 2014. This search was supplemented by searching conference proceedings and contacting experts. Retrospective and prospective studies that included at least one of the following: conversion rate (proportion of TWR referrals diagnosed with cancer – positive predictive value) or detection rate (proportion of diagnosed cancers referred via the TWR - sensitivity) were included. Two reviewers assessed studies for inclusion and extracted data independently. Heterogeneity was assessed by inspection of forest plot confidence interval overlap and calculation of I2. Random-effects meta-analysis was undertaken Results: 17 studies were included; all reported conversion rate; 10 of these also reported detection rate. Meta-analysis indicated an overall pooled conversion rate of 8.8% (95% CI 7.0%-10.7%) and a pooled detection rate of 40.8% (95% CI 25.7% – 55.8%) Subgroups analysing maxillofacial (OFMS) and otolaryngology (ENT) units showed no significant difference in conversion rate (8.3% and 8.8%; p = 0.73). Subgroup analyses of ‘early’ studies (< 2008) and ‘late’ studies (2008 – 2014), showed a significant reduction in conversion rates from 10.6% to 6.6%, p = <0.0001. These ‘early’ and ‘late’ subgroups showed a significant increase in detection rate (35.0% to 49.7%, p = 0.0008). Conclusions: The conversion and detection rates are similar to those for a number of other cancer sites that rely on a list of signs/symptoms for referral and were similar in ENT and maxillofacial units. There is evidence to support the view that TWR conversion rates are falling whilst detection rates are rising, due to increasing referrals. The influence of the TWR on outcomes, particularly survival is not well known. Keywords: Fast-track cancer referral, two-week rule, head and neck cancer