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Testing the two-week rule

Lung cancer [1]
Colorectal cancer [2]

In April 2000, the UK Department of Health issued national guidelines for urgent referral by a GP of suspected cancer, where suspected was defined as either a perceived level of risk, or a hunch. This was achieved by something called a two-week rule for fast-tracking suspected referrals. The two-weeks then became a target, by which healthcare organisations could be managed.

At least that is the theory. Bandolier lacks the will to try to determine what evidence the theory was based upon, but it is interested in how well it works. Can a national policy like this make a difference, and can it make things better? Two recent studies suggest that may not be the case.

Lung cancer [1]

This was a retrospective audit of patient referrals for suspected lung cancer in Nottingham in the 12 months before and 24 months after the DoH guidelines. It abstracted route of referral, reasons, symptoms, and eventual diagnosis, as well as various markers, like time from referral to outpatient visit, diagnosis, or treatment. It involved 1,044 referrals to respiratory physicians with suspected diagnosis of lung cancer.


Before the introduction of the guidelines, almost every case was an urgent referral (98%). After the introduction, referrals were either under the two-week wait referral procedures (60%), or were urgent referrals (40%). Figure 1 shows the number of referrals, and the number of cancers diagnosed. The former increased substantially, whilst the number of cancers diagnosed did not change, nor did the stage at which cancers were detected.

Figure 1: Total referrals and total lung cancers diagnosed before and after two week rule

Times between referral and diagnosis and treatment were either the same, or increased (worsened), and median times are shown in Table 1.

Table 1: Waiting times before and after two week rule

Median waiting time (days)
Referral To
first hospital visit

Colorectal cancer [2]

This systematic review conducted a search for published reports commenting on the effectiveness of the two-week rule in UK NHS colorectal cancer diagnostic services. Information was abstracted on the referral route, number of cancers, and cancer stage.


Eight articles reported on about 10,000 patients referred by their GP, two retrospective and six prospective, performed between 2000 and 2003. Of these, only 24% were referred using the two-week rule procedure (range 17% to 48%), with another 24% referred as emergency cases, and 52% using other referral procedures.

Overall, 1,173 colorectal cancers were detected, about 12% of the total referred. Of patients referred under the two-week rule procedure, the proportion with colorectal cancer was 10% (range 8% to 14%).

Most patients were seen by a hospital specialist within the two-week target, and no studies reported any significant difference in the stage of colorectal cancer patients referred under the two-week rule, or by other methods.


Neither the lung cancer study nor the colorectal cancer review could identify any improvement in treatment using the two week rule. In both cases almost all patients were seen within two weeks anyway, whatever the mechanism of referral. Widespread implementation of guidelines did not increase the number of cancers detected, nor the stage at which they were detected.

It would seem that for lung and colorectal cancer, we had a system that wasn't broke, and intervention didn't fix it. A cynic might think that one way of hitting targets is to set one up that is already being reached, and then trumpet it as a success.

As best Bandolier knows, there was little in the way of pilots, or extensive work to figure out what was needed to make an already good system better. But an awful lot of hassle was created and treasure spent for no apparent purpose.


  1. NR Lewis et al. Under utilisation of the 2-week wait initiative for lung cancer by primary care and its effects on the urgent referral pathway. British Journal of Cancer 2005 93: 905-908.
  2. K Thorne et al. The effects of the Two-Week rule on NHS colorectal cancer diagnostic services: a systematic literature review. BMC Health Services Research 2006: 43.

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