Peta Hughes - The Royal Marsden

The Royal Marsden
Appropriateness of two week
rule referrals for skin cancer
Peta Hughes
Clinical Nurse Specialist - Skin & Melanoma
The Royal Marsden NHS Foundation Trust
1

2
The Royal Marsden
Introduction
An audit was undertaken at The Royal Marsden
(TRM) to determine the appropriateness of two week
wait referrals for a suspected skin cancer (MM/ SCC).

3
The Royal Marsden
Aims & objectives
The aim of the audit was to:
1. Evaluate appropriateness of referrals
2. Determine the demographics of patients referred by
two week rule to TRM
3. Evaluate the breach rate for referrals
4. Evaluate the take up/use of of SWLCN referral
proforma
5. Determine the pick up rate of skin cancer

4
The Royal Marsden
Method
1. 20 sets of notes were identified: 10 in Fulham Rd
and 10 in Sutton
2. Timeframe: 6-month period from September 2011
3. A piloted spreadsheet (audit proforma) was
populated

5
The Royal Marsden
To be completed with audit proformas template

6
The Royal Marsden
Results
1. Appropriateness:
– Appropriate: 17/20 [85%]
– Inappropriate reasons: 1 benign, 2 BCC & not offering
diagnosis (and no biopsy)
– If no diagnosis offered = ‘inappropriate’: therefore 14/20
[70%] however one of these turned out to be melanoma,
therefore appropriate, two others without diagnoses were not
biopsied therefore possibly ‘inappropriate’
– If GPs are given benefit of doubt, appropriateness: 75-85%
– Location of lesion not stated: 2/20 [10%]

7
The Royal Marsden
Results (continued)
2. Demographics:
– F: 7 & M: 12 (1 not identified)
– Age range: 29-92
3. Breach rate:
– 3/20 [15%]: all due to DNA or cancellation by patient
4. SWLCN proforma:
– Proforma used: 7/20 [35%](TRM is excluded on one version)
– Alternative forms: 3/20 [15%]
– Referral letter (stating TWR): 9/20 [45%]
– From private clinic: 1/20 [5%]

8
The Royal Marsden
Results (continued)
5. Pick-up rate (consultant diagnostic breakdown):
– SCC/ MM: 6/19 [32%] (confirmed with histology: 3/19 [16%])
– BCC: 2/19 [11%] (confirmed with histology: 2/19 [11%])
– Total biopsies: 11/19 [58%], showing 5 cancers [26%]
– Total skin cancers (confirmed): 6/20 [30%], one was for
squamoid eccrine ductal carcinoma (referred from private
practice and already biopsied)

9
The Royal Marsden
Conclusion
1. Referral proformas for suspected skin cancers to TRM are
used less than SWCLN as a whole [35% vs. 59%]
2. The appropriateness of referral is not particularly high when
compared with SWLCN [75-85% vs. 82-96%]
3. The pick-up rate for skin cancer is relatively good [26% vs.
25%]
4. The breach rate for this small sample was relatively high [15%
vs. 9%]

10
The Royal Marsden
Action plan
1. Collate available proformas and decide on most
effective. Make revisions as needed (via TWG or
London Alliance)
2. Agree with PCTs/commissioning groups how to
make best use of proformas, and the TWR service,
for skin cancer (via TWG/ London Alliance)