Explaining an Urgent Suspected Cancer (2 week wait) Referral – OSCE Guide

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This guide provides a step-by-step approach to explaining an urgent suspected cancer (2 week wait) referral in an OSCE setting. You should also read our overview of how to effectively communicate information to patients.


Urgent suspected cancer referrals

In the United Kingdom, an urgent suspected cancer referral (a ‘2 week wait’ referral) is made for patients with symptoms or signs that may indicate cancer.

The NICE criteria outline specific symptoms and clinical findings that may suggest cancer and warrant urgent referral. Some examples include:

  • An unexplained breast lump in patients over 30 years (breast cancer)
  • Haemoptysis in patients over 40 (lung cancer)
  • A persistent change in bowel habit (colorectal cancer)

For more information on referral criteria, see the NICE guidelines on suspected cancer.

Urgent suspected cancer referrals are usually from primary careΒ (e.g., GPs, nurses or dentists) to secondary care/hospital services.3

Pathways for urgent suspected cancer referrals will vary depending on the design of local services and the suspected cancer. Patients may undergo an investigationΒ (‘straight to test’ referrals, e.g. endoscopy) or attend an outpatient appointment with a specialist. Some services may run ‘one-stop‘ clinics to assess patients (including investigations and specialist review) in one attendance.

Suspected cancer referral guidelines

Cancer Research UK have summarised the NICE urgent cancer referral guidelines into a downloadableΒ symptom reference guide.

You might also be interested in our premium collection of 1,000+ ready-made OSCE Stations, including a range of communication skills stations ✨

Structuring your explanation

When sharing information with a patient, it is important to have a structure for the consultation. The BUCES structure can be used:

  • Brief history
  • Understanding
  • Concerns
  • Explanation
  • Summarise

How you structure your consultation willΒ vary depending on the clinical presentationΒ and theΒ OSCE scenario.

You may need to explain an urgent suspected cancer referral as part of a longer station set in primary care (e.g. taking a history from a patient presenting to their GP with a breast lump and then explaining the referral). Alternatively, you may need to counsel a worried patient following a referral made by another clinician.

Some OSCE scenarios may be set inΒ secondary care (e.g. a patient attending breast clinic for triple assessment). However, for this OSCE guide, we will focus on explaining the urgent suspected cancer referral from primary care.Β 


Opening the consultation

Note: this section is not required if you are explaining an urgent suspected cancer referral as part of a longer consultation (e.g. a history station).Β 

Wash your handsΒ andΒ don PPEΒ if appropriate.

Introduce yourself to the patient including yourΒ nameΒ andΒ role.

Confirm the patient’sΒ nameΒ andΒ date of birth.

BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before explaining the various aspects of the referral, having a common starting point with your patient is fundamental. This helps establish rapport and creates an open environment where the patient can raise concerns, ask questions and gain a better understanding of their problem.

After introducing yourself, it is essential to take a brief history (this is the first part of the BUCES structure):

  • What has brought the patient in to see you today?
  • Clarify the reason for the consultation
  • What is the background to their referral? Who made the referral and why?
  • What are their symptoms, if any?
  • Have symptoms changed since the initial referral, and have any new symptoms developed?
  • β€œCan you catch me up on what’s been happening?”

For example, a patient may have had a test or screening investigation (e.g. mammogram) or presented with a red flag symptom.1


What does the patient understand?

Following a brief history, it is important to gauge the patient’s knowledge of the current situation.

If you are explaining an urgent suspected cancer referral as part of aΒ longer consultation, you will already have started to gauge the patient’s understanding of the situation.Β 

Some patients may have had experience with urgent suspect cancer referrals and therefore understand what it means. Other patients may be unsure of what is happening and why they are being referred.Β 

Due to these reasons, it is important to start withΒ open questioning. Good examples include:

  • β€œWhat has been explained to you about your recent referral?”
  • β€œWhat do you know about a β€˜two-week wait’ referral?”
  • “Could you briefly explain to me what we’ve discussed so far?”

Open questioning should help you determine what the patient currently understands, allowing you to tailor your explanation appropriately.

At this stage, primarily focus onΒ listening to the patient. It may also be helpful to giveΒ positive feedbackΒ as the patient talks (i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal communication such as nodding).

Checking theΒ patient’s understandingΒ should not be solely confined to this point of the consultation but should be done throughout by repeatedly β€˜chunking and checking’.

Throughout the consultation, be receptive to the patient’s language and try only to use words and terminology they areΒ comfortableΒ with.


Ideas, concerns and expectations

A key component of the consultationΒ involves exploring a patient’s ideas,Β concerns,Β andΒ expectationsΒ (often referred to asΒ ICE) to gain insight into the patient’s thoughts about their referral, what they are worried about and what they expect from the consultation. When discussing concerns, do so sensitively and honestly.

If you are explaining an urgent suspected cancer referral as part of aΒ longer consultation, you will already have started to exploreΒ ICE and address any patient concerns.Β 

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided severalΒ examplesΒ for each of the three areas below.

Ideas

  • β€œWhat do you already know about this referral?”
  • β€œDo you know why the referral was made?”

Concerns

  • β€œWhat are you most concerned about at this point?”
  • β€œIs there anything that particularly worries you about this referral?”

Expectations

  • β€œIs there anything you wanted to focus on or discuss today?”

Acknowledging the patient’s concerns helps put them at ease by empathising with their situation.

β€œI understand that this may be a stressful time for you. But I will do my best to answer your questions and any concerns you may have. Does this sound okay?”


What is an urgent suspected cancer referral?

Explain to the patient that an urgent suspected cancer referral is a fast-track pathway to investigate signs, symptoms or abnormal test results that may indicate cancer.1,2Β  These pathways are designed to enable rapid diagnosis and treatment of cancer.

The patient will attend an outpatient clinic or a diagnostic investigationΒ at the hospital. This will vary depending on the referral pathway.4

You must inform the patient of theΒ purpose of the referral.Β Reassure the patient that worrying when an urgent referral is made is normal. However, most patients referred under the urgent suspected cancer pathway do not have cancer but may have another condition requiring hospital diagnosis and treatment.5, 6

β€œThis referral was made by your primary care provider (GP/nurse/dentist) to investigate something concerning, like a symptom or abnormal test result”, orΒ “Based on what you’ve told me, these symptoms do sound concerning. I’d like to refer you for some further investigations at the hospital.”

β€œYou will be offered an appointment at the hospital to see a specialist within two weeks. This is to avoid any delay so we can start tests and make a diagnosis.”

β€œYour symptoms/test results may suggest a serious underlying illness such as cancer.”

β€œIt’s normal to feel worried when you are referred urgently like this. It’s important to remember that most patients referred do not have cancer but may have another condition requiring hospital diagnosis and treatment.”

Why is it important to be seen quickly?

Inform patients that the urgent suspected cancer pathway is designed so anyone with symptoms that may indicate cancer is seen by a specialist as quickly as possible. Most patients are seen within two weeks, and thisΒ can improve a patient’s prognosis and quality of life.2

β€œThis rapid referral means we can rule out cancer or make a diagnosis and start any necessary treatment as soon as possible. This can significantly improve the chances of successful treatment and recovery.”


What to expect after the referral is made

Patients should expect a letter or phone call from the hospital providing details of their appointment time and location. It’s important to note that this communication will arrive within two weeks of the referral.2,4,8Β 

The type of appointment will vary depending on the local suspected cancer pathway. As described earlier, some cancer pathways involve patients going ‘straight to test’, meaning they attend for an initial investigation (e.g. endoscopy or colonoscopy), and are followed up with the results. Other pathways involve the patient attending an outpatient clinic appointment.Β 

After the initial appointment, the patient may be discharged, discussed in MDT, referred to a different specialist, or require further tests.

β€œAfter your referral, you will receive a letter or phone call informing you of your appointment and location. This will be within two weeks of your referral.”

“In some hospital departments, all patients referred are asked to have a test done first to investigate their symptoms further. This is followed by an in-person or telephone appointment to discuss the results with a specialist. In other departments, patients see the specialist, who will then organise tests afterwards if needed. The letter that you receive will tell you exactly what to expect at your first appointment.”

β€œYou may need further tests, which can occur before, during, or after your first hospital appointment. You will receive information on preparing for your appointment and what to bring.”

β€œDuring the appointment, you will meet with a specialist who will want to discuss the symptoms you have been experiencing. They may perform a physical examination and will discuss the results of any tests with you.”

β€œAfter this appointment, you may need further investigations, be discussed in a team meeting or referred to a different specialist to get to the bottom of your symptoms.”


Safety netting

Safety netting is crucial as it ensures patient wellbeing and appropriate follow-up.2,8

Explain to patients that they should seek medical attention if their symptoms worsen or they become unwell.

Patients should ensure their GP has up-to-date contact information, including their address and telephone number. They should inform the referrer if they don’t receive their appointment details within a week.

Patients must be available for their appointment within the next two weeks. If they are unavailable, they must inform the hospital as soon as possible so alternative arrangements can be made.

β€œIf your symptoms worsen or you become unwell, seek medical attention urgently.”

β€œPlease ensure we have your up-to-date contact information, including your address and telephone number. If you do not receive appointment details within the next week, you must let us know so we can follow up with the hospital.”

β€œYour appointment will be within the next two weeks, and it’s important to attend as early diagnosis, and treatment can improve outcomes. If you can’t attend your appointment or need to reschedule, please get in touch with the hospital as soon as possible.”


Support

Undergoing investigations for suspected cancer can be stressful and uncertain for patients. It’s important to reassure patients that there is support available for them.2,8

Patients can ask their GP or specialist any questions or concerns about the referral process, diagnosis, or treatment.

In addition, national and local organisations such as Macmillan Cancer Support or Cancer Research UK can offer extra information and support.9

β€œI understand that this is an uncertain and worrying time for you. Many people go through this process, and support is available to help you.”

β€œIf you have more questions or concerns, please speak to your GP or specialist.”

β€œSome organisations like Macmillan Cancer Support can provide further information and support.”

β€œBringing a family member or close friend with you to appointments may also be helpful for emotional support.”


Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise theΒ key pointsΒ of the consultation.

Ask the patient if they have any questions or concerns that have not been addressed.

β€œIs there anything you would like me to go over again?”

β€œDo you have any other questions before we finish?”

Finally,Β thank the patientΒ for their time and offer them aΒ leafletΒ summarising the key information.

DisposeΒ ofΒ PPEΒ appropriately andΒ wash your hands.


Reviewers

Dr Nikki Hedges

General Practitioner

Dr Lara Stewart

General Practitioner


References

  1. Cancer Research UK. Cancer waiting times. 2022. Available from: [LINK]
  2. Cancer Research UK. Your Urgent suspected cancer referral. 2022. Available from: [LINK]
  3. Hull University Teaching Hospitals NHS trust. Urgent β€˜two week wait’ referral to hospital – information for patients. 2017. Available from: [LINK]
  4. Norfolk and Norwich university teaching hospitals NHS trust. What is a two week wait? 2022. Available from: [LINK]
  5. NHS. Colorectal patient information for urgent β€˜bowel’ clinical referrals. 2016. Available from: [LINK]
  6. Patient information for urgent breast unit referrals. 2016. Available from: [LINK]
  7. NICE. Suspected Cancer: recognition and referral. 2015. Available from: [LINK]
  8. University Hospitals Sussex NHS trust. Patient information leaflet. 2022. Available from: [LINK]
  9. Macmillan Cancer Support. Cancer information and support. 2023. Available from: [LINK]
  10. NHS Interim Management and Support. Delivering Cancer Waiting Times. 2015. Available from: [LINK]

 

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