We have received several queries relating to the application of cancer waiting times guidance during the coronavirus pandemic.
This note sets out the common areas for which clarification has been requested. Please cascade this to stakeholders within your alliance.
1. Referrals – the existing rules still apply. A referral can only be downgraded or withdrawn with the explicit agreement of the referrer (usually a GP).
2. A telephone consultation can count as a first-seen date, provided it is a consultant-led clinic, and a patient’s full symptoms are considered.
3. Where possible, tele-dermatology provides a more efficient service without the requirement to see a patient. This should only apply when, following review of the photo, a clinical decision has been made that seeing a patient is not required. In this scenario, the referral would not be recorded in the cancer waiting times dataset, but it is important that systems are in place to record and communicate the clinical decision to the patient.
Where a follow-up is required, the first-seen date will be recorded as the clinic visit following this decision, with the clock starting from the date of initial referral received by the secondary care provider.
4. Where a Faecal Immunochemical Test (FIT) is requested for lower GI referrals, the request, receipt or reporting of the result cannot be classed as a first-seen date. FIT testing is encouraged to help stratify referrals for urgency of investigation.
5. Patient tracking list (PTL) management: patients should not be discharged if their pathway has been delayed by the COVID-19 pandemic. If cancer is still suspected, the patient should remain on the secondary care PTL until the pathway can be progressed.
6. Active monitoring should only be recorded as a treatment where no treatment is normally required. It should not be used because a patient’s treatment is delayed due to coronavirus, if the plan is still to provide a treatment once capacity becomes available and/or the coronavirus risk decreases.
7. Existing rules around hormone treatments remain during the coronavirus pandemic. Where hormone treatment is prescribed as a temporising measure prior to another cancer treatment until there is available capacity or the coronavirus risk changes, this should not be recorded as a definitive treatment. The following illustrate the interpretation of this in common scenarios:
a. Breast cancer, ER+ suitable for surgery but delayed due to capacity/risk to patient and started on hormones, would not stop the clock.
b. Breast cancer, ER+ not suitable for surgery and operation not planned, hormones would count as a clock stop.
c. Prostate cancer, plan for hormones is for a specified period of time, followed by radiotherapy – hormones would stop the clock.
d. Prostate cancer, surgery planned but delayed due to capacity/risk to patient and started on hormones, would not stop the clock.
e. Prostate cancer, started on hormones, no current plans for other treatments but could be reviewed in the future. Would count as a clock stop.
8. Treatment adjustment. This should be applied as follows in relation to coronavirus:
a. Where a clinical decision is taken to offer a patient treatment now (for example, the clinical view is that the risk of delay outweighs the coronavirus risk), but the patient declines and requests a later date, an adjustment can be taken from the offered date to the date the patient is willing to come for treatment. In such situations, a process should be put in place to review the patient at fixed intervals to check whether their view has changed.
b. Where the clinical recommendation, agreed with the patient, is to delay treatment until the coronavirus risk decreases, a treatment adjustment cannot be taken.
c. If a patient chooses not to access treatment due to concerns about coronavirus they should remain on the appropriate active waiting list and remain visible. In line with current cancer waiting times standards, waiting times will not be ‘paused’ and clocks will continue to tick through the period that the patient chooses not to attend.
d. If a patient waiting for treatment – with a decision to treat (DTT) – tests positive for coronavirus then the clinically urgent treatment adjustment guidance can be applied. In such cases, the adjustment would apply from the point at which it is confirmed that a patient has tested positive, to the point at which it is deemed that it is clinically appropriate to proceed with treatment.
Please continue to submit any additional queries on this guidance to the national cancer waiting times helpdesk by emailing [email protected].