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If the evidence base for referral guidelines is unfavourable they should be abandoned
The proposition that the early diagnosis of brain tumours is desirable is one with which few, if any, neurologists would disagree. Concerns about delayed diagnosis are also a common theme among patients.1 Although consensus may be lacking about optimal treatment in certain situations such as low-grade glioma, early identification at the least permits monitoring, and at best may improve prognosis. However, the best method for the early identification of central nervous system (CNS) tumours remains uncertain, as the possible presentations are diverse and overlap with many other neurological conditions.
In 1997, the UK government issued a white paper entitled The New NHS – Modern, Dependable (Department of Health, HMSO), which guaranteed that everyone with suspected cancer would be able to see a specialist within 2 weeks of their general (primary care) practitioner deciding that they needed to be seen urgently and requesting an appointment. Initially implemented for breast cancer, the 2-week policy (also known as the 2-week standard, 2-week rule or 2-week wait) was later implemented for many other tumour types, including CNS or brain cancers. In Referral guidelines for suspected cancer, published by the UK Department of Health (DoH) in 2000, the indications for urgent referral were specified (box).2
Box: Brain tumours—guidelines for urgent referral
Subacute progressive neurological deficit developing over days to weeks (eg, weakness, sensory loss, dysphasia and ataxia)
New onset seizures characterised by one or more of the following:
prolonged postictal focal deficit (>1 hour)
associated interictal focal deficit
Patients with headache, vomiting and papillo-oedema
Cranial nerve palsy (eg, diplopia, visual failure, including optician-defined visual field loss, unilateral sensorineural deafness)
Consider urgent referral for patients with non-migrainous headaches of recent onset, present for at least one …
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