The ‘Two-Week Wait’ (2WW) pathway is central to the NHS cancer strategy, ensuring rapid review of suspected malignancies. For testicular cancer, NICE NG12 advises urgent referral based solely on clinical suspicion (typically a solid, non-transilluminable scrotal mass) without requiring prior imaging. While aimed at avoiding missed cancers, this approach leads to many benign referrals because non-malignant conditions often mimic cancer on examination. Testicular cancer is rare, accounting for 1% of male cancers, though it is the most common cancer in men aged 15–45 and highly curable when detected early. Far more prevalent conditions, such as hydroceles, epididymal cysts, varicoceles and spermatoceles, can resemble malignancy clinically. Scrotal ultrasonography (US) has high diagnostic accuracy, yet access in primary care is limited, and GPs are discouraged from ordering US before referral. This study audited 100 consecutive 2WW referrals for suspected testicular cancer at a tertiary NHS centre (June 2023 – May 2025). Only one patient (1%) underwent US prior to referral. Three patients (3%) had malignancy – two germ-cell tumours and one lymphoma – while 97% had benign pathology. Hydroceles (41%) and epididymal cysts (26%) were the most common findings. The 3% cancer conversion rate falls well below the expected 5–10% benchmark, suggesting over-referral and unnecessary patient anxiety. Several NHS regions have implemented GP-access or community US services, which safely reduce urgent referrals and speed diagnosis. Point-of-care US performed by trained GPs has also shown reliability in distinguishing benign from suspicious lesions. Based on our findings, we propose updating guidance to permit community-based US for non-suspicious scrotal swellings. Only cases with indeterminate or suspicious imaging should follow the 2WW pathway, while clearly benign lesions could be reassured or referred routinely. In conclusion, the current 2WW testicular cancer pathway has a very low malignancy yield. Improving access to primary-care US offers a practical, cost-effective way to enhance triage, reduce service burden and improve patient experience.
