Colorectal (lower GI) 2WW

Scope

This guidance covers the referral of a patient who presents with symptoms suggestive of colorectal or anal cancer to a team specialising in the management of lower gastrointestinal cancer, depending on local arrangements.

Unless there is ongoing rectal bleeding, ALL patients referred for suspected lower GI cancer should have a FIT test prior to referral, and the result should be included on the referral form.

If it is not possible to defer the referral for long enough to enter the result, please indicate that the FIT test has been sent and that the result is awaited.

Please see this letter from Joe Mays and the revised pathway document for more information.

  • If you have concerns about a patient's symptoms and/or signs, consider a discussion with the local specialist.
  • GPs can refer a patient they suspect of having cancer to be seen within 14 days by a specialist. GPs must send the referral within 24 hours of the decision to refer.
  • Please use the referral forms listed on this page to ensure appropriateness. They have been agreed by the Peninsula Cancer Alliance, commissioners, LMC and all the acute hospital trusts.
  • Patients with some level of GP concern but not meeting the criteria for 2WW referral may be suitable for Faecal Immunochemical Testing.

Investigations

Unless there is ongoing rectal bleeding, ALL patients referred for suspected lower GI cancer should have a FIT test prior to referral, and the result should be included on the referral form.

If it is not possible to defer the referral for long enough to enter the result, please indicate that the FIT test has been sent and that the result is awaited.

Please see this letter from Joe Mays and the revised pathway document for more information.

Faecal Immunochemical Testing (FIT)

FIT testing with a threshold of 10mcg/g for detecting human haemoglobin in faeces ( FIT 10) is deemed a positive result (high risk for LGI cancer).

When FIT is below 10ug/g (low risk), this suggests an extremely low probability of LGI cancer. However, it should be remembered that LGI cancers with FIT below 10ug/g, do occur. Patients with bowel cancer and a FIT below 10μg/g often have other symptoms or signs of cancer, including anaemia, weight loss etc.

A review of the low-risk group after 2-4 weeks by phone or video consultation is appropriate as a safety netting process. Where symptoms persist, and the GP does not feel able to offer appropriate treatment, they could consider options such as advice and guidance and routine secondary care review as alternatives to referral via a suspected cancer pathway.

If there is still concern or uncertainty without fulfilling the pathway criteria, but still a "gut-feeling" by the GP, then timely advice should be sought by employing Advice & Guidance, use of the local Rapid Diagnostic Service –non site specific protocol, or onward referral on the LGI Urgent Suspected referral pathway (e.g., even if FIT test is below 10ug/g).

FIT testing is commissioned test for patients meeting the following criteria:

  1. ALL patients referred for suspected lower GI cancer that don't have ongoing bleeding
  2. Aged 50 years and over with unexplained abdominal pain or weight loss
  3. Aged 50- 60 years with changes in their bowel habit or iron deficiency anaemia
  4. Aged 60 years and over and have anaemia in the absence of iron deficiency

Test kits are available in all GP practices and contain explicit instructions for how the test is administered. Patients meeting these criteria and testing positive for FIT 10 should be referred via the suspected cancer pathway.

When referring,

Important Information for the consultant to enable triage straight to test:

It is very helpful to have Hb, HbA1c, U&E's and a stool sample for MCS checked within last 6 weeks. If the patient has iron-deficiency anaemia a ferritin level would also be useful. If the patient has diarrhoea testing should ideally include B12, folate, TFTs, TTG, LFTs, calcium and plasma viscosity.

Is the patient on any of the following medications?

  • Aspirin, Clopidogrel/Prasugrel etc., Warfarin, NOAC (Rivaroxaban etc.), Insulin

Referral

Referral Criteria

Unless there is ongoing rectal bleeding, ALL patients referred for suspected lower GI cancer should have a FIT test prior to referral, and the result should be included on the referral form.

If it is not possible to defer the referral for long enough to enter the result, please indicate that the FIT test has been sent and that the result is awaited.

Please see this letter from Joe Mays and the revised pathway document for more information.

Colorectal cancer
  1. Aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings (consider):
    1. abdominal pain;
    2. change in bowel habit;
    3. weight loss;
    4. iron-deficiency anaemia (Hb and ferritin within the past four weeks would be extremely helpful)
  2. Aged 40 and over with unexplained weight loss and abdominal pain
  3. Aged 50 and over with unexplained rectal bleeding
  4. Aged 60 and over with either of:
    1. iron-deficiency anaemia or
    2. changes in bowel habit
  5. Rectal or abdominal (but not pelvic) mass (consider)
  6. Patient with low-risk symptoms testing positive for FIT 10
Anal cancer
  1. Unexplained anal mass or unexplained anal ulceration (consider)

Referral Instructions

The GP should use e-Referral Service to book an appointment or send the referral.

Please ensure you include:

  • The patient's NHS number
  • Tell the patient that this is an urgent referral and they will be seen within 14 days

e-Referral service:

  • Specialty: 2WW
  • Clinic type: 2WW Lower GI
  • Service: 2WW Colorectal Surgery/Lower GI - NDHCT - NDDH - RBZ

For any patients that you are unable to process through NHS e-Referral please contact the drss.helpdesk@nhs.net

2WW Colorectal referrals will be triaged by Northern Devon NHS Trust upon receipt. The triage will result in the patient being offered one of three types of appointment:

  • Consultant face to face appointment
  • Clinical Nurse Specialist face to face appointment
  • Clinical Nurse Specialist telephone appointment

Referral Forms

Microtest: Please use No Merge Fields as a Microtest version is currently unavailable.

Suspected Lower GI cancer referral form - No Merge Fields

Suspected Lower GI cancer referral form - Emis WEB

Suspected Lower-GI cancer-referral form-Systmone

NDDH Open Access Flexible Sigmoidoscopy

NDDH Open Access Gastroscopy and Colonoscopy for Investigation of Iron Deficiency Anaemia

Last updated: 09-11-2020

 

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