Straight to flexible sigmoidoscopy: rationalization of 2-week wait referrals in suspected colorectal cancer

Randomized controlled trial of effects of a familiarization video and patient-controlled Entonox inhalation on patient stress levels and clinical efficacy of flexible sigmoidoscopy without analgesia or sedation for investigation of fresh rectal bleeding

BACKGROUND AND AIM

Flexible sigmoidoscopy (FS) without analgesia or sedation can be unpleasant for patients, resulting in unsatisfactory examinations. Prior familiarization videos (FVs) and intra-procedural Entonox inhalation have shown inconsistent effects. This study investigated their effects on undesirable participant factors (anxiety, stress, discomfort, pain, satisfaction, later unpleasant recall of procedure, and vasovagal reactions) and clinical effectiveness (extent of bowel seen, lesions detected, and procedural/recovery times).

METHODS

This cluster-randomized single-center study evaluated 138 participants undergoing FS. There were 46 controls, 49 given access to FV, and 43 access to both FV and self-administered Entonox. Participant factors were measured by self-administered questionnaires, independent nurse assessments, and heart rate variability (HRV) metrics.

RESULTS

Questionnaires showed that the FV group was slightly more tense and upset before FS, but knowledge of Entonox availability reduced anxiety. Nonlinear HRV metrics confirmed reduced intra-procedural stress response in the FV/Entonox group compared with controls and FV alone (P < 0.05). Entonox availability allowed more bowel to be examined (P < 0.001) but increased procedure time (P < 0.05), while FV alone had no effect. FV/Entonox participants reported 1 month after FS less discomfort during the procedure. Other comparisons showed no significant differences between treatment groups, although one HRV metric showed some potential to predict vasovagal reactions.

CONCLUSIONS

Entonox availability significantly improved clinical effectiveness and caused a slight reduction in undesirable participant factors. The FV alone did not reduce undesirable participant factors or improve clinical effectiveness. Nonlinear HRV metrics recorded effects in agreement with stress reduction and may be useful for prediction of vasovagal events in future studies.

Outcomes of patients with non-lower gastrointestinal cancer diagnosed via the lower gastrointestinal two-week-wait service

INTRODUCTION

Patients referred via lower gastrointestinal two-week-wait (LGI-2WW) services deemed at 'low risk' of LGI cancer may have delayed or no investigation. However, 20% of patients diagnosed with cancer via the LGI-2WW have non-LGI cancer. This study investigates the outcomes in this under-reported group.

METHODS

A retrospective analysis of patients referred to a UK LGI-2WW service with a non-LGI cancer diagnosis (International Classification of Diseases 10th revision) between 1 January 2015 and 31 December 2018. The primary outcome was all-cause mortality. Statistical analysis was undertaken using Kaplan-Meier survival curves with generalised log-rank test and binomial logistic regression of pre-investigation information to predict death. A p-value of < 0.05 represented statistical significance.

RESULTS

In total, 140 patients were diagnosed with non-LGI cancer (of 10,155 patients referred via the LGI-2WW pathway). Median follow-up was 13 months (range 0-65 months). Thirty-five patients (35/140; 25%) did not meet LGI-2WW referral criteria. Median survival varied by cancer site (upper gastrointestinal: 43/140 patients, median survival 4 months; gynaecological: 25/140, 25 months; haematological: 22/140, < 50% died; urological: 21/140, 47 months; unknown primary: 12/140, 3 months; lung: 10/140, 17 months; breast: 3/140, 5 months; retroperitoneal: 2/140, 9 months; brain: 1/140, 4 months; adrenal: 1/140, 52 months). Binomial logistic regression was statistically significant (chi-squared goodness-of-fit test = 12.334; p = 0.03); but the presence of comorbidity was the only significant predictive factor of death (p = 0.03).

CONCLUSIONS

Patients with non-LGI cancers cannot be easily predicted and have a poor prognosis. Pathways to streamline investigations for LGI cancer should include computed tomography scans for patients at 'low risk' of LGI cancer to ensure that non-LGI cancers are diagnosed.

Systematic review with meta-analysis of over 90 000 patients. Does fast-track review diagnose colorectal cancer earlier?

BACKGROUND

National UK data on colorectal cancer (CRC) stage at diagnosis is incomplete. Site-specific fast-track (2-week wait) cancer data are not collected directly by NHS England. Policy making based on these data alone can lead to inaccuracy.

AIMS

To review available data on key outcomes (cancer conversion rate and stage at diagnosis) for the UK's lower gastrointestinal 2-week wait pathway.

METHODS

A comprehensive literature search was conducted between 2000 and 2017. Primary outcomes were cancer conversion rate and cancer stage at diagnosis. Results were expressed as proportions with 95% CIs. A random effects model was used for meta-analysis; heterogeneity was assessed by I² .

RESULTS

Of 95 papers reviewed, 49 were included in analysis with a total study population of 93,655. Cancer conversion rate was 7.7% (95% CI: 6.9-8.5). The proportion presenting at Dukes A = 11.2% (95% CI 7.4-15.6), B = 36.7% (95% CI 30.8-42.8), C = 35.7% (95% CI: 30.8-40.8) and D = 11.1% (95% CI 7.3-15.5). No colonic pathology was diagnosed in 54.6% (95% CI: 46.2-62.8).

CONCLUSIONS

Only 7.7% of patients referred by the 2-week wait pathway were found to have CRC. No beneficial effect on stage at diagnosis was found compared to non-2-week wait referral pathways. Over half of patients had no colonic pathology and detection of adenomas was very low. These results should prompt a reconsideration of the benefits of the 2-week wait pathway in CRC diagnosis and outcomes, with more focus on strategies to improve patient selection.

Need For Whole Large Bowel Investigation in Sole Change in Bowel Habit: An Analysis of 719 Patients

Purpose/Aim of the study: Patients referred for suspected colorectal cancer typically undergo whole large bowel investigation (WLBI) as per national guidelines. Sole change in bowel habit (CIBH) with no anemia/abdominal mass at time of referral has low oncological yield following diagnostic investigations, particularly for tumors proximal to the splenic flexure. Study aims were to evaluate cancer yield of patients referred for suspected colorectal cancer presenting with sole-symptom CIBH and to assess clinical and financial feasibility of a straight-to-test flexible sigmoidoscopy (FS). Materials and methods: We analyzed all 2-week wait referrals with sole CIBH between January 2013 and 2015. Information collected included cancer yield and oncological management. Results: Overall 1831 patient referrals were made during our study time. 719 (39.3%; median age 72 years, interquartile range: 65-79.5) were identified with sole CIBH at referral and underwent subsequent WLBI. 597 (83%) patients reported predominant looser/increased frequency stool (PLS) whilst the remaining 122 (17%) had predominant hard/decreased frequency stool (PHS). Overall, 18 were diagnosed with colorectal cancer (2.5%) with a further 9 patients (1.3%) harboring non-colorectal malignancies. The PHS group yielded a significantly higher proportion of colorectal cancers than the PLS group (adjusted OR 3.24, 95% CI: 1.23-8.54; p = .02). Colonic tumors proximal to the splenic flexure are uncommon in patients with sole CIBH (0.69%). In those with PLS, one proximal malignancy (0.17%) was detected with WLBI. Conclusions: Sole CIBH without anemia/abdominal mass yields a 2.5% colorectal malignancy rate from 2-week wait referrals. Those with PLS had a 0.17% yield of proximal tumors. A straight-to-test FS in this low risk group would be clinically effective with potential annual savings of more than £50 000.

Safe investigation of isolated change in bowel habit with a flexible sigmoidoscopy? A systematic review and meta-analysis

INTRODUCTION

Public awareness campaigns have led to increasing referrals of patients to colorectal surgery for possible cancer. Change in bowel habit, is traditionally described as a symptom of a left sided bowel cancer. If this is the case in practice, it raises the potentially attractive option of investigating such patients with flexible sigmoidoscopy only. This study sought to systematically review the literature describing tumour location of patients with bowel cancer presenting with left-sided symptoms to establish the safety of potential investigation of these patients with flexible sigmoidoscopy alone.

METHODS

A systematic review of studies reporting both the presenting symptoms of patients with bowel cancer and the location of their cancer in the bowel was prospectively registered (CRD42017072492). MEDLINE, EMBASE and CENTRAL were searched with no date or language restriction.

RESULTS

Seven studies were included. Isolated change in bowel habit (with or without rectal bleeding) was a presenting symptom of 73% (95% CI 41-96%, I2 = 99%) of left-sided cancers but also in 13% (95% CI 2-30%, I2 = 96%) of right-sided cancers. In all patients with cancer who presented with isolated change in bowel habit (with or without rectal bleeding), the cancer was right sided in 8% (95% CI 4-12%, I2 = 69%).

CONCLUSIONS

There is a higher than expected risk that if a cancer is diagnosed in a patient presenting with either an isolated change in bowel habit or a combination of change in bowel habit with rectal bleeding, the cancer may be right sided.

Whole-colon investigation vs. flexible sigmoidoscopy for suspected colorectal cancer based on presenting symptoms and signs: a multicentre cohort study

BACKGROUND

Patients with suspected colorectal cancer (CRC) usually undergo colonoscopy. Flexible sigmoidoscopy (FS) may be preferred if proximal cancer risk is low. We investigated which patients could undergo FS alone.

METHODS

Cohort study of 7375 patients (≥55 years) referred with suspected CRC to 21 English hospitals (2004-2007), followed using hospital records and cancer registries. We calculated yields and number of needed whole-colon examinations (NNE) to diagnose one cancer by symptoms/signs and subsite. We considered narrow (haemoglobin <11 g/dL men; <10 g/dL women) and broad (<13 g/dL men; <12 g/dL women) anaemia definitions and iron-deficiency anaemia (IDA).

RESULTS

One hundred and twenty-seven proximal and 429 distal CRCs were diagnosed. A broad anaemia definition identified 80% of proximal cancers; a narrow definition with IDA identified 39%. In patients with broad definition anaemia and/or abdominal mass, proximal cancer yield and NNE were 4.8% (97/2022) and 21. In patients without broad definition anaemia and/or abdominal mass, with rectal bleeding or increased stool frequency (41% of cohort), proximal cancer yield and NNE were 0.4% (13/3031) and 234.

CONCLUSION

Most proximal cancers are accompanied by broad definition anaemia. In patients without broad definition anaemia and/or abdominal mass, with rectal bleeding or increased stool frequency, proximal cancer is rare and FS should suffice.

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

BACKGROUND

For patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a safe and clinically effective investigation for some patients. These findings require validation in a multicentre study.

OBJECTIVES

To investigate the links between patient symptoms at presentation and CRC risk by subsite, and to provide evidence of whether or not FS is an effective alternative to whole-colon investigation (WCI) in patients whose symptoms do not suggest proximal or obstructive disease.

DESIGN

A multicentre retrospective study using data collected prospectively from two randomised controlled trials. Additional data were collected from trial diagnostic procedure reports and hospital records. CRC diagnoses within 3 years of referral were sourced from hospital records and national cancer registries via the Health and Social Care Information Centre.

SETTING

Participants were recruited to the two randomised controlled trials from 21 NHS hospitals in England between 2004 and 2007.

PARTICIPANTS

Men and women aged ≥ 55 years referred to secondary care for the investigation of symptoms suggestive of CRC.

MAIN OUTCOME MEASURE

Diagnostic yield of CRC at distal (to the splenic flexure) and proximal subsites by symptoms/clinical signs at presentation.

RESULTS

The data set for analysis comprised 7380 patients, of whom 59% were women (median age 69 years, interquartile range 62-76 years). Change in bowel habit (CIBH) was the most frequently presenting symptom (73%), followed by rectal bleeding (38%) and abdominal pain (29%); 26% of patients had anaemia. CRC was diagnosed in 551 patients (7.5%): 424 (77%) patients with distal CRC, 122 (22%) patients with cancer proximal to the descending colon and five patients with both proximal and distal CRC. Proximal cancer was diagnosed in 96 out of 2021 (4.8%) patients with anaemia and/or an abdominal mass. The yield of proximal cancer in patients without anaemia or an abdominal mass who presented with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom was low (0.5%). These low-risk groups for proximal cancer accounted for 41% (3032/7380) of the cohort; only three proximal cancers were diagnosed in 814 low-risk patients examined by FS (diagnostic yield 0.4%).

LIMITATIONS

A limitation to this study is that changes to practice since the trial ended, such as new referral guidelines and improvements in endoscopy quality, potentially weaken the generalisability of our findings.

CONCLUSIONS

Symptom profiles can be used to determine whether or not WCI is necessary. Most proximal cancers were diagnosed in patients who presented with anaemia and/or an abdominal mass. In patients without anaemia or an abdominal mass, proximal cancer diagnoses were rare in those with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom. FS alone should be a safe and clinically effective investigation in these patients. A cost-effectiveness analysis of symptom-based tailoring of diagnostic investigations for CRC is recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95152621.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 66. See the NIHR Journals Library website for further project information.

Straight-to-test colonoscopy for 2-week-wait referrals improves time to diagnosis of colorectal cancer and is feasible in a high-volume unit

AIM

We have introduced 'straight-to-test' (STT) colonoscopy as part of our 2-week-wait (2WW) pathway to address increasing numbers of urgent referrals for colorectal cancer (CRC) within the National Health Service. In this study we evaluated the ability of this initiative to shorten the time to diagnosis of CRC.

METHOD

We amended our 2WW referral form to include performance status and comorbidities. General practitioners were asked to provide data on estimated glomerular filtration rate and full blood count/ferritin. Our 2WW referrals were screened by a colorectal consultant and a nurse specialist. Those deemed unsuitable for STT were offered outpatient assessment (OPA).

RESULTS

Of 553 2WW referrals screened, 352 were considered suitable, 65 of whom failed a telephone assessment or were uncontactable, and accordingly 287 were offered the STT pathway. The STT group was significantly younger than the OPA group (median 65.9 years vs 78.7 years; P < 0.0001). STT colonoscopy significantly reduced the time to first test (13 days vs 22 days; P < 0.0001) and tissue diagnosis from the referral date (17 days vs 24.5 days; P < 0.0001). Thirty-seven (6.8%) CRCs were detected. Proportionately fewer patients in the STT pathway were managed with 'best supportive care only' compared with patients attending OPA (one of 15 vs six of 22, respectively). STT colonoscopy obviated the need for clinic attendance before testing in 287 patients, representing a potential net cost benefit of at least £48 500 in 4 months.

CONCLUSION

STT colonoscopy was safe and effective for selecting out a group of symptomatic patients who could proceed straight to endoscopic examination and receive a diagnosis more rapidly.