Straight to colonoscopy: the ideal patient pathway for the 2-week suspected cancer referrals?

The increasing burden of the 2-week wait colorectal cancer pathway in a single centre: the impact of faecal immunochemical tests

INTRODUCTION

Two-week wait (TWW) volume and colorectal cancer (CRC) detection pose an increasing challenge for NHS cancer services. Primary aims were to assess the introduction of faecal immunochemical tests (FIT) into clinical practice at our centre, the impact on TWW referral volume and CRC diagnoses, and to provide an update to previously published work. A secondary aim was to correlate FIT value and investigation.

METHODS

TWW CRC data following incorporation of FIT into clinical practice were analysed (1 June 2019-31 July 2021). Parameters assessed were monthly referral volume, CRC detection, primary care FIT volume and secondary care investigations. Referrals and CRC detection rates were compared with previously published data (2009-2019). Data relating to primary care FIT were collated from Berkshire and Surrey Pathology Services.

RESULTS

TWW referrals increased 360% (2009-2020). CRC incidence decreased from 8.87% to 3.24%. Following incorporation into clinical practice, primary care FIT requests have increased to >450/month and accompanied 1,722/4,796 referrals. CRC incidence is static (3-4%). Patients with FIT <10µg Hb/g faeces undergo radiological imaging more commonly, whereas FIT-positive patients are more likely to undergo endoscopy, although the difference is not statistically significant.

CONCLUSIONS

No significant change in CRC diagnosis was observed, despite increasing TWW referrals. Increasing utilisation of FIT in both primary and secondary care has helped maintain CRC detection while avoiding diagnostic delay. This study supports growing evidence highlighting the value of FIT in triage, referral and TWW investigation. FIT appears increasingly important for allocating secondary care resources (endoscopy), while guiding primary care referral. Additional low-cost strategies to determine prioritisation or reassurance (e.g. repeat FIT) require further evaluation.

The rapid assessment for prostate imaging and diagnosis (RAPID) prostate cancer diagnostic pathway

OBJECTIVE

To report outcomes within the Rapid Assessment for Prostate Imaging and Diagnosis (RAPID) diagnostic pathway, introduced to reduce patient and healthcare burdens and standardize delivery of pre-biopsy multiparametric magnetic resonance imaging (MRI) and transperineal biopsy.

PATIENTS AND METHODS

A total of 2130 patients from three centres who completed the RAPID pathway (3 April 2017 to 31 March 2020) were consecutively entered as a prospective registry. These patients were also compared to a pre-RAPID cohort of 2435 patients. Patients on the RAPID pathway with an MRI score 4 or 5 and those with PSA density ≥0.12 and an MRI score 3 were advised to undergo a biopsy. Primary outcomes were rates of biopsy and cancer detection. Secondary outcomes included comparison of transperineal biopsy techniques, patient acceptability and changes in time to diagnosis before and after the introduction of RAPID.

RESULTS

The median patient age and PSA level were 66 years and 6.6 ng/mL, respectively. Biopsy could be omitted in 43% of patients (920/2130). A further 7.9% of patients (168/2130) declined a recommendation for biopsy. The percentage of biopsies avoided among sites varied (45% vs 36% vs 51%; P < 0.001). In all, 30% (221/742) had a local anaesthetic (grid and stepper) transperineal biopsy. Clinically significant cancer detection (any Gleason score ≥3 + 4) was 26% (560/2130) and detection of Gleason score 3 + 3 alone constituted 5.8% (124/2130); detection of Gleason score 3 + 3 did not significantly vary among sites (P = 0.7). Among participants who received a transperineal targeted biopsy, there was no difference in cancer detection rates among local anaesthetic, sedation and general anaesthetic groups. In the 2435 patients from the pre-RAPID cohor, time to diagnosis was 32.1 days (95% confidence interval [CI] 29.3-34.9) compared to 15.9 days (95% CI 12.9-34.9) in the RAPID group. A total of 141 consecutive patient satisfaction surveys indicated a high satisfaction rate with the pathway; 50% indicated a preference for having all tests on a single day.

CONCLUSIONS

The RAPID prostate cancer diagnostic pathway allows 43% of men to avoid a biopsy while preserving good detection of clinically significant cancers and low detection of insignificant cancers, although there were some centre-level variations.

Straight to test reduces time to investigation and treatment

Straight to test (STT) is a recognised pathway for improving the waiting time for red flag referrals. Electronic patient care records (ECR) provide clinicians with a greater volume of clinical information allowing virtual triage and STT. We aimed to assess if using ECR and STT can reduce delays in diagnosis and treatment. A review of 300 colorectal referrals between 2018-2019 was performed. Patients awaiting an appointment were reviewed electronically, by a single colorectal surgeon and re-triaged STT if appropriate. The delay in time from referral to initial review was removed, creating a second group for statistical comparison to demonstrate time saved if the strategy was adopted at the point of original triage. 91.3% (n= 274) were red flag referrals. 94% (n=282) were sent STT. Patients processed via traditional referral and clinic had a median time to scope of 36 days compared with 22.5 days, p < 0.001 if triaged STT via virtual clinic. Median time to management was 59 days for traditional and 35 days for STT, p < 0.001.

"One stop" clinic for upper gastrointestinal cancer-an alternative to "straight to test" referrals?

BACKGROUND

Patients suspected to have upper gastrointestinal (UGI) cancer can be referred directly for investigation; however, at times this may result to inappropriate referrals. This study explores the model of a "one-stop" clinic as an alternative to the direct referral system. The current study aims to assess the feasibility and outcomes of a one-stop UGI clinic and evaluate sensitivity and specificity of "on-the-day" diagnoses.

METHODS

A retrospective analysis of case notes of patients seen in one-stop clinic, between January 2017 and January 2019, was conducted. All General Practitioner (GP) referrals were screened by a specialist nurse.

RESULTS

After completion of the post-GP referral screening process, 252 patients (median age 68 years, IQR 58.8-77.3 years; M:F ratio 118:134) were allocated to the one-stop clinic. OGD was not required, contra-indicated or declined in 27 cases (10.7%). The records of three patients could not be found. One patient did not attend. Overall, 221 patients underwent testing and received "on-the-day" diagnoses. Sensitivity was 94% (range 87-100%), and specificity was 92% (88-96%). Ninety-six percent of patients received a diagnosis on the day.

CONCLUSIONS

The one-stop clinic was feasible and had good specificity and sensitivity. The finding of 10.7% of cases not being suitable for OGD indicates that a patient/specialist consultation is necessary to prevent misuse of endoscopy appointments. The authors recommend widespread adoption of one-stop clinics in UGI surgery.

Straight-to-test colonoscopy: Has it improved the detection of colorectal cancer? A 7- year review

AIM

Early diagnosis of colorectal cancer (CRC) improves outcome. Straight-To-Test (STT) pathway was introduced in Whittington Hospital in 2012. The aim was to reduce the time to first oncological treatment and minimise unnecessary outpatient clinic appointments. However, this pathway has added significant burden to the trust in terms of number of procedures to be done.We assessed the diagnostic yield and the effectiveness of this pathway in improving the time to diagnosis of colorectal cancer. We also performed a cost-effective analysis and discussed the current literature along with interventions to further improve the benefits of STT investigations.

METHOD

This is a prospectively collected data of all patients who underwent STT examinations in a single centre from January 2012 till December 2018. The parameters collected were patient details, procedures performed, findings and discharge plan. We also performed a cost-effective analysis.

RESULTS

A total 1648 (90.8%) of patients identified suitable for STT pathway underwent colonoscopy or flexible sigmoidoscopy. From this, 764 (50.2%) patients had diagnosed pathology and CRC was detected in 50(3%) of the patients. We also estimated annual savings of £ 21,599.54 (£151,196.76 in seven years). Patients on the STT pathway took 25 days to obtain results as compared to 40 days in the standard pathway. The decision to take the patient off the cancer pathway was shortened by 3 weeks.

CONCLUSION

STT pathway has proven to be safe and cost-effective means of investigation. However, further improvement is needed in the implementation to make it a sustainable. mode of investigation in long run and increase the pickup rate of colorectal cancer through STT.

COVID-19 recovery: tackling the 2-week wait colorectal pathway backlog by optimising CT colonography utilisation

AIM

To review the indications for computed tomography colonography (CTC) performed on patients referred via the 2-week wait colorectal pathway (2WWCP).

MATERIALS AND METHODS

A retrospective study was performed on all patients referred through the 2WWCP between October 2018 and September 2019. The referrals were audited against the National Institute for Health and Care Excellence (NICE) NG12/DG30 guidelines for referral to the 2WWCP, and against the Royal College of Radiologists (RCR) 2017 guidelines for CTC.

RESULTS

Over the study period, there were 1,707 2WWCP referrals, and 362 (21.2%) of these patients underwent CTC. The median age was 66 years, and 55% were female. Forty-six patients did not meet the NICE NG12/DG30 guidelines for referral to the 2WWCP, and a further 268, although meeting the NICE guidelines, did not meet the RCR 2017 guidelines for CTC. In total, only 13% of CTCs performed complied with both guidelines.

CONCLUSION

This audit demonstrated a significant opportunity to reallocate CTC resources in the recovery stage of the COVID-19 pandemic. To improve outcomes for colorectal cancer (CRC) in the UK, establishing a selective straight-to-test CTC 2WWCP should be considered. Documented consent detailing the risks and benefits of CTC versus colonoscopy should take place in order to assist the patient in making an informed choice.

Removing hospital-based triage from suspected colorectal cancer pathways: the impact and learning from a primary care-led electronic straight-to-test pathway

BACKGROUND

The 2-week wait referral pathway for suspected colorectal cancer was introduced in England to improve time from referral from a general practitioner (GP) to diagnosis and treatment. Patients are required to be seen by a hospital clinician within 2 weeks if their symptoms meet the criteria set by the National Institute for Health and Care Excellence (NICE) and to start cancer treatment within 62 days. To achieve this, many hospitals have introduced a straight-to-test (STT) strategy requiring hospital-based triage of referrals. We describe the impact and learning from a new pathway which has removed triage and moved the process of requesting tests from hospital to GPs in primary care.

METHOD

An electronic STT pathway was introduced allowing GPs to book tests supported by a decision aid based on NICE guidance eliminating the need for a standard referral form or triage process. The hospital identified referrals as being on a cancer pathway and dealt with all ongoing management. Routinely collected cancer data were used to identify time to cancer diagnosis compared with national data RESULTS: 11357 patients were referred via the new pathway over 3 years. Time from referral to diagnosis reduced from 39 to 21 days and led to a dramatic improvement in patients starting treatment within 62 days. Challenges included adapting to a change in referral criteria and developing a robust hospital system to monitor the pathway.

CONCLUSION

We have changed the way patients with suspected colorectal cancer are managed within the National Health Service by giving GPs the ability to order tests electronically within a monitored cancer pathway halving time from referral to diagnosis.

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.

Straight-to-test for the two-week-wait colorectal cancer pathway under the updated NICE guidelines reduces time to cancer diagnosis and treatment

INTRODUCTION

The 2015 National Institute for Health and Care Excellence guidelines widened the referral criteria for the two-week-wait pathway for suspected lower gastrointestinal cancer. We implemented a straight-to-test protocol to accommodate the anticipated increase in referrals. We evaluated the impact of these changes for relevant pathway metrics and clinical outcomes using a retrospective cohort study with historic controls.

MATERIALS AND METHODS

We analysed data from all patients referred to a teaching hospital via the two-week-wait pathway for suspected lower gastrointestinal cancer under the previous guidelines between 1 March and 31 August 2015 compared with the same period in 2016, when the updated guidelines and straight-to-test protocol had been implemented.

RESULTS

In the 2015 cohort, there were 64 cancer diagnoses from 664 referrals (9.6% pick-up) compared with 58 cancer diagnoses from 954 referrals in the 2016 cohort (6.1% pick-up). Our straight-to-test protocol reduced the median time to cancer diagnosis by 12.5 days (P < 0.001) and reduced the median time to cancer treatment by 7.5 days (P < 0.05) An increased proportion of non-colorectal cancers were diagnosed in 2016 compared with 2015, (37.9% vs 17.2%, P < 0.05) and more adenomas were removed in 2016 compared with 2015 (377 vs 193).

DISCUSSION AND CONCLUSION

Our straight-to-test protocol has resulted in a reduction in times to cancer diagnosis and cancer treatment, despite an increase in the number of referrals. The new referral criteria have considerable resource implications, but their implementation did not result in an increase in the total number of cancers diagnosed.

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.

Improving colorectal cancer referrals

The colorectal services at The Royal Bournemouth Hospital needed to adapt to meet the extra demand on fast-track patient referrals to the outpatient department, as a consequence of the changes in the National Institute for Health and Care Excellence (NICE) guidance on cancer referrals in June 2015. Learning from other units, a telephone assessment clinic (TAC) triaging patients straight to colonoscopy was trialled. A Plan-Do-Study-Act (PDSA) methodology was used. A baseline study showed that fast-track colorectal patients referred from their general practitioner (GP) were taking on average 30 days until they received their colonoscopy. This quality improvement project focused on sending fast-track colorectal GP referrals through a straight-to-colonoscopy TAC. The results of this intervention showed an improvement from GP referral to colonoscopy. Both PDSA cycle 1 and PDSA cycle 2 showed an average of 24 days. This reduction of 6 days was a promising improvement in a 62-day patient pathway, so funds were accessed to invest in a temporary full-time TAC nurse appointment to allow more data to be collected. PDSA cycle 3 showed a reduction of the average from referral to colonoscopy to 19 days and a reduction in the variation. This outcome will be sustainable, as the TAC role is now a permanent position.

Early Colonoscopy Improves the Outcome of Patients With Symptomatic Colorectal Cancer

BACKGROUND

Long waiting times from early symptoms to diagnosis and treatment may influence the staging and prognosis of patients with colorectal cancer. We analyzed the effect of colonoscopy timing on the outcome of these patients.

OBJECTIVE

This study aimed to compare the outcome (tumoral staging and long-term survival) of patients with suspected colorectal cancer according to diagnostic colonoscopy timing.

DESIGN

This study is an analysis of a prospectively maintained database.

SETTINGS

The study was conducted at the Open Access Endoscopy Service of the tertiary public healthcare center Hospital Universitario de Canarias, in the Spanish island of Tenerife.

PATIENTS

Consecutive patients diagnosed of colorectal cancer between February 2008 and October 2010, fulfilling 1 or more National Institute for Health and Clinical Excellence criteria, were assigned to early colonoscopy (<30 days from referral) or to standard-schedule colonoscopy at the discretion of the referring physician. Tumor staging (TNM classification) at diagnosis and long-term survival after treatment were compared in both strategies.

MAIN OUTCOME MEASURES

The primary outcomes measured were the stage at presentation and overall survival, as determined by prompt or standard referral.

RESULTS

Overall, 257 patients with colorectal cancer were diagnosed (101 at early colonoscopy and 156 at standard-schedule colonoscopy). TNM stages I and II were found in 52 (54.2%) and 60 (41.7%) patients in the early colonoscopy group and standard-schedule colonoscopy group. Stage IV was confirmed in 13 patients (13.5%) diagnosed in the early colonoscopy group and in 40 (28%) detected in the standard-schedule colonoscopy group. Survival rates at 12 and 60 months after treatment were significantly higher in the early colonoscopy group compared with the standard-schedule colonoscopy group (p < 0.001).

LIMITATIONS

Controlled randomization of early versus standard-referral colonoscopy, size and scope of analysis, the time interval from symptom onset to first physician assessment, and the different locations of colorectal cancer between groups were limitations of the study.

CONCLUSIONS

Colonoscopy within 30 days from referral improves outcome in patients with symptomatic colorectal cancer. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.

Primary-to-secondary care referral experience of suspected colorectal malignancy in young adults

INTRODUCTION

Colorectal cancer in patients younger than 50 years of age is increasing steadily in the UK with limited guidelines available indicating need for secondary care referral. The aims of this study were to report the cancer incidence in those aged under 50 years referred to secondary care with suspected colorectal malignancy and also to analyse the quality of those referrals.

METHODS

A total of 197 primary care referrals made between 2008 and 2014 to a UK district general hospital for suspected colorectal malignancy were analysed. All confirmed cancers were further evaluated regarding presenting symptoms, tumour characteristics and clinical outcomes. Each referral was given a referral performance score (out of 9) dependant on relevant information documented.

RESULTS

The overall malignancy rate was 9.1% (11 male and 7 female patients). The median age in this cohort was 41.5 years (interquartile range [IQR]: 37-49 years). Abdominal pain was the only presenting symptom to differ significantly when comparing malignant with non-malignant patients (44.4% vs 21.8% respectively, p=0.042). The median time period between referral date and colorectal specialist consultation was 11 days (IQR: 7-13 days) and the median referral performance score was 5 (range: 3-9).

CONCLUSIONS

Malignancy is prevalent in patients under 50 years of age who are referred to secondary care for suspected colorectal cancer. Those referred with abdominal pain in the presence of other high risk lower gastrointestinal symptoms are at significant risk of having a malignancy. Major deficiencies are apparent in urgent primary care referrals, highlighting the need for further national guidance to aid early diagnosis of colorectal cancer in the young.

Improving the diagnostic stage of the suspected colorectal cancer pathway: A quality improvement project

We aimed to improve the lead-time and the patient experience of the diagnostic stage of the suspected colorectal cancer pathway. This project worked within the constraints of limited resources and an austere environment. The core team included a project manager trained in quality improvement methodologies. Senior and Fleming's planned change model was used as the overall framework. Baseline data supported the case for change and highlighted targets for improvement. A stakeholder workshop employed social movement theory, lean thinking, experience-based design and patient stories to engage influential leaders and secure support and commitment. Solutions that arose from the workshop were then researched. A "Genchi Genbutsu" ethos took the team to Northumbria to learn about another unit's pathway innovations. Subsequently, our new pathway employed solutions aimed at increasing the proportion of patients who went straight-to-test. Consensus on the design was achieved using Schein's process consultation theory. Implementation of the new pathway resulted in a significant reduction in the median time from referral to endoscopy from 26 days to 14 days (P<0.001), and a significant increase in the proportion going straight-to-test from 6% to 43%. Changes to improve patient experience were also implemented, however data to evidence this has not yet been collected. Going forward, further standardisation is required and issues around sustainability need to be tackled. This project exemplified, amongst others, the value of working from data from the beginning and a comprehensive early stakeholder engagement.

The straight to test endoscopy service for suspected colorectal cancer: meeting national targets but are we meeting our patients' expectations?

AIM

The NHS Cancer Plan describes initiatives to improve patient care in the UK, including the two-week rule cancer referral pathway. To meet this target a straight to test (STT) endoscopy service was devised to expedite diagnosis of suspected colorectal cancer. Our novel study aimed to determine patient satisfaction with this new approach to rapid access investigation.

METHOD

An anonymized questionnaire was posted to 300 patients who had undergone STT endoscopy in our unit between January and June 2010. It assessed satisfaction with the service overall, time from referral to investigation, pre-test information, bowel preparation instructions and time to results as well as preference for a traditional pre-test or post-test outpatient appointment and awareness that the referral was for suspected bowel cancer.

RESULTS

In all, 174 questionnaires were obtained (58% yield; mean age 68.8; 44.8% men). 82.2% of patients were 'very satisfied' with the service overall, 82.8% with time from referral to test, 75.2% with time from test to results, 73% with endoscopy information and 69.5% with bowel preparation instructions. Eight per cent would rather have seen a specialist prior to endoscopy, 31.6% would have preferred a post-test appointment and 68.4% of patients were aware that referral was for suspected bowel cancer.

CONCLUSION

Straight to test is popular with patients. It offers a fast and cost effective service in the diagnosis of colorectal cancer and meets national targets whilst reducing the volume burden on outpatient clinics. However, its success heavily relies on accurate communication between general practitioner, patient and secondary care.

The impact of the two-week wait referral pathway on rectal cancer survival

AIM

The aim of this study was to compare the outcome of patients with rectal cancer referred through the two-week wait (TWW) system with those identified by routine referral pathways (non-TWW).

METHOD

A prospective study was carried out of 125 consecutive patients diagnosed with rectal cancer between January 2000 and December 2005 (6 years) in one district general hospital. Data were recorded prospectively in a local clinicopathological registry. The patients were divided into two groups: group 1 (TWW) and group 2 (routine referral pathway).

RESULTS

Fifty-two (41%) of the 125 patients were diagnosed through the TWW (group 1). There was no significant difference in patient demographics, including baseline tumour characteristics, between the two groups. There was no difference in preoperative or postoperative T stage between the two groups (P = 0.63). There was no significant difference in circumferential margin positivity (five of 52 in group 1 vs four of 73 in group 2; P = 0.52) or local recurrence rates (P = 0.37). The 5-year all-cause mortality was 49% for group 1 and 52% for group 2 (P = 0.3). The overall disease-free survival was similar in the two groups (1521 days for group 1 vs 1591 days for group 1, P = 0.29).

CONCLUSION

Referral under the TWW strategy does not translate into improved survival in rectal cancer.