Outcomes in 2748 patients referred to a colorectal two-week rule clinic

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.

Trends in urgent referrals for suspected colorectal cancer: an increase in quantity, but not in quality

INTRODUCTION An understanding of the volume of incoming referrals to a colorectal cancer (CRC) service is essential for adequate delivery of service. We hypothesised that the number of 2-week-wait (2WW) referrals has increased over recent years, with a concomitant increase in demand for endoscopic and imaging investigations. METHODS A retrospective review of all referrals from primary care with suspected malignancy to Barking, Havering and Redbridge NHS Trust (BHRNHST, London, UK) from 2009 to 2014 was undertaken. Annual numbers of CRC diagnoses, colonoscopies and CT scans among these patients were reviewed. Linear regression models were used to determine the significance of observed trends. RESULTS Annual number of 2WW referrals for all cancers increased steadily from 14,031 to 19,983 during the study period (p<0.01). Referrals for suspected CRC increased from 1,706 to 2,874 (p=0.02). Number of colonoscopies and CT scans carried out in 2WW patients also increased significantly. Proportion of patients referred as a 2WW diagnosed with CRC decreased from 7.9% in 2009 to 4.7% in 2014 (p=0.02). DISCUSSION Number of referrals for suspected cancer from primary care to BHRNHST is increasing steadily, which has implications for service provision. Prevalence of cancer diagnoses from these referrals is decreasing. CONCLUSIONS There has been a sustained and substantial increase in the number of urgent referrals for suspected CRC at BHRNHST over recent years, without an increase in the number of resulting cancer diagnoses.

Prevalence of pelvic floor symptoms in female patients attending the two-week wait clinic with suspected colorectal cancer

Introduction The aim of this study was to establish the prevalence of pelvic floor symptoms in women referred to a colorectal two-week wait (2WW) clinic with suspected colorectal cancer. Methods A questionnaire assessing faecal incontinence (FI) (Wexner score) and obstructed defecation syndrome (ODS) (Renzi score) was offered to 98 consecutive female patients attending a colorectal 2WW clinic at a single trust. Results Overall, 56 (57%) of the 98 patients had significant ODS and/or FI (scores >9/20), 33 (34%) had ODS and 40 (41%) had FI. Seventeen patients (17%) had both ODS and FI. Analysis of the 63 patients referred with a change in bowel habit (CIBH) showed 40 (63%) to be Renzi and/or Wexner positive compared with 16 (46%) of the 35 patients who presented without CIBH (p=0.095, Fisher's exact test). Further analysis showed that 31 (78%) of the 40 patients with FI presented with CIBH compared with 32 (55%) of the 58 without FI (p=0.032). In terms of ODS, 23 (70%) of the 33 patients with ODS presented with CIBH compared with 40 (62%) of the 65 without ODS (p=0.506). Conclusions Over half of the female patients attending our colorectal 2WW clinic had significant pelvic floor dysfunction (FI/ODS), which may account for their symptoms (especially in the CIBH referral category). While it is important for malignancy to be excluded, many patients may benefit from investigation and management of their pelvic floor dysfunction as the cause for their presenting symptoms.

Views of general practitioners and head and neck surgeons on the referral system for suspected cancer: a survey

BACKGROUND

The two-week wait referral system for suspected cancer was introduced in the National Health Service in 2000. This study aimed to identify areas for improvement to the two-week wait system by seeking the opinions of doctors working in primary and secondary care.

METHOD

A questionnaire was distributed to general practitioners and head and neck surgeons within North West England with ethical consent.

RESULTS

Twenty-seven general practitioners and 15 head and neck surgeons responded. Of the general practitioners, 59.3 per cent declared that they never attend training on referrals in this specialty. Overall, 59.3 per cent of general practitioners and 86.7 per cent of head and neck surgeons felt that the two-week wait system could be improved.

CONCLUSION

The main areas for further work are development of pre-referral communication between primary and secondary care along with development of practical educational measures for general practitioners.

The 2-week wait service: a UK tertiary colorectal centre's experience in the early identification of colorectal cancer

OBJECTIVES

National Institute for Health and Clinical Excellence (NICE) guidelines were introduced in the UK to ensure that patients with high-risk symptoms of colorectal cancer were reviewed promptly. We assessed the proportion of patients referred to our department's nurse-led 2-week wait (2WW) clinic with high-risk symptoms or signs that met these guidelines and the rate of colorectal cancer pickup.

PATIENTS AND METHODS

Patients were identified from a prospectively maintained logbook of 2WW referrals over a 1-year period (1 January 2008-31 December 2008). Computerized notes were reviewed to obtain the following information: referral symptoms or signs and the proportion of patients diagnosed with colorectal cancer.

RESULTS

A total of 720 patients were seen in the 2WW clinic over this period. Only 356/720 (49.4%) met the referral criteria. The overall pickup rate of colorectal cancer was 52/720 (7.2%) and was not found to be significantly higher in patients meeting guidelines compared with those who did not exhibit these features (7.6 vs. 6.9%; P=0.771). Over the 5-year follow-up period, no patients discharged from the 2WW pathway subsequently re-presented with colorectal cancer.

CONCLUSION

Over half of the referrals did not meet the NICE criteria, suggesting that the system is being used as a rapid access route to investigation. Despite this, there is no significant difference in the pickup rate of colorectal cancer in patients with or without high-risk features. Nurse-led 2WW clinics with subsequent investigation appear to be effective in both the identification and exclusion of colorectal cancer.

The effectiveness of a rapid-access flexible sigmoidoscopy clinic in a district hospital

Historically rapid-access colorectal clinics have had high proportions of nonconforming referrals from primary care physicians, which calls into question the clinics' efficacy. We aim to determine the effectiveness of our rapid-access flexible sigmoidoscopy clinic, and the adherence to the referral guidelines for suspected bowel cancer by general practitioners. We performed a 3-month retrospective audit to evaluate (1) the proportion of patients seen within 2 weeks, (2) the appropriateness of referrals, (3) the proportion of patients with findings, and (4) the proportion of patients who had further tests. A total of 59 patients (19 male, 40 female; age 35-86 years) were included in the study. All were offered an appointment within 2 weeks. Forty-one cases (82%) were appropriate referrals. Twenty-eight patients (47%) had pathology at sigmoidoscopy. Cancer pick-up rate was 6%. Thirty-seven patients (74%) had further investigations. We determined that our rapid-access clinic for symptomatic patients has high diagnostic accuracy and that access to early investigation is being used appropriately by general practitioners. In the current climate of spending cuts and streamlining services, our study confirms we are meeting targets for delivery of our colorectal service. The majority of referrals under the 2-week rule are appropriate. Rapid access to early investigation is being used appropriately by general practitioners contrasting previous studies with high proportions of nonconforming referrals.

Same-day assessment and management of urgent (2-week wait) colorectal referrals: an analysis of the outcome of 1606 patients attending an endoscopy unit-based colorectal clinic

AIM

The Rapid Access Diagnosis and Remedy (RADAR) clinic combines 2-week wait (TWW) specialist consultation with 'straight-to-test' flexible sigmoidoscopy (FS) for left-sided 'red-flag' TWW criteria (excluding right-sided mass or iron-deficiency anaemia). The study aims were to determine the effectiveness of RADAR in differentiating colorectal cancer from benign disease and to evaluate the need for whole colonic investigation (WCI) following FS, in symptomatic patients.

METHOD

Prospectively collated data of all RADAR patients from November 2005 to November 2009 were analysed, excluding patients referred internally for a FS. The local histology database was later interrogated to detect any missed cancers.

RESULTS

Of 1690 patients (729 men; median (range) age: 68 (18-96) years) assessed in RADAR, 84 were excluded. Colorectal cancer (CRC) was diagnosed in 117 (7.3%). Eighty-seven cancers were diagnosed on the day of attendance and a further 13 within a week (88.9% overall). Two patients after a cancer-free FS were found to have a right-sided CRC on WCI (0.24%) and one synchronous cancer was found. No patient with a cancer-free FS having a WCI was subsequently found to have CRC at a median of 35 (12-58) months.

CONCLUSION

Flexible sigmoidoscopy, in the context of an endoscopy unit TWW clinic, allows same-day diagnosis of most patients referred with left-sided symptoms, and immediate reassurance and treatment of most benign diagnoses. For these patients, the use of routine WCI following a cancer-free FS does not appear to be beneficial. Adopting this system would significantly reduce the number of barium enemas and colonoscopies currently performed.

The Two-Week Referral System for colorectal cancer--not fit for purpose

PURPOSE

The UK government target expects all suspected colorectal cancer (CRC) patients to be seen within the Two-Week Referral (TWR) system made by general practitioners. These guidelines originally derived from only level 5 evidence. However, this has significant impact on the workload for colorectal surgeons. The aim of the study is to investigate the effectiveness of this colorectal service and whether the referral criteria are predictive of CRC.

METHODS

A retrospective study of all patients referred under the TWR guidance in 2010 was assessed. The first 573 TWRs were piloted for analysis. Clinical information from each patient was collected regarding TWR criteria and additional colorectal symptoms or risk factors. Multiple regression analysis was performed to determine which symptoms independently correlated with CRC.

RESULTS

One hundred twenty-six CRCs were diagnosed via all methods of referral in 2010. There were 940 patients referred under the TWR guidelines in that year, when 50 CRC patients were identified. Amongst the 573 patients, 32 CRCs were diagnosed. Multiple regression analysis revealed tenesmus to be independently associated with CRC (p = 0.003, Pearson's r = 0.09185). None of the individual TWR criteria confidently predicted CRC.

CONCLUSION

Our preliminary results suggest that the current TWR guidelines cannot effectively predict CRC. There is an urgent need for an evidence-based approach to referral criteria for suspected CRC.

Patients' experiences of referral for colorectal cancer

Background

Outcomes for colorectal cancer patients vary significantly. Compared to other countries, Australia has a good record with patient outcomes, yet there is little information available on the referral pathway. This paper explores the views of Australian patients and their experiences of referral for colorectal cancer treatment following diagnosis; the aim was to improve our understanding of the referral pathway and guide the development of future interventions.

Methods

A purposive sampling strategy was used, recruiting 29 patients representing urban and rural areas from 3 Australian states who participated in 4 focus groups. Seven patients provided individual interviews to supplement the data. Recordings were transcribed verbatim, data was coded with NVivo software and analysed thematically before deductive analysis.

Results

Four aspects of the referral process were identified by patients, namely detection/diagnosis, referral for initial treatment/specialist care, the roles of the GP/specialist, and the patient’s perceived involvement in the process. The referral process was characterised by a lack of patient involvement, with few examples of shared decision-making and few examples of limited choice. However, patients did not always feel they had the knowledge to make informed decisions. Information exchange was highly valued by patients when it occurred, and it increased their satisfaction with the process. Other factors mediating care included the use of the public versus private health system, the quality of information exchange (GP to specialist and GP to patient), continuity of care between GP and specialist, and the extent of information provision when patients moved between specialist and GP care.

Conclusions

Patients described poor GP continuity, ad hoc organisational systems and limited information exchange, at both interpersonal and inter-organisational levels, all leading to sub-optimal care. Implementation of a system of information feedback to GPs and engagement with them might improve information exchange for patients, enabling them to be more involved in improved referral outcomes.

Repeat 2-week wait referrals for colorectal cancer

AIM

The inappropriate use of the '2-week wait' pathway for suspected colorectal cancer (CRC2ww) may overload urgent clinics and delay the assessment and investigation of other patients. Those who have been previously referred and investigated for suspected colorectal cancer may present one group that does not warrant repeat urgent referral. This paper aims to identify the incidence and diagnostic yield of repeat CRC2ww referrals.

METHOD

All CRC2ww patients referred to our unit over a 4-year period were identified retrospectively. Referral indication, outcome and instances of repeat referral were identified from multidisciplinary team, endoscopy and imaging databases.

RESULTS

In all, 2735 CRC2ww referrals were made over the study period. Of these, 122 were repeated CRC2ww referrals, with the incidence increasing from 2% in 2008 to 6% in 2010 (P = 0.0006). The median time to repeat referral was 1070 days. After initial referral 267 cancers were detected, including 212 colorectal cancers. The diagnostic yield was lower but not significantly so after repeated referral (six cancers) compared with initial referral (5%vs 10%, P = 0.07).

CONCLUSION

The incidence of repeat referral is low but the diagnostic yield is not insignificant. Exclusion of these patients from urgent assessment and investigation will not significantly reduce workload and may risk missing some patients with cancer.

Analysis of referral pathways in patients diagnosed with urological cancer

Objective:

To compare the clinical pathways of patients referred under the two-week rule (2WR) with those referred in a standard manner and subsequently diagnosed as having urological cancer.

Patients and methods:

A retrospective case note review was undertaken of 209 patients coded as having urological cancer over a six-month period. Patients that were not referred through either pathway, who had no symptoms or signs suspicious of cancer or who did not have a newly-diagnosed cancer during this period were excluded. The dates of relevant clinical events within each patient pathway were recorded and compared (e.g. dates of referral, first clinic appointment, diagnosis and first treatment).

Results:

Of the 209 cases reviewed, 58 cases were excluded. Eighty-two cases were referred through the standard referral pathway and 69 by the 2WR. Overall, patients referred through the 2WR pathway were seen sooner, had their cancer diagnosed earlier and received treatment more quickly than those referred through the standard route. However, the delay between diagnosis and treatment was similar for both groups. Prostate cancer accounted for two thirds of diagnoses, with 54% of 2WR referrals having advanced disease and 66% of cases with localised disease being referred by the standard route.

Conclusion:

The 2WR accelerates all clinical event times but with little clinical advantage to the patient. The 2WR for suspected cancer should be abandoned in favour of retention of the existing 18-week standard for the commencement of treatment following referral.

Assessment of a rapid referral pathway for suspected colorectal cancer in Madrid

OBJECTIVE

To assess the results achieved with a rapid referral pathway for suspected colorectal cancer (CRC), comparing with the standard referral pathway.

METHODS

Three-year audit of patients suspected of having CRC routed via a rapid referral pathway, and patients with CRC routed via the standard referral pathway of a health care district serving a population of 498,000 in Madrid (Spain). Outcomes included referral criteria met, waiting times, cancer diagnosed and stage of disease.

RESULTS

Two hundred and seventy-two patients (mean age 68.8 years, SD 14.0; 51% male) were routed via the rapid referral pathway for colonoscopy. Seventy-nine per cent of referrals fulfilled the criteria for high risk of CRC. Fifty-two cancers were diagnosed: 26% Stage A (Astler-Coller), 36% Stage B, 24% Stage C and 14% Stage D. Average waiting time to colonoscopy for the rapid referral patients was 18.5 days (SD 19.1) and average waiting time to surgery was 28.6 days (SD 23.9). Colonoscopy was performed within 15 days in 65% of CRC rapid referral patients compared to 43% of standard pathway patients (P = 0.004). Overall waiting time for patients with CRC in the rapid referral pathway was 52.7 days (SD 32.9); while for those in the standard pathway, it was 71.5 days (SD 57.4) (P = 0.002). Twenty-six per cent Stage A CRC was diagnosed in the rapid referral pathway compared to 12% in the standard pathway (P < 0.001).

CONCLUSION

The rapid referral pathway reduced waiting time to colonoscopy and overall waiting time to final treatment and appears to be an effective strategy for diagnosing CRC in its early stages.

Use of a patient consultation questionnaire and weighted numerical scoring system for the prediction of colorectal cancer and other colorectal pathology in symptomatic patients: a prospective cohort validation study of a Welsh population

OBJECTIVE

There is currently no system in widespread use that accurately prioritizes colorectal referrals in symptomatic patients with an acceptable degree of sensitivity and specificity. We have validated a weighted numerical scoring system for the prioritization of such colorectal referrals in an attempt to rectify this, with detection of colorectal cancer (CRC) the primary outcome.

METHOD

We conducted a prospective study of symptomatic patients referred by primary care to the colorectal service in a district general hospital. A computer-generated weighted numerical score (WNS) was derived from the primary symptoms and symptom combinations. Patients underwent colorectal investigations and a final diagnosis was established. Sensitivity, specificity and accuracy of CRC detection as determined by the WNS, Department of Health (DOH) and National Institute for Health and Clinical Excellence guidelines was determined. Primary Care compliance with guidelines was analysed.

RESULTS

A definitive diagnosis was established in 3457 patients. One hundred and eighty-six (5.4%) had CRC. The mean score for the cancer patients (76.9, 95%CI 72-81) was significantly higher than that of non-cancer patients (52, 95%CI 52-53) P < 0.001. Receiver Operator Curve analysis demonstrates a high discriminatory power for the Patient Consultation Questionnaire (PCQ) with an area under curve of 0.76. Compliance by primary care with the nationally recommended referral guidelines was poor with only 55% and 58% compliance with DOH and National Institute for Clinical Excellence referral guidelines for suspected cancer respectively.

CONCLUSION

The PCQ and the WNS is an efficient, objective system that allows the accurate prioritization of colorectal referrals with a high sensitivity for cancer and other serious colorectal pathologies.

How important is it to investigate the whole of the colon after initial assessment at a rapid access colorectal clinic?

BACKGROUND

The Stirling Royal Infirmary Rapid Access Colorectal Clinic (RACC) is a one-stop clinic that uses flexible sigmoidoscopy as the initial investigation to diagnose patients referred urgently with colorectal symptoms. This study aimed to examine the diagnoses and outcomes of patients who attended the RACC in 2006.

PATIENTS AND METHODS

All patients who attended the RACC from 1 January 2006 to 31 December 2006 were identified and retrospectively reviewed from our prospectively collected unit database and case notes.

RESULTS

Five hundred ninety-one patients attended the RACC in 2006. One hundred sixteen (19.6%) patients were discharged after the first clinic attendance, and the remaining 475 (80.4%) had further investigations or clinic review. There were 370 barium enemas requested with 92.4% compliance. The most common pathology identified by barium enemas was diverticular disease which only required reassurance and lifestyle changes. There were nine false-positive findings from barium enemas requiring further investigations. Of the 105 patients without barium enema, 49 had a colonoscopy. In total, 42 colorectal cancers were diagnosed with 34 (81.0%) distal to the splenic flexure and eight (19.0%) proximal. Of these, 32 (76%) were diagnosed by flexible sigmoidoscopy, three (7%) by barium enemas, three (7%) by colonoscopy, and four (10%) by computed tomography.

CONCLUSIONS

A rapid access colorectal clinic using flexible sigmoidoscopy as the initial diagnostic test was safe and effective in investigating distal colonic pathologies. However, over two thirds of patients proceeded to imaging of the remaining colon, and most of them were found to have only benign pathologies. The cost effectiveness and acceptability of this were unclear.

The one-stop trial: does electronic referral and booking by the general practitioner (GPs) to outpatient day case surgery reduce waiting time and costs? A randomized controlled trial protocol

Background

Waiting time and costs from referral to day case outpatient surgery are at an unacceptably high level. The waiting time in Norway averages 240 days for common surgical conditions. Furthermore, in North Norway the population is scattered throughout a large geographic area, making the cost of travel to a specialist examination before surgery considerable. Electronic standardised referrals and booking of day case outpatient surgery by GPs are possible through the National Health Network, which links all health care providers in an electronic network. New ways of using this network might reduce the waiting time and cost of outpatient day case surgery.

Materials and Methods

In a randomised controlled trial, selected patients (inguinal hernia, gallstone disease and pilonidal sinus) referred to the university hospital are either randomised to direct electronic referral and booking for outpatient surgery (one stop), or to the traditional patient pathway where all patients are seen at the outpatient clinic several weeks ahead of surgery.

Consultants in gastrointestinal surgery designed standardised referral forms and guidelines. New software has been designed making it possible to implement referral forms, guidelines and patient information in the GP's electronic health record. For "one-stop" referral, GPs must provide mandatory information about the specific condition. Referrals were linked to a booking system, enabling the GPs to book the hospital, day and time for outpatient surgery. The primary endpoints are waiting time and costs. The sample size calculation was based on waiting time. A reduction in waiting time of 60 days (effect size), 25%, is significant, resulting in a sample size of 120 patients in total.

Discussion

Poor communication between primary and secondary care often results in inefficiencies and unsatisfactory outcomes. We hypothesised that standardised referrals would improve the quality of information, making it feasible to use a one-stop approach for all patients undergoing surgery on an outpatient basis for inguinal hernia, pilonidal sinus and gallstones.

In this study we wanted to investigate the waiting time and cost-effectiveness of direct electronic referral and booking of outpatient surgery compared to the traditional patient pathway, where the patient is seen at the outpatient clinic prior to surgery.

Trial registration

This trial has been registered at ClinicalTrials.gov. The trial registration number is: NCT00692497