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 gut microbiota in adults with cystic fibrosis compared to colorectal cancer

BACKGROUND

Gut dysbiosis is implicated in colorectal cancer (CRC) pathogenesis. Cystic fibrosis (CF) is associated with both gut dysbiosis and increased CRC risk. We therefore compared the faecal microbiota from individuals with CF to CRC and screening samples. We also assessed changes in CRC-associated taxa before and after triple CF transmembrane conductance regulator (CFTR) modulator therapy.

METHODS

Bacterial DNA amplification comprising V4 16S rRNA analysis was conducted on 84 baseline and 53 matched follow-up stool samples from adults with CF. These data were compared to an existing cohort of 430 CRC and 491 control gFOBT samples from the NHS Bowel Cancer Screening Programme. Data were also compared to 26 previously identified CRC-associated taxa from a published meta-analysis.

RESULTS

Faecal CF samples had a lower alpha diversity and clustered distinctly from both CRC and control samples, with no clear clinical variables explaining the variation. Compared to controls, CF samples had an increased relative abundance in 6 of the 20 enriched CRC-associated taxa and depletion of 2 of the 6 taxa which have been reported as reduced in CRC. Commencing triple modulator therapy had subtle influence on the relative abundance of CRC-associated microbiota (n = 23 paired CF samples).

CONCLUSIONS

CF stool samples were clearly dysbiotic, clustering distinctly from both CRC and control samples. Several bacterial shifts in CF samples resembled those observed in CRC. Studies assessing the impact of dietary or other interventions and the longer-term use of CFTR modulators on reducing this potentially pro-oncogenic milieu are needed.

O013 The increasing burden of the two-week wait colorectal cancer pathway within a single centre

Introduction

Increasing demand has placed colorectal cancer (CRC) two-week wait (TWW) pathways under pressure. The primary aims of this paper are to review TWW referral numbers and CRC diagnoses within our centre over the past 3 years (before, during and in recovery from the COVID-19 pandemic) and compare outcomes to our previously published data (2009–18). This incorporates the introduction of FIT into our clinical practice.

Methods

TWW CRC referral data from 1st July 2018–31st July 2021 was analysed. Parameters assessed; monthly TWW referrals, CRC detection, % of TWW referrals seen <14 days and investigations utilised. Data from January 2009 to 31 June 2018 was combined. Unpaired t-test was used to compare group means.

Results

TWW referrals have increased 360% from 2009 to 2020. The proportion of TWW referrals with CRC has decreased from 8.87% to 3.24% over this period, whilst the incidence of CRC remained static (mean 58.7 per annum). From 2009–18, TWW referrals=8921, CRC diagnoses=533, mean monthly CRC detection rate=4.7, ratio of referrals to CRC=16.7:1. From 2018–21, TWW referrals= 6523, CRC diagnoses=232, mean monthly CRC detection rate=6.3, ratio of referrals to CRC=28.4:1. There was a statistically significant difference in mean monthly referrals (p-value<0.00001) between the two periods.

Conclusion

Despite ever-increasing TWW referral numbers, no significant change in CRC diagnoses has occurred. We find our service under ever-increasing strain. Additional strategies and guidance are required to help address this. Further studies evaluating FIT and repeat FIT in the symptomatic TWW cohort may have a role in generating such a consensus.

Take-home message

Two week wait colorectal cancer referrals have increased 360% in 12 years. Colorectal cancer detection rate remains static over this timeframe.

The two-week rule colorectal cancer pathway: an update on recent practice, the unsustainable burden on diagnostics and the role of faecal immunochemical testing

INTRODUCTION

Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services.

METHODS

A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports.

FINDINGS

There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.

Diagnostic accuracy of placental growth factor and ultrasound parameters to predict the small-for-gestational-age infant in women presenting with reduced symphysis-fundus height

OBJECTIVES

To assess the diagnostic accuracy of placental growth factor (PlGF) and ultrasound parameters to predict delivery of a small-for-gestational-age (SGA) infant in women presenting with reduced symphysis-fundus height (SFH).

METHODS

This was a multicenter prospective observational study recruiting 601 women with a singleton pregnancy and reduced SFH between 24 and 37 weeks' gestation across 11 sites in the UK and Canada. Plasma PlGF concentration < 5(th) centile, estimated fetal weight (EFW) < 10(th) centile, umbilical artery Doppler pulsatility index > 95(th) centile and oligohydramnios (amniotic fluid index < 5 cm) were compared as predictors for a SGA infant < 3(rd) customized birth-weight centile and adverse perinatal outcome. Test performance statistics were calculated for all parameters in isolation and in combination.

RESULTS

Of the 601 women recruited, 592 were analyzed. For predicting delivery of SGA < 3(rd) centile (n = 78), EFW < 10(th) centile had 58% sensitivity (95% CI, 46-69%) and 93% negative predictive value (NPV) (95% CI, 90-95%), PlGF had 37% sensitivity (95% CI, 27-49%) and 90% NPV (95% CI, 87-93%); in combination, PlGF and EFW < 10(th) centile had 69% sensitivity (95% CI, 55-81%) and 93% NPV (95% CI, 89-96%). The equivalent receiver-operating characteristics (ROC) curve areas were 0.79 (95% CI, 0.74-0.84) for EFW < 10(th) centile, 0.70 (95% CI, 0.63-0.77) for low PlGF and 0.82 (95% CI, 0.77-0.86) in combination.

CONCLUSIONS

For women presenting with reduced SFH, ultrasound parameters had modest test performance for predicting delivery of SGA < 3(rd) centile. PlGF performed no better than EFW < 10(th) centile in determining delivery of a SGA infant.

Setting core standards: privacy, identity & interoperability

This position paper focuses on strategic developments and underlying concepts emerging out of the standards and associated domains. It addresses the issue of personal privacy in the wider context of interoperability across an ever-growing range of e-health and social care support systems and processes. These will increasingly be driven by major growth in the elderly segment of national populations where unambiguous identification of both patients and care staff both in hospitals and the community will become significant issues. This is particularly so where remote patient monitoring and access control to personal data is concerned, and is further complicated where racial, cultural and linguistic barriers are prevalent.

Cluster headache in children--experience from a specialist headache clinic

BACKGROUND

Cluster headache is a primary headache disorder with the distinct clinical features: unilaterality, extreme pain, cranial autonomic features and periodicity. The prevalence of the disorder is 0.1% in adults and with a male predominance. The age of onset is usually in the second and third decade of life but the onset in the first decade is recognised. We describe our experience of cluster headache in children and review the literature. We have attempted to define the clinical features of cluster headache in children as compared to adults, the role of clinical investigations, reliability of clinical diagnosis, effective treatment and management options.

METHODS

A retrospective casenotes review was conducted on all children with suspected cluster headache seen in our centre from 2000 to 2005. Case ascertainment was conducted using International Headache Society guidelines, and by telephone interviews with the parents.

RESULTS

Eleven children were identified, (seven male and four female). The median age of onset was 8.5 years (range 2-14). The median age at diagnosis was 11.5 years (range 7-17). Eight children had episodic and 3 children had chronic cluster headaches. The average attack duration was 72 min. The commonest reported bout frequency was one per day. Several children had circadian and circumannual periodicity and most displayed the other features of the disorder, such as agitated movement and cranial autonomic activation. Oxygen, methysergide, verapamil, zolmitriptan and dihydroergotamine were the drugs which were effective in terminating the headache. Paracetamol, ibuprofen and paracetamol/codeine combinations were not.

CONCLUSION

We describe our experience with cluster headache in eleven children who all presented before the age of 16.

Active ageing: independence through technology assisted health optimisation

The potential doubling in the percentage of the elderly within the populations of Europe and beyond over the next decades has focused informatics research on the development Assistive Technologies and Smart Homes. However its concentration on creating a supportive home environment also has the potential for makings its users over dependent on its facilities and as a result trapped within it. This paper outlines an approach that extends the smart homes concept out into the wider community to create a smart environment that not only maintains contact with all their home-based services, but also expands these to include other facilities needed to assist them whilst on the move. This involves the convergence of physiological monitoring, communications and computing with leading-edge textile technologies, which uses a multi-layered, multi-functional clothing system as a mobile and extended variant of a smart home IP hub. In addition to variable functionality capabilities of the clothing layers in terms of thermal, shock-absorbent and other characteristics, wireless IP connectivity is provided between layers with external links typically being WiFi enabled. Health optimisation is provided by on-going lifestyle guidance/action feedback based on auto-diagnostic analysis.

Assistive technology--behaviourally assisted

In considering the recurrent problems involved in technology led initiatives within the public sector, this paper seeks to identify change management requirements needed to help avoid these latent pitfalls in the widespread introduction of Assistive Technology. It develops a change process approach based on current clinical psychology techniques used in assessing sources and level of resistance to behavioural change and applies them to managing effective benefits realisation.

Benign paroxysmal torticollis of infancy: four new cases and linkage to CACNA1A mutation

Benign paroxysmal torticollis of infancy (BPTI) is a disorder characterized by recurrent episodes of head tilt secondary to cervical dystonia. Attacks are often accompanied by vomiting, pallor, and ataxia, settling spontaneously within hours or days. Episodes begin within the first 12 months of life and resolve by 5 years. We report four patients with BPTI. Symptoms started from 3 months of age, with head tilting lasting between 10 minutes and 2 months; the shorter episodes were followed by vomiting, apathy, and unsteadiness. Head tilt became less prominent after infancy, replaced by vertigo and eventually by migraine headaches. Two patients came from a kindred with familial hemiplegic migraine linked to CACNA1A mutation. BPTI may be regarded as a migraine aura equivalent. The syndrome poses interesting questions regarding varying phenotypic expression of calcium channelopathies at different stages of development.

An unknown combination of infantile spasms, retinal lesions, facial dysmorphism and limb abnormalities

A female patient is presented with infantile spasms, punched-out retinal lesions, facial dysmorphism, short upper arms, short thumbs, left lower limb hypoplasia with foot deformity, a hemivertebra, atrial septal defect, growth retardation and severe developmental delay. There is some similarity to patients with Aicardi syndrome (AS), but the retinal lesions in our patient are different and she does not have agenesis of the corpus callosum, one of the diagnostic features of AS. She might represent an atypical form of this syndrome with additional features, usually not present in AS. As there is no diagnostic test for AS yet, this diagnosis cannot be confirmed nor rejected with certainty. However, it might be more likely that our patient has another, possibly unique, condition.

Anterior forebrain pathway is needed for stable song expression in adult male white-crowned sparrows (Zonotrichia leucophrys)

The anterior forebrain pathway of the avian song system is involved in juvenile song learning, but its function in adult song behavior is not known. This report uses lesions to study the role of a particular forebrain nucleus, IMAN, in the seasonal regeneration of song in adult white-crowned sparrows (Zonotrichia leucophrys oriantha). White-crowned sparrows, even when acoustically isolated as juveniles, crystallize a single song which they maintain throughout adulthood. The lateral portion of the magnocellular nucleus of the anterior neostriatum (1MAN) was lesioned bilaterally in adult males maintained on short days (8 h of light). Daylength was increased to 16 h following the surgeries, and all birds were recorded in the post-lesion singing season. Lesioned birds showed a large decrease in song note frequency following the lesions, significantly larger than did intact, age-matched controls. Further changes were seen in the post-lesion songs of seven of 11 successfully lesioned males. These changes included variability in song pattern, loss of frequency control and addition of new notes, some of which had been practiced during juvenile song development. These changes seemed especially large in birds that had either been acoustically isolated or had not fully copied a tape-tutor song during juvenile song development. These results are the first to indicate that the motor memories for song elements that had been practiced and discarded early in life are retained, and they suggest that 1MAN affects seasonal song expression by selectively reinforcing a particular song pattern.

Lucifer Yellow filling of area X-projecting neurons in the high vocal center of female canaries

The avian high vocal center (HVC) is a complex forebrain nucleus that coordinates the sensorimotor integration necessary for song learning and production. It receives auditory and potentially somatosensory input, and sends major projections to vocal motor and anterior forebrain nuclei. The HVC has at least four morphological classes of neurons for which the connectivity remains uncertain. Previous studies have alluded to the functional identity of the cell classes, but none have provided the definitive evidence necessary for subsequent identification of behaviorally relevant changes within known neuronal populations. The cell filling technique we have adapted for use in the song system provides a method by which hodologically identified classes can be described with precision, and song related changes in their morphology can be readily identified. Neurons in female canaries (Serinus canarius) that project to Area X of the anterior forebrain pathway were retrogradely labeled, selectively filled with Lucifer Yellow in a fixed slice preparation, and converted to a Golgi-like stain through an immunocytochemical reaction. We have identified Area X-projecting neurons as belonging to the thick dendrite class of Nixdorf et al. [B.E. Nixdorf, S.S. Davis, T.J. DeVoogd, Morphology of golgi-impregnated neurons in hyperstriatum ventralis, pars caudalis in adult male and female canaries, J. Comp. Neurol. 284 (1989) 337-349] and have shown definitively that they are among the HVC neurons that can receive direct auditory input, as this cell class has short dendrites that extend into the shelf region ventral to HVC that is known to receive auditory inputs. Well-filled axons had collaterals that ramified and terminated within the nucleus, demonstrating a network through which Area X-projecting cells can contribute to intrinsic HVC communication.

Motion-deblurring in human vision

If photographs are taken of moving objects at slow shutter speeds the images of the objects are blurred. In human vision, however, we are not normally conscious of blur from moving objects despite the fact that the temporal response of the photoreceptors is sluggish. It has been suggested that there are motion-deblurring mechanisms specifically to aid the visual system in the analysis of the shape of retinally moving targets. Models of motion deblurring have been influenced by the finding that certain very precise spatial pattern discriminations are unaffected by motion. An example is vernier hyperacuity, in which the observer must detect the direction of offset between two lines with abutting ends. With a stationary stimulus, observers can detect a vernier cue of less than 10 arcsec and acuity is unaffected by retinal-image motion of up to 3 deg s-1 We confirm this finding, but provide evidence against any general deblurring mechanism by showing that another kind of hyperacuity, discrimination of the distance between two parallel lines (spatial interval acuity), is interfered with by motion. This argues against a general deblurring mechanism, such as a neural network 'shifter circuit', and we point out that the high level of vernier acuity for moving stimuli is susceptible to an alternative explanation.

Joubert syndrome

Joubert syndrome is an autosomal recessive condition in which there is a variable combination of central nervous system defects with a distinctive congenital retinal dystrophy, ocular motor abnormalities, and respiratory abnormalities in early infancy. The retinal dystrophy has been previously classified as a variant of Leber's congenital amaurosis. We report electrophysiologic and eye movement findings in a series of seven consecutive children with Joubert syndrome. Unlike patients with Leber's congenital amaurosis, all but one of these children had preserved flash and pattern-reversal visual evoked potentials. Six of the seven children had abnormalities of smooth pursuit, optokinetic nystagmus, and saccades. Six of the children had nystagmus: three had a pendular torsional nystagmus and three had a form of see-saw nystagmus. An alternating hyperdeviation was present in five of the patients, two of whom also had a tonic deviation of their eyes laterally. All seven patients had cerebellar vermis hypoplasia on a magnetic resonance imaging scan. Developmentally delayed children with an absent or highly attenuated electroretinogram should be investigated for Joubert syndrome.

Effect of lecithin on disability and plasma free-choline levels in Friedreich's ataxia

Four patients with Friedreich's ataxia took part in an open trial, in which they consumed 50-100g/day lecithin granules (containing approximately 22% phosphatidycholine) for 16 weeks, but no improvement resulted. Several unwanted effects including diarrhoea, nausea, depression, "hot flushes" and weakness were experienced. Resting levels of free-choline in plasma were within the range found in 19 normal subjects. Sixteen other patients with Friedreich's ataxia also had normal free-choline levels. Treatment with lecithin significantly increased plasma free-choline levels, but there was a trend for these to fall towards baseline levels, despite continued ingestion of lecithin.

Vision in the temporal crescent in occipital infarction

Four patients with hemianopias due to occipital infarction are described. In each of these patients there was useful residual vision in the unpaired temporal crescent. Moving stimuli were particularly well perceived in this part of the field. Preservation of the temporal crescent results in strikingly incongruous fields. The significance of this part of the visual field is discussed in relation to perception of movement and to the fixation reflex, and also with regard to recent reports of residual visual ability in patients with striate cortex lesions, and to the possible role of the monocular temporal field in striate and tectal visual systems.

Penicillamine-induced neuromyotonia

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