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Two week rule referral for patients with colorectal cancer below the age of 50; Are we being ageist?
original article J. Shabbir V. Vijayan M. Silavant A. L. Fowler T. A. Cook M. E. Lucarotti Dept. of Colorectal Surgery, Gloucestershire Royal Hospital, Gloucester Correspondence to: J Shabbir, SpR Colorectal Surgery, Frenchay Hospital, Bristol Tel: +441179505050 Email: [email protected]
TWO WEEK RULE REFERRAL FOR PATIENTS WITH COLORECTAL CANCER BELOW THE AGE OF 50; ARE WE BEING AGEIST? Objectives: The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment. Methods: The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years. Results: There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician’s referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria. Conclusion: Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor. keywords: colorectal cancer, two week referral Surgeon, 1 October 2009, pp. 276-81
Introduction Colorectal cancer is the second most common malignancy in the UK.1 It is second only to lung cancer in terms of mortality and is responsible for more than 10% of cancer deaths in the UK.1,2 The survival rates from colorectal cancer (CRC) are poor in the UK compared to the rest of Europe.3,4 This may be due to a late presentation or an advanced stage of disease at presentation.4,5 The peak incidence in the UK for CRC is between the age of 70 and 79 years; however it is estimated that 4% of all newly diagnosed CRC are below 45 years of age.6 In July 2000, the Department of Health (DoH) introduced a two-week referral (TWR) rule for all patients with suspected CRC. This was in an attempt to improve the quality of cancer services in the NHS. Patients who were referred to a secondary care service with suspected CRC were to be seen within two weeks of the initial GP referral.1 In spite of being a common malignancy nationally, a full-time GP 276 |
the royal colleges of surgeons of edinburgh and ireland
is expected to see only one new patient with CRC each year.7 In order to facilitate the TWR process, the DoH published guidelines outlining criteria for urgent referrals. These guidelines (Table 1) provide a list of high-risk symptoms and aim to aid the identification of up to 90% of patients with bowel cancer.8 Two of the six criteria outlined in the guidelines refer to symptoms in patients above 60 years of age. We designed this audit to investigate whether age should be included in the referral criteria for TWR referrals for suspected CRC.
Methods Patients under the age of 50 years presenting with CRC between January 2001 and December 2005 were identified from the hospital colorectal database. The referral route and the times from referral to specialist consultation and initiation of treatment were recorded. © 2009 Surgeon 7; 5: 276-81
table 1. Criteria for two week referral for suspected colorectal cancer RB+CIBH
Rectal bleeding WITH a change in bowel habit to looser stools and/or increased frequency of defecation for six weeks
All ages
RB
Rectal bleeding persistently WITHOUT anal symptoms (soreness, discomfort, itching, lumps and prolapse as well as pain)
Over 60 years
CIBH-RB
Change in bowel habit to loose stools and/or increased frequency of defecation WITHOUT rectal bleeding and persistent for six weeks
Over 60 years
RM
A denite palpable rectal (not pelvic) mass
All ages
RAM
A denite palpable right-sided abdominal mass
All ages
IDA
Iron deciency anaemia WITHOUT an obvious cause. (Hb<11g/dl in men or <10g/dl in postmenopausal women)
All ages
RB=rectal bleeding, CIBH=change in bowel habit, RM=rectal mass RAM=right sided abdominal mass, IDA=iron deciency anaemia
Fig. 2. Time from referral to seen
© 2009 Surgeon 7; 5: 276-81
the royal colleges of surgeons of edinburgh and ireland | 277
Fig. 3. Time from referral to treatment
Fig. 4. Site of tumours 278 |
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 5: 276-81
Fig. 5. T-Staging
Results There were 911 patients diagnosed with CRC during the study period. Of these, 41 (4.5%) patients were under 50 years of age. There were 16 men. Thirty-eight case notes were retrieved and reviewed. The median age was 47 years (range 22-49 years). Of these, 14 (37%) presented as an emergency, 9 (24%) were referred via the TWR, 8 (21%) were non-TWR referrals to surgical outpatients and the remainder were referred via other routes (direct endoscopy, in-hospital physician’s referral). The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the other (direct endoscopy, in-hospital physician’s referral) referral routes (Fig. 2). The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the SOPD group and 96 days (range 27-270 days) in the others group (Fig. 3). The majority of the tumours (26/38) were left sided (Fig. 4). Fourteen patients had T3 and 10 patients had T4 disease on histological examination (Fig. 5). Five patients had metastatic disease at presentation. Flexible sigmoidoscopy was the commonest (13/38) investigation followed by colonoscopy (7/38). Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria.
Discussion CRC in people under the age of 50 is relatively uncommon and accounts for only 2-10% of the total incidence of CRC.5 How this group compares to older age groups in terms of outcome is unclear. © 2009 Surgeon 7; 5: 276-81
Some studies report a poor long-term prognosis for CRC in patients below the age of 45 years but suggest that this could be related to a delay in diagnosis, advanced disease at presentation or a more aggressive form of tumour.9,10 Conversely, other studies have shown a similar or better prognosis in this age group.11,12 Concerns about delays in the diagnosis of CRC patients in the UK led to the publication of referral guidelines by the DoH in the year 2000.1 The purpose of these guidelines was to identify patients with high-risk symptoms for CRC and to facilitate them being seen by a specialist within two weeks. The implementation of these guidelines has been very successful across the NHS in terms of these patients being seen within two weeks.13,14 Whether the primary objectives of this system (i.e. early diagnosis and improved survival from CRC) were achieved, remains questionable.5 Eccersley et al. demonstrated that patients who fulfil the TWR criteria have a 25% chance of a diagnosis of CRC.15 The majority (81-90%) of CRC is diagnosed in patients who were referred outside the TWR pathway.14,16 Vieten et al. have shown that only 37% of their CRC patients were referred through the TWR system. In addition, the system was shown to be neither specific nor sensitive for picking up CRC.17 Only 24% of the CRCs diagnosed in our study were referred via the TWR system. The guidelines for TWR lack specificity, thus they account for only 9-14% of all the CRC diagnosed in any UK centre. The more worrying thing is the delay faced by patients who are referred through the traditional non-urgent routes but account for 81-90% of all CRCs.5,17Pullyblank et al. showed, over a one year period, that
the royal colleges of surgeons of edinburgh and ireland | 279
patients referred outside of the TWR had to wait twice as long for the initiation of treatment. Furthermore, two-thirds of the non fasttracked patients actually did fulfil the criteria for fast-track referral on review of their GP referral letters.18 Our results highlight a similar problem, where median referral to treatment time in younger patients was 51 days for patients referred via the TWR system compared to 103 days for routine GP referrals (Fig. 3). Diagnosis of CRC in a primary care setting is not straightforward.19,20 Symptoms and physical signs suggestive of underlying cancer are more frequently benign in nature. Two of the six criteria used in guidelines (i.e. rectal bleeding without anal symptoms and change in bowel habits without rectal bleeding) refer to symptoms in patients of above 60 years of age. Rectal bleeding poses a difficult problem for GPs. It is a classical symptom of CRC; however, it is also a symptom of benign diseases such as haemorrhoids and inflammatory bowel disease. Several studies have looked at the positive predictive value of rectal bleeding with respect to cancer and the evidence relating to the predictive and diagnostic value of rectal bleeding for cancer remains contradictory. Two studies from Australia and one from England found a 10% predictive value for cancer in patients presenting with rectal bleeding and suggested that all patients over 40 years with rectal bleeding should be referred to secondary care for further investigation.5,21-23 Similar results are shown by recent Dutch and Belgian studies.24,25 Du Toit et al. recently reported a 5.7% positive predictive value for colorectal cancer in patients above 45 years of age with new onset rectal bleeding and 10.6% for all colorectal neoplasia.26 They also reported that only two patients in their study with CRC had rectal bleeding with associated diarrhoea. This is an important finding as in the current guidelines, rectal bleeding without change in bowel habit or accompanying anal symptoms does not qualify for urgent referral unless the patient is above the age of sixty. Based on their findings they recommend that current guidelines should be changed and all patients with new onset rectal bleeding should be referred to secondary care irrespective of age and accompanying symptoms. However, contrary to the above a study from Holland showed a 3% predictive value for cancer in patients with rectal bleeding and suggested a more selective approach for referral and investigation should be used.27 The criteria referring to a change in bowel habit to looser stools persisting for six weeks without rectal bleeding in patients above the age of 60 are also of questionable validity. There is no evidence to support that a change in bowel habit should persist for longer than six weeks before the patient qualifies for urgent referral.28 Chaplin et al. showed that 9% of the general population describe a change in bowel habit during GP consultation; however, only 1.5% consider it significant enough to report to primary care.29 Carlson et al. estimated a positive predictive value of 3% for CRC associated with a change in bowel habits.25 This figure rises to 7% and 8% for increased frequency and looseness of stools respectively.29,30 In our study 73% of the patients would have fitted the TWR criteria if age was excluded. According to DoH figures, 99.6% of two-week referrals are seen by a specialist within the target time, with the majority of trusts achieving 100% compliance.14 However, as highlighted above, this urgent pathway accounts for only 9-14% of all the CRCs diagnosed.16 There has been a rapid increase in urgent referrals, and there is concern that this may have a negative impact on the waiting times of those patients who present via less urgent referral routes and do not fulfil 280
|
the TWR criteria.18 Scott et al. showed in their study that a single common urgent pathway for all colorectal referrals reduced the time to diagnosis and treatment.16
Conclusion This study has shown that patients under the age of 50 with symptoms suggestive of CRC are less likely to be referred under the TWR system. Three quarters of the younger patients would have been eligible for TWR referral if age were not a deciding factor. We acknowledge that our study has too small a cohort of patients to draw definitive conclusions but it highlights an important weakness in the TWR referral system for young patients with symptoms suggestive of CRC. We propose that TWR referral of all patients with sinister symptoms suggestive of CRC, irrespective of their age, would avoid unnecessary delays in patients less than 50 years of age
Copyright © 14 May 2009
REFERENCES 1. Department of Health, London (2000). Referral Guidelines for Suspected Cancer. Department of Health 2000 2. Leff DR, Chen A, Roberts D et al. Colorectal cancer in the young patient. Am Surg 2007; 73(1): 42-47 3. Berrino F, De Angelis R, Sant M et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995–99: results of the EUROCARE-4 study. Lancet Oncol 2007; 8(9):77383 4. Spurgeon P, Barwell F, Kerr D. Waiting times for cancer patients in England after general practitioner referral: retrospective national survey. BMJ 2000; 320:838-39 5. Rai S, Kelly MJ. Prioritization of colorectal referrals: a review of the 2-week wait referral system. Colorectal Disease 2007; 9(3):195-202 6. Heys SD, O’Hanrahan TJ, Brittenden J et al. Colorectal cancer in young patients: a review of the literature. Eur J Surg Oncol 1994; 20(3):225-31 7. Hamilton W, Sharp D. Diagnosis of colorectal cancer in primary care: the evidence base for guidelines. Fam Pract 2004; 21(1):99-106 8. Thorne K, Hutchings HA, Elwyn G. The effects of the two-week rule on NHS colorectal cancer diagnostic services: A systematic literature review. BMC Health Service Research 2006; 6(43):1-5 9. Clinical Signicance of rectal cancer in young patients. Dis Colon Rectum 1989; 32:473-76 10. Minardi AJ, Jr., Sittig KM, Zibari GB et al. Colorectal cancer in the young patient. Am Surg 1998; 64(9):849-53 11. Chung YF, Eu KW, Machin D et al. Young age is not a poor prognostic marker in colorectal cancer. Br J Surg 1998; 85(9):1255-59 12. Mitry E, Benhamiche AM, Jouve JL et al. Colorectal adenocarcinoma in patients under 45 years of age: comparison with older patients in a welldened French population. Dis Colon Rectum 2001; 44(3):380-87 13. Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ 2001; 322:1555-56
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 5: 276-81
14. Debnath D, Dielchner N, Gunning KA. Guidelines, compliance and effectiveness: a 12 month audit in an acute district general health care trust on the two week rule for suspected colorectal cancer. Postgrad Med J 2002; 78:748-51 15. Eccersley AJ, Wilson EM, Makris A et al. Referral guidelines for colorectal cancer – do they work? Ann R Coll Surg Eng 2003; 85:107-10 16. Scott MA, Knight A, Brown K et al. A single common urgent pathway for all colorectal referrals reduces time to diagnosis and treatment. Colorectal Disease 2006; 8:766-71 17. Vieten D, Carrey LJ, Hollowood A et al. The 2 week referral pathway for colorectal cancer – potential to miss serious disease. Colorectal Disease 2002; 4:A50 18. Pullyblank AM, Silavant M, Cook TA. Failure to recognise high-risk symptoms of colorectal cancer in standard referral letters leads to a delay in initiation of treatment. Colorectal Disease 2003; 5:A20 19. Summerton N. The changing role of UK primary cancer care. Lancet Oncol 2001; 2:717-18 20. Hamilton WT, Round AP, Sharp D et al. GPs can separate oncological wheat from chaff. BMJ 2003; 326:397 21. Goulston KL, Cook I, Dent OE. How important is rectal bleeding in the diagnosis of bowel cancer and polyps? Lancet 1986; 2:261-65 22. Mant A, Bokey EL, Chapuis PH. Rectal bleeding. Do other symptoms aid in diagnosis? Dis Colon Rectum 1989; 32(3):191-96
© 2009 Surgeon 7; 5: 276-81
23. Metcalfe JV, Smith J, Jones R et al. Incidence and causes of rectal bleeding in general practice as detected by colonoscopy. Br J Gen Pract 1996; 46:16164 24. Fijten GH, Starmans R, Muris JW et al. Predictive value of signs and symptoms for colorectal cancer in patients with rectal bleeding in general practice. Fam Pract 1995; 12(3):279-86 25. Wauters H, Van Casteren V, Buntinx F. Rectal bleeding and colorectal cancer in general practice:diagnostic study. BMJ 2000; 321:998-99 26. du Toit J, Hamilton W, Barraclough K. Risk in primary care of colorectal cancer from new onset rectal bleeding: 10 year prospective study. BMJ 2006; 333:6970 27. Fijten GH, Muris JW, Starmans R. The incidence and outcome of rectal bleeding in general practice. Fam Pract 1993; 10:283-87 28. Hamilton W, Sharp D. Diagnosis of colorectal cancer in primary care: the evidence base for guidelines. Fam Pract 2004; 21(1):99-106 29. Chaplin A, Curless R, Thomson R et al. Prevelance of lower gastrointestinal symptoms and associated consultation behaviour in a British elderly population determined by face to face interview. Br J Gen Pract 2000; 50:798-802 30. Carlsson L, Hakansson A, Nordenskjold B. Common cancer related symptoms among GP patients. Opportunistic screening in primary health care. Scand J Primary Health Care Suppl 2001; 19:199203
the royal colleges of surgeons of edinburgh and ireland | 281
TWO WEEK RULE REFERRAL FOR PATIENTS WITH COLORECTAL CANCER BELOW THE AGE OF 50; ARE WE BEING AGEIST? Objectives: The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment. Methods: The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years. Results: There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician’s referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria. Conclusion: Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor. keywords: colorectal cancer, two week referral Surgeon, 1 October 2009, pp. 276-81
Introduction Colorectal cancer is the second most common malignancy in the UK.1 It is second only to lung cancer in terms of mortality and is responsible for more than 10% of cancer deaths in the UK.1,2 The survival rates from colorectal cancer (CRC) are poor in the UK compared to the rest of Europe.3,4 This may be due to a late presentation or an advanced stage of disease at presentation.4,5 The peak incidence in the UK for CRC is between the age of 70 and 79 years; however it is estimated that 4% of all newly diagnosed CRC are below 45 years of age.6 In July 2000, the Department of Health (DoH) introduced a two-week referral (TWR) rule for all patients with suspected CRC. This was in an attempt to improve the quality of cancer services in the NHS. Patients who were referred to a secondary care service with suspected CRC were to be seen within two weeks of the initial GP referral.1 In spite of being a common malignancy nationally, a full-time GP 276 |
the royal colleges of surgeons of edinburgh and ireland
is expected to see only one new patient with CRC each year.7 In order to facilitate the TWR process, the DoH published guidelines outlining criteria for urgent referrals. These guidelines (Table 1) provide a list of high-risk symptoms and aim to aid the identification of up to 90% of patients with bowel cancer.8 Two of the six criteria outlined in the guidelines refer to symptoms in patients above 60 years of age. We designed this audit to investigate whether age should be included in the referral criteria for TWR referrals for suspected CRC.
Methods Patients under the age of 50 years presenting with CRC between January 2001 and December 2005 were identified from the hospital colorectal database. The referral route and the times from referral to specialist consultation and initiation of treatment were recorded. © 2009 Surgeon 7; 5: 276-81
table 1. Criteria for two week referral for suspected colorectal cancer RB+CIBH
Rectal bleeding WITH a change in bowel habit to looser stools and/or increased frequency of defecation for six weeks
All ages
RB
Rectal bleeding persistently WITHOUT anal symptoms (soreness, discomfort, itching, lumps and prolapse as well as pain)
Over 60 years
CIBH-RB
Change in bowel habit to loose stools and/or increased frequency of defecation WITHOUT rectal bleeding and persistent for six weeks
Over 60 years
RM
A denite palpable rectal (not pelvic) mass
All ages
RAM
A denite palpable right-sided abdominal mass
All ages
IDA
Iron deciency anaemia WITHOUT an obvious cause. (Hb<11g/dl in men or <10g/dl in postmenopausal women)
All ages
RB=rectal bleeding, CIBH=change in bowel habit, RM=rectal mass RAM=right sided abdominal mass, IDA=iron deciency anaemia
Fig. 2. Time from referral to seen
© 2009 Surgeon 7; 5: 276-81
the royal colleges of surgeons of edinburgh and ireland | 277
Fig. 3. Time from referral to treatment
Fig. 4. Site of tumours 278 |
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 5: 276-81
Fig. 5. T-Staging
Results There were 911 patients diagnosed with CRC during the study period. Of these, 41 (4.5%) patients were under 50 years of age. There were 16 men. Thirty-eight case notes were retrieved and reviewed. The median age was 47 years (range 22-49 years). Of these, 14 (37%) presented as an emergency, 9 (24%) were referred via the TWR, 8 (21%) were non-TWR referrals to surgical outpatients and the remainder were referred via other routes (direct endoscopy, in-hospital physician’s referral). The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the other (direct endoscopy, in-hospital physician’s referral) referral routes (Fig. 2). The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the SOPD group and 96 days (range 27-270 days) in the others group (Fig. 3). The majority of the tumours (26/38) were left sided (Fig. 4). Fourteen patients had T3 and 10 patients had T4 disease on histological examination (Fig. 5). Five patients had metastatic disease at presentation. Flexible sigmoidoscopy was the commonest (13/38) investigation followed by colonoscopy (7/38). Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria.
Discussion CRC in people under the age of 50 is relatively uncommon and accounts for only 2-10% of the total incidence of CRC.5 How this group compares to older age groups in terms of outcome is unclear. © 2009 Surgeon 7; 5: 276-81
Some studies report a poor long-term prognosis for CRC in patients below the age of 45 years but suggest that this could be related to a delay in diagnosis, advanced disease at presentation or a more aggressive form of tumour.9,10 Conversely, other studies have shown a similar or better prognosis in this age group.11,12 Concerns about delays in the diagnosis of CRC patients in the UK led to the publication of referral guidelines by the DoH in the year 2000.1 The purpose of these guidelines was to identify patients with high-risk symptoms for CRC and to facilitate them being seen by a specialist within two weeks. The implementation of these guidelines has been very successful across the NHS in terms of these patients being seen within two weeks.13,14 Whether the primary objectives of this system (i.e. early diagnosis and improved survival from CRC) were achieved, remains questionable.5 Eccersley et al. demonstrated that patients who fulfil the TWR criteria have a 25% chance of a diagnosis of CRC.15 The majority (81-90%) of CRC is diagnosed in patients who were referred outside the TWR pathway.14,16 Vieten et al. have shown that only 37% of their CRC patients were referred through the TWR system. In addition, the system was shown to be neither specific nor sensitive for picking up CRC.17 Only 24% of the CRCs diagnosed in our study were referred via the TWR system. The guidelines for TWR lack specificity, thus they account for only 9-14% of all the CRC diagnosed in any UK centre. The more worrying thing is the delay faced by patients who are referred through the traditional non-urgent routes but account for 81-90% of all CRCs.5,17Pullyblank et al. showed, over a one year period, that
the royal colleges of surgeons of edinburgh and ireland | 279
patients referred outside of the TWR had to wait twice as long for the initiation of treatment. Furthermore, two-thirds of the non fasttracked patients actually did fulfil the criteria for fast-track referral on review of their GP referral letters.18 Our results highlight a similar problem, where median referral to treatment time in younger patients was 51 days for patients referred via the TWR system compared to 103 days for routine GP referrals (Fig. 3). Diagnosis of CRC in a primary care setting is not straightforward.19,20 Symptoms and physical signs suggestive of underlying cancer are more frequently benign in nature. Two of the six criteria used in guidelines (i.e. rectal bleeding without anal symptoms and change in bowel habits without rectal bleeding) refer to symptoms in patients of above 60 years of age. Rectal bleeding poses a difficult problem for GPs. It is a classical symptom of CRC; however, it is also a symptom of benign diseases such as haemorrhoids and inflammatory bowel disease. Several studies have looked at the positive predictive value of rectal bleeding with respect to cancer and the evidence relating to the predictive and diagnostic value of rectal bleeding for cancer remains contradictory. Two studies from Australia and one from England found a 10% predictive value for cancer in patients presenting with rectal bleeding and suggested that all patients over 40 years with rectal bleeding should be referred to secondary care for further investigation.5,21-23 Similar results are shown by recent Dutch and Belgian studies.24,25 Du Toit et al. recently reported a 5.7% positive predictive value for colorectal cancer in patients above 45 years of age with new onset rectal bleeding and 10.6% for all colorectal neoplasia.26 They also reported that only two patients in their study with CRC had rectal bleeding with associated diarrhoea. This is an important finding as in the current guidelines, rectal bleeding without change in bowel habit or accompanying anal symptoms does not qualify for urgent referral unless the patient is above the age of sixty. Based on their findings they recommend that current guidelines should be changed and all patients with new onset rectal bleeding should be referred to secondary care irrespective of age and accompanying symptoms. However, contrary to the above a study from Holland showed a 3% predictive value for cancer in patients with rectal bleeding and suggested a more selective approach for referral and investigation should be used.27 The criteria referring to a change in bowel habit to looser stools persisting for six weeks without rectal bleeding in patients above the age of 60 are also of questionable validity. There is no evidence to support that a change in bowel habit should persist for longer than six weeks before the patient qualifies for urgent referral.28 Chaplin et al. showed that 9% of the general population describe a change in bowel habit during GP consultation; however, only 1.5% consider it significant enough to report to primary care.29 Carlson et al. estimated a positive predictive value of 3% for CRC associated with a change in bowel habits.25 This figure rises to 7% and 8% for increased frequency and looseness of stools respectively.29,30 In our study 73% of the patients would have fitted the TWR criteria if age was excluded. According to DoH figures, 99.6% of two-week referrals are seen by a specialist within the target time, with the majority of trusts achieving 100% compliance.14 However, as highlighted above, this urgent pathway accounts for only 9-14% of all the CRCs diagnosed.16 There has been a rapid increase in urgent referrals, and there is concern that this may have a negative impact on the waiting times of those patients who present via less urgent referral routes and do not fulfil 280
|
the TWR criteria.18 Scott et al. showed in their study that a single common urgent pathway for all colorectal referrals reduced the time to diagnosis and treatment.16
Conclusion This study has shown that patients under the age of 50 with symptoms suggestive of CRC are less likely to be referred under the TWR system. Three quarters of the younger patients would have been eligible for TWR referral if age were not a deciding factor. We acknowledge that our study has too small a cohort of patients to draw definitive conclusions but it highlights an important weakness in the TWR referral system for young patients with symptoms suggestive of CRC. We propose that TWR referral of all patients with sinister symptoms suggestive of CRC, irrespective of their age, would avoid unnecessary delays in patients less than 50 years of age
Copyright © 14 May 2009
REFERENCES 1. Department of Health, London (2000). Referral Guidelines for Suspected Cancer. Department of Health 2000 2. Leff DR, Chen A, Roberts D et al. Colorectal cancer in the young patient. Am Surg 2007; 73(1): 42-47 3. Berrino F, De Angelis R, Sant M et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995–99: results of the EUROCARE-4 study. Lancet Oncol 2007; 8(9):77383 4. Spurgeon P, Barwell F, Kerr D. Waiting times for cancer patients in England after general practitioner referral: retrospective national survey. BMJ 2000; 320:838-39 5. Rai S, Kelly MJ. Prioritization of colorectal referrals: a review of the 2-week wait referral system. Colorectal Disease 2007; 9(3):195-202 6. Heys SD, O’Hanrahan TJ, Brittenden J et al. Colorectal cancer in young patients: a review of the literature. Eur J Surg Oncol 1994; 20(3):225-31 7. Hamilton W, Sharp D. Diagnosis of colorectal cancer in primary care: the evidence base for guidelines. Fam Pract 2004; 21(1):99-106 8. Thorne K, Hutchings HA, Elwyn G. The effects of the two-week rule on NHS colorectal cancer diagnostic services: A systematic literature review. BMC Health Service Research 2006; 6(43):1-5 9. Clinical Signicance of rectal cancer in young patients. Dis Colon Rectum 1989; 32:473-76 10. Minardi AJ, Jr., Sittig KM, Zibari GB et al. Colorectal cancer in the young patient. Am Surg 1998; 64(9):849-53 11. Chung YF, Eu KW, Machin D et al. Young age is not a poor prognostic marker in colorectal cancer. Br J Surg 1998; 85(9):1255-59 12. Mitry E, Benhamiche AM, Jouve JL et al. Colorectal adenocarcinoma in patients under 45 years of age: comparison with older patients in a welldened French population. Dis Colon Rectum 2001; 44(3):380-87 13. Jones R, Rubin G, Hungin P. Is the two week rule for cancer referrals working? BMJ 2001; 322:1555-56
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 5: 276-81
14. Debnath D, Dielchner N, Gunning KA. Guidelines, compliance and effectiveness: a 12 month audit in an acute district general health care trust on the two week rule for suspected colorectal cancer. Postgrad Med J 2002; 78:748-51 15. Eccersley AJ, Wilson EM, Makris A et al. Referral guidelines for colorectal cancer – do they work? Ann R Coll Surg Eng 2003; 85:107-10 16. Scott MA, Knight A, Brown K et al. A single common urgent pathway for all colorectal referrals reduces time to diagnosis and treatment. Colorectal Disease 2006; 8:766-71 17. Vieten D, Carrey LJ, Hollowood A et al. The 2 week referral pathway for colorectal cancer – potential to miss serious disease. Colorectal Disease 2002; 4:A50 18. Pullyblank AM, Silavant M, Cook TA. Failure to recognise high-risk symptoms of colorectal cancer in standard referral letters leads to a delay in initiation of treatment. Colorectal Disease 2003; 5:A20 19. Summerton N. The changing role of UK primary cancer care. Lancet Oncol 2001; 2:717-18 20. Hamilton WT, Round AP, Sharp D et al. GPs can separate oncological wheat from chaff. BMJ 2003; 326:397 21. Goulston KL, Cook I, Dent OE. How important is rectal bleeding in the diagnosis of bowel cancer and polyps? Lancet 1986; 2:261-65 22. Mant A, Bokey EL, Chapuis PH. Rectal bleeding. Do other symptoms aid in diagnosis? Dis Colon Rectum 1989; 32(3):191-96
© 2009 Surgeon 7; 5: 276-81
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