Colorectal Referrals Research Articles

FP3.4 - Identifying missed opportunities in emergency presentations of colorectal cancer to improve patient outcomes

Abstract Introduction and Aim A significant proportion of patients diagnosed with colorectal cancer are diagnosed during emergency admissions with presentations such as bowel obstruction, perforation and bleeding. Despite increasing numbers of suspected colorectal cancers referrals from the community being sent straight to test, the proportion of patients presenting as emergencies in the United Kingdom remains at20%. Emergency presentations of colorectal cancer are associated with significantly worse outcomes – both short- and long-term, with research suggestive that emergency presentations remain an independent poor prognostic factor following curative colorectal resection. This study aims to assess if patients diagnosed with colorectal cancer following emergency presentation had missed opportunities of diagnosis on previous presentations in secondary care. Methods A database of patients who have been diagnosed with colorectal cancer following emergency presentation from January2020-October2023 was analysed. Previous attendances to the emergency department and outpatient department were identified and assessed for symptoms of colorectal cancer – including abdominal pain, change in bowel habits, rectal bleeding and iron deficiency anaemia – and if these prompted investigation. Results Of 100 patients – 6were identified that had previous presentations with symptoms suggestive of colorectal malignancy. 2 had been reviewed in colorectal clinic prior to their diagnosis, with appropriate planned investigations but were lost to follow up. A further 4 had been seen in ED with symptoms of colorectal cancer but further investigations were not performed. Conclusion The majority of patients diagnosed with colorectal malignancy following emergency presentation had no earlier opportunities of diagnosis in secondary care. Further work needs to be done ensuring the continuity of care of patients following discharge from both the emergency department and clinic.

516 Diagnosis Following Two-Week Wait Colorectal Referrals in FIT Patients

516 Diagnosis Following Two-Week Wait Colorectal Referrals in FIT Patients

Utility of Computerized Axial Tomography (CT) Investigation in Two-Week Wait Colorectal Referral Pathway During the COVID-19 Pandemic: A Retrospective Analysis

Utility of Computerized Axial Tomography (CT) Investigation in Two-Week Wait Colorectal Referral Pathway During the COVID-19 Pandemic: A Retrospective Analysis

1874 Developing a pathway direct to elderly medicine clinic for frail patients referred via colorectal fast-track: pilot and outcomes

Abstract Introduction It is increasingly recognised within oncogeriatrics that standard fast-track pathways for suspected malignancy can be inappropriate for frail and elderly patients (Thomas et. al.; Age and Ageing; 2021; 50; ii8-ii13). Specifically for colorectal referrals, following standard pathways can mean undergoing invasive and expensive endoscopic investigations which may be unwanted and not alter overall management. Streaming frail patients to elderly medicine may increase opportunities for comprehensive geriatric assessment whilst reducing unwanted invasive tests and time spent on fast-track pathways. Methods A 3-month retrospective audit of frail patients seen in colorectal fast-track clinic was conducted to evaluate existing practice at Bradford Teaching Hospitals. This informed the design of a new pathway streaming frail patients directly to elderly clinic within 2 weeks. This was implemented in a 3-month pilot with data prospectively collected to compare outcomes. Cohorts: - 26 patients (median age 79, WHO performance status 3) seen by colorectal team March-June 2022. - 20 patients (median age 85, WHO performance status 2) streamed to elderly medicine clinic October 2022- March 2023. Results - Median time to fast-track pathway removal was 62 days for patients managed via colorectal clinic compared to 31 days via elderly medicine. - Invasive tests and imaging (CT/endoscopy) fell from 1.4 tests per patient in colorectal clinic to 0.4 patients in the pilot. - 2 diagnoses of cancer made via colorectal clinic, but no further treatment for either patient. 1 diagnosis of lung cancer in pilot group, patient undergoing radiotherapy. - Patients seen in elderly clinic had greater rates of positive diagnosis for symptoms (e.g: infective/iatrogenic). Conclusions Streaming frail elderly patients referred via colorectal fast-track to elderly medicine reduced the number of invasive investigations undertaken and time spent on fast-track pathways. Expanding this successful pilot could improve long-term clinical quality in the service and more widely if disseminated.

Sociodemographic variations in the uptake of faecal immunochemical tests in primary care: a retrospective study.

Faecal immunochemical test (FIT) usage for symptomatic patients is increasing, but variations in use caused by sociodemographic factors are unknown. A clinical pathway for colorectal cancer (CRC) was introduced in primary care for symptomatic patients in November 2017. The pathway was commissioned to provide GPs with direct access to FITs. To identify whether sociodemographic factors affect FIT return in symptomatic patients. A retrospective study was undertaken in Nottingham, UK, following the introduction of FIT as triage tool in primary care. It was mandated for all colorectal referrals (except rectal bleeding or mass) to secondary care. FIT was used, alongside full blood count and ferritin, to stratify CRC risk. All referrals from November 2017 to December 2021 were retrospectively reviewed. Sociodemographic factors affecting FIT return were analysed by multivariate logistic regression. A total of 35 289 (90.7%) patients returned their index FIT, while 3631 (9.3%) did not. On multivariate analysis, males were less likely to return an FIT (odds ratio [OR] 1.11, 95% confidence interval [CI] = 1.03 to 1.19). Patients aged ≥65 years were more likely to return an FIT (OR 0.78 for non-return, 95% CI = 0.72 to 0.83). Unreturned FIT more than doubled in the most compared with the least deprived quintile (OR 2.20, 95% CI = 1.99 to 2.43). Patients from Asian (OR 1.82, 95% CI = 1.58 to 2.10), Black (OR 1.21, 95% CI = 0.98 to 1.49), and mixed or other ethnic groups (OR 1.29, 95% CI = 1.05 to 1.59) were more likely to not return an FIT compared with patients from a White ethnic group. A total of 599 (1.5%) CRCs were detected; 561 in those who returned a first FIT request. FIT return in those suspected of having CRC varied by sex, age, ethnic group, and socioeconomic deprivation. Strategies to mitigate effects on FIT return and CRC detection should be considered as FIT usage expands.

Faecal immunochemical testing reduces demand and improves yield of Leicester's 2-week pathway for change in bowel habit.

We look at the effect of introducing the faecal immunochemical test (FIT) in the straight-to-test 2-week pathway for change in bowel habit (CIBH). The FIT in primary care triages 2-week wait (2WW) colorectal referrals for patients aged 60 years and above for straight-to-test CT colonography (CTC). We compare the impact of the FIT on numbers of 2WW CTCs, in the year before and after FIT, in both colorectal cancer (CRC) detection and cost-effectiveness at both 4 μg Hb/g faeces and 10 μg Hb/g faeces. At a threshold of 4μg Hb/g faeces, the positive predictive value of the FIT for diagnosis of CRC is 5.0% with a negative predictive value of 99.8% and a polyp detection rate of 25.5%. The introduction of the FIT resulted in a reduction in the number of CTCs performed through the CIBH pathway from a mean of 143.9 per month prior to the FIT to 66.8 CTCs per month once the FIT was well established. Given a FIT threshold of 10μg Hb/g the number of CTCs would be predicted to fall by 70.4% to 42.6 CTCs per month resulting in higher CRC and polyp detection rate, and an estimated annual cost saving of £238 258 in our institution. The FIT use in primary care improves the yield of 2WW referrals for CIBH alone and reduces the burden and cost of investigations to exclude CRC. Improvements may be possible by increasing the cut-off employed, without adversely affecting the risk of missing a cancer.

Clinical Pathological Approach to Polyps of the Colon

Elements of its lumen from the areas of the mucosa or submucosa are called colon polyps. Colon polyps major implications of malignancy. Multiple colorectal referrals are made for evaluation of polyp or polypoid evaluations. Detection excision is the most important step in the prevention of malignancy and histopathological evaluation of colon polyps. Colon polyps are divided into two groups as non-neoplastic and neoplastic. They include hyperplastic polyps as non-neoplastic polyps, while the majority of neoplastic polyps are adenomatous polyps. Adenomatopolyps are transitional as tubular-tubulevous-villi. The incidence is tubular (65-80%), tubulovillous (10-25%) and villous (5-15%) adenomas. This is on the right track of diagnoses. In this product, clinical disease limits are emphasized in polyps.

Clinical Pathological Approach to Polyps of the Colon

Elements of its lumen from the areas of the mucosa or submucosa are called colon polyps. Colon polyps major implications of malignancy. Multiple colorectal referrals are made for evaluation of polyp or polypoid evaluations. Detection excision is the most important step in the prevention of malignancy and histopathological evaluation of colon polyps. Colon polyps are divided into two groups as non-neoplastic and neoplastic. They include hyperplastic polyps as non-neoplastic polyps, while the majority of neoplastic polyps are adenomatous polyps. Adenomatopolyps are transitional as tubular-tubulevous-villi. The incidence is tubular (65-80%), tubulovillous (10-25%) and villous (5-15%) adenomas. This is on the right track of diagnoses. In this product, clinical disease limits are emphasized in polyps.

SP3.1.8 2ww Colorectal referral proformas: is the inclusion of recent bowel investigations relevant?

Abstract Aims Straight-to-test (STT) decisions are made on the basis of the details contained within the referrer's documentation. This is particularly important for Two-week wait (2ww) referrals where incomplete or missing information may result in unnecessarily duplicating investigations- incurring a cost to resources as well as exposing patients to potential harm. Through reviewing GP 2ww referrals, we highlight the prevalence of incomplete information relating to recent bowel investigations. Methods A prospectively maintained database consisting of 2ww Colorectal referrals from primary care was analysed over a 12-month period (January 2021- December 2021). The agreed local standard is that any bowel investigations within the last 3 years are included on the referral proforma. Proformas compliant with this requirement were marked as ‘Yes, complete’. A total of 3410 referrals took place during this period- 36 were excluded from analysis as no information regarding their status was available. Results Only 37% of proformas included a complete history of recent bowel investigations over the past 3 years, and 62% had no documentation regarding this information. Between January-April 2021 the proportion with complete documentation was 42%, which fell to 30% by September-December 2021. Conclusions Including details of recent bowel investigations over the past 3 years appears to be an area that is commonly overlooked by referring local GPs. Given that patients may have had investigations at different Trusts, in the absence of a cohesive data sharing network between Trusts, GPs are best placed to collate this important information when referring to the Colorectal unit.

EP-609 Doctor-led Straight to Test Service: Streamlining the Colorectal 2ww referral pathway

Abstract Aims Since its introduction in 2000, the Two-week wait referral pathway (2ww) has become entrenched in NHS practice to fast-track the investigation, diagnosis and management of suspected cancer. Straight-to-test (STT) routes further expedite this process: staff screen referrals and offer a diagnostic test within 2 weeks where appropriate. Our Trust has provided a doctor-led STT service for the Colorectal Department since January 2021. We hypothesize that physician-led strict scrutiny of referral proformas, with incomplete forms being returned to GPs, has led to improved compliance with the referral process. Methods A prospectively maintained database consisting of 2ww Colorectal referrals from primary care was analysed over a 12-month period (January 2021- December 2021). Agreed key referral criteria required to make an STT decision were identified as ‘complete’ or ‘incomplete’. Incomplete referrals were returned to GPs, with a request for complete information (usually provided within a median period of 2 weeks). Results There were 1112 referrals during January-April 2021, 1140 during May-August 2021 and 1158 during September-December 2021. The proportion of referrals containing incomplete datasets fell from 28% (January-April 2021) to 17% in the latter two 4-monthly time intervals. Conclusions Our data is promising- the proportion of incomplete referrals has reduced since the introduction of our doctor-led STT triage service. These figures may reflect a positive change in the referral practises of local GPs. Submission of complete referral forms improves communication between primary and secondary care, enabling our doctors to make timely informed decisions about STT pathways.

EP.TU.296A Significant Difference in Cancer Proportions Between Two Modelled Cohorts Investigated by 2-WeekWait (2WW) Colorectal referral pathway

Abstract Aim To compare the proportions of malignancy between two modelled cohorts of referred and investigated by our colorectal 2 WW referrals pathway. Methods Two modelled cohorts were analysed from our prospectively maintained colorectal 2WW referrals database from August 2018 to July 2019. One cohort (group A) included patients without anemia, rectal mass or overt rectal bleeding. The other (group B) included the rest of referrals. Data collected and analysed in each group included total numbers of referrals, investigated referrals and malignancy proportion in each group. One tailed Z test was used to analysis statistical difference. Results 4240 referrals were made to our colorectal 2 WW pathway during the given period. 1333 (31%) were group A and 2907 (69%) were group B. Total number of patients investigated in group A was 1227, of those only 34 (2.8%) were colorectal cancer and 18 (1.5%) were extracolonic cancer. One the other hand, 2705 patients were investigated in group B, colorectal malignancy were found in 142 (5.3%) patients and 33 (1.2%) were extracolonic. There was a significant difference (p < 0.05) in total number of malignancies between Group A (53/4.3%) and Group B (175/6.5%). Conclusion While the 2 Week-Wait referral pathway plays an important role in rapid testing and identifying colorectal cancer, there was a difference between malignancy distribution within the referrals. this difference doesn’t reflect a clinical significance but it can be a good stratification tool.

EP.TU.465Role of CT scan as initial investigation in colorectal rapid access patients

BackgroundWe looked into CT colonoscopies and CT abdomen and pelvis which were booked as initial investigation in patients referred via the colorectal rapid access pathway. These tests were directly booked following the referral after a nurse led triage.As per our colorectal straight to test protocol (STT) any patients over the age of 75 or unfit individuals will have a CT colonoscopy (virtual colonoscopy) instead of colonoscopy. CT trunk was used during COVID pandemic as the initial investigation when the aerosol generating procedures were stopped. CT trunks are also the initial investigation as per the STT protocol when patients are referred with suspected abdominal mass, weight loss or abdominal pain.MethodsRetrospective analysis of prospective electronic data base of colorectal STT referrals from Feb 2020 to end of October 2020.ResultsTotal no colorectal STT referrals -1524CT colonoscopies and CT trunks booked as initial investigation 420(27.55%)Patients who refused to have the scans due to COVID 93/420 (22.14%)Colorectal cancer diagnosis 25/327 (7.64%)Non-colorectal cancer diagnosis 20/327(6.11%) Incidental AAA 15/327(4.58%)Normal examination 91/327(27.82%)Colonic polyps 27/327(8.25%)Diverticular disease 92/327(28.13%)ConclusionCT colonoscopies and CT trunks form part of initial diagnostic tool in the colorectal rapid access patients. They are particularly useful in high risk patients who cannot tolerate colonoscopy. These investigations complement the lower GI endoscopy. These scans also identify non-colorectal malignancies and retroperitoneal pathology such as AAA.CT trunks were useful tools during COVID 19 Pandemic.

EP.WE.330The role of computerized tomography scan in 2 week wait colorectal pathway during COVID-19 pandemic

AimsThe standard way to investigate patients referred on the two week wait colorectal cancer (2WW) pathway is to do a colonoscopy when patients are deemed fit. Due to limited endoscopy services during the COVID-19 lockdown period, we performed computerized tomography scan of thorax, abdomen and pelvis (CT TAP) for all fast-track colorectal referrals in addition to colonoscopy when service restarted. The aim of this study is to assess the benefit of CT scan in this group of patients.MethodsAll 2WW patients referred to our district general hospital from April 1, 2020 to July 31, 2020 were included in the study. The data were collected retrospectively from GP referral forms and the electronic patient records. Patient demographics, presenting complaints, investigations, diagnosis and treatment were recorded.ResultsA total of 658 patients were included in the study. The commonest presenting complaint was change in bowel habit (62.5%). A total of 414 colonoscopies, 347 CT TAP, 89 flexible sigmoidoscopies and 37 CT colonography were performed. 194 patients had both CT TAP and colonoscopy and another 32 patients had both CT TAP and flexible sigmoidoscopy showing that 34% of patients had both CT TAP and endoscopy. 41 patients were diagnosed with colorectal malignancy (6.2%) and 120 had polyps (18%). CT TAP missed 3 colorectal cancers but picked up 28 patients (4.3%) diagnosed with extra-colonic tumours.ConclusionsColonoscopy remains the gold standard for investigating colorectal cancer. However, CT scan have their value in diagnosing extra-colonic tumours in this specific group of patients.

TP10.2.11The consequences of COVID-19 on the colorectal red-flag cancer pathway- A 3 month review 2019 to 2020

AimThe COVID-19 pandemic is an evolving healthcare challenge introducing greater burden on existing resources. With 1,100 people in Northern Ireland diagnosed with colorectal cancer (CRC) per annum, concerns over disruption of cancer services and secondary consequences have been highlighted. We aim to evaluate the impact of COVID-19 on the CRC red flag pathway in comparison to the pre-COVID era.MethodsTwo comparative data sets were compiled through retrospective analysis of red-flag colorectal referrals over a 3-month period for both April to June 2019 and 2020. A comprehensive review of each patient’s electronic care record and medical notes was completed. Patient demographics, co-morbidity, referral information, time to hospital appointment and investigation modality were documented. For patients identified with CRC the stage and time to first definitive treatment was documented.ResultsA total of 47 CRCs were identified from both red-flag referral groups; 25 CRCs 2019 compared to 22 in 2020. Median age at time of referral was 79 years in 2019 compared to 71 years in 2020. Time to outpatient review was significantly less during 2020 compared to 2019; 16 days and 31 days respectively (p < 0.05). Time to first treatment was 103 days 2019 compared to 75 days 2020 (p < 0.05). Advanced diagnostic stage or increased number of emergency hospital presentations in the COVID-19 period was not demonstrated.ConclusionDespite disruption of established colorectal cancer services during the COVID-19 pandemic, we demonstrated patients waited less time to outpatient review and intervention. With comparative cases of CRC to the pre-COVID era diagnosed.

Video consultation for new colorectal patients.

For patients, an outpatient review can lead to a stressful journey to hospital with the resultant risks associated with breaching social distancing. Despite this, video consultations (VCs) have not been frequently used in colorectal practice. We assessed outcomes, including the economic and environmental impact, of a VC clinic for new colorectal referrals. This was a prospective observational study. Fifty consecutive patients attending a VC colorectal appointment were reviewed between March 2019 and February 2020. Face-to-face appointments during the same time period were also assessed. The distance, time, cost and carbon emissions of journeys were estimated using web-based resources. Estimated loss of earnings used data from the Office for National Statistics. The subsequent management plans were also recorded. Of 50 patients using VC, 40 used home devices and 10 used equipment in their local medical facility. Three patients had difficulties with the technology and converted to telephone review. Failure to attend VC appointments was less than for face-to-face appointments (4% vs 6.1%). VC appointments saved 6685 miles of travel (range 2-364 miles), 148h travelling time and £1767 costs. Additional savings for loss of earnings were approximately £33.56 per patient. The carbon emissions saved was 4659 lb CO2 equivalent, corresponding to over 250000 charges of a smartphone. The use of VC resulted in significant savings related to travel and reduced time and costs for patients who chose to use the service, in addition to the environmental benefits. In this current climate VC clinics have a central role in outpatient care for both new patients and follow-ups.

Is a “straight to test” strategy a pragmatic alternative to the conventional two-week wait referral pathway for colorectal cancer in an ethnically diverse hospital catchment area? A single-centre case series

IntroductionIn a climate of rising pressure to ameliorate cancer services, a “straight to test” (STT) model whereby two-week wait (TWW) colorectal referrals undergo an investigative procedure prior to an outpatient assessment has been explored as a method to expedite the clinical pathway. We aim to evaluate the potential for its application in an ethnically diverse region and assess whether this model improves the time to diagnosis compared to the conventional route. Presentation of casesBetween September and October 2016, we performed a prospective comparative case series of 132 consecutive TWW colorectal referrals to a district general hospital. Following a two-stage triage process, 24 patients were allocated to a STT group and 108 patients were assessed in clinic first. The times to the first investigation, endoscopic procedure and established diagnosis were compared between the two groups. DiscussionThe median time to the first investigation was 13.5 days in the STT group versus 24 days in the non-STT group (p < 0.001). A diagnosis was established at a median time of 14 days for the STT group versus 25 days in the non-STT group (p < 0.001). 62/132 (47%) of all TWW referrals were excluded from STT owing to language barriers and medical grounds. ConclusionA STT approach minimises the time from TWW referral to investigations and diagnosis for patients with suspected colorectal cancer. Application of a STT model may be limited by local population factors including language issues and a high prevalence of medical comorbidity.

Chronic Idiopathic Anal Pain. Results of a Diagnostic-Therapeutic Protocol in a Colorectal Referral Unit

IntroductionChronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service. Materials and MethodsWe performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011. ResultsWe evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established.Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments. ConclusionThrough proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases.

Colorectal telephone assessment pathway: setting up a nurse-led service

It has been well documented that the cancer yield from 2-week-wait (2ww) colorectal referrals is low. Many patients diagnosed with colorectal cancer (CRC) are referred via non-2ww pathways. In the author's unit, 82% of colorectal cancers were diagnosed via routine pathways, some taking up to 6 months from referral to diagnosis. Therefore, in 2008, a colorectal telephone assessment pathway (CTAP) was introduced. Results show that the time to diagnosis decreased from 23 to 4 weeks, with high GP- and patient-satisfaction rates. This article describes how the CTAP was set up by the consultant nurse, and explores the issues involved and how they were addressed. It explains how results were achieved at no extra cost, and in reality, generated income. Development of this pathway has been proposed, but goes against existing Department of Health guidance. This is also explored, alongwith the dissemination work underway via an NHS Improving Quality initiative.

OC-071 Screening For Anal Pre-cancer In Hiv Positive And Negative Men Who Have Sex With Men (msm) And Renal Transplant Recipients: Early Experience From A Manchester Based Prospective Study

IntroductionThe UK National Screening Committee has suggested that screening for anal intraepithelial neoplasia (AIN) in populations at high-risk of anal squamous cell carcinoma may be of benefit, but that further...

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

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. 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. 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. 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.