Colorectal 2 week wait pathways and “Getting FIT”

The two week Cancer Pathway 14 days 17 days 31 days Time to see in clinic Time to make diagnosis Time to start treatment

Earlier diagnosis Five year Forward View Improving Outcomes: a strategy for Cancer The likely impact of earlier diagnosis of cancer on costs and benefits in the NHS

Nottingham Cancers

Staging Matters

2 Week Wait referrals

New referral form

Co-morbidity

2WW pathway Introduced in 2000 Based on symptoms Not very effective locally and nationally Continually rising referral rates with no evidence of earlier stage detection (compare with BCSP) Evidence of reduced emergency presentation Low rates of cancer diagnosis & almost as many diagnoses from non-2WW referrals High rates of normal results from invasive tests Multiple symptoms have higher specificity than single symptoms but often diagnose later stage tumours Patients present with CIBH have cancer diagnosis excluded but get no help with their symptoms T1 rectal polyp cancer (BCSP)

Direct to test (DTT) The 2WW pathway has become a “CRC exclusion” pathway 150 - 180 referrals/month at NUH only (not TC) Pre-DTT: Overwhelming majority seen by Colorectal Nurse Practitioners independently with limited Consultant input DTT introduced in August 2014 to expedite diagnosis and introduce Consultant vetting

Direct To Test (DTT)

Outcomes Only 39-71% 2WW referrals (wide monthly variation) actually satisfy 2WW referral criteria. “Change in bowel habit to looser stools/more frequent stools” We investigate anyway. 2015 data: 45-50% DTT 15-25% seen by Cons 25-35% Nurse 5-10% other Outcome Audit: 1st August – 30th November 2014 553 referrals Colorectal Cancer (incl. anal) diagnoses = 37(6.7%) DTT patients significantly Younger Quicker first investigation (12 v 23 days) Quicker tissue diagnosis (16 v 26 days) DTT patients twice as likely to have colonoscopy (87 v 42%) BUT rates of normal colonoscopy same in both groups The rate of cancer diagnosis (8.5%) in asymptomatic BCSP patients with abnormal gFOBT in same time period was higher than in our symptomatic 2WW patients.

Anaemia Audit of 1000 DTT referrals to NUH: 20% had no Hb done at referral 38% were anaemic at time of referral but 2/3 were referred for other reasons Anaemic patients with sx are 4.4 times more likely to have cancer than non-anaemic patients Anaemia with bowel symptoms is a better predictor of CRC – particularly Right sided cancer Fe deficiency anaemia particularly so

New NICE guidance (NG12) Symptom based Looser Which we know is poor particularly “change in bowel habit” Looser Lower specificity Increased demand on stretched services Clinic Endoscopy Radiology Non-symptom based Use of FOBT Not rectal bleeding >50yo abdo pain or weight loss <60yo with CIBH <60yo iron deficiency anaemia (??) >60yo anaemia without Fe deficiency Broadening screening by the back door?

No clarity on…. Which FOBT? gFOBT (subjective & categorical) or FIT (objective, more sensitive, quantitative but less specific the lower you go)? gFOBT was withdrawn as test in symptomatic patients due to poor clinical effectiveness Studies (mainly within BCSP) demonstrate FIT>>gFOBT BUT what level of blood in a FIT warrants ix? No consensus…as yet Normal levels of blood in FIT vary according to age, sex and geography We do not know what to advise you with patients who have intermediate levels of blood in a FIT test…..at present

“Getting FIT” Prospective service evaluation Collaborative Primary care Nottingham Colorectal Service Bowel Cancer Screening Hub Two pathways I: Evaluating FIT levels in patients without rectal bleeding in the 2WW pathway II: GP access to FIT in appropriate patients

The future Local and national questions: Can Negative Predictive Value of FIT be used to avoid unnecessary investigation? Can FIT and anaemia be used to stratify referrals into high and low risk? Can CT colon reduce need for Colonoscopy? Is whole colon investigation necessary in absence of abdominal mass, anaemia and/or negative FIT?

Take home messages Please use the right form AND please request bloods on 2WW or “Getting FIT” referral FBC, UE and CRP BUT NOT CEA DTT team will check the results Please do not ask for FIT (or any FOBT) on Patients with rectal bleeding Patients over 60yo: they can call BCSP for a standard gFOBT kit “Negative”FOBT results DO NOT exclude cancer We would prefer you refer Fe def anaemia on a 2WW pathway for now

Questions?