1. Colorectal 2 week wait pathways and “Getting FIT”

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

5. 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

6. Nottingham Cancers

7. Staging Matters

8. 2 Week Wait referrals

9. New referral form

10. Co-morbidity

11. 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)

12. Direct to test (DTT)
The 2WW pathway has become a “CRC exclusion” pathway
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

13. Direct To Test (DTT)

14. 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.

15. 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

17. 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?

18. 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

19. “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

21. 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?

22. 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

23. Questions?