ACPGBI Referral guidelines for colorectal cancer

Thompson, Michael R.

doi:10.1046/j.1463-1318.2002.00348.x

Cited by 49 publications

(42 citation statements)

References 66 publications

(95 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…3 This has led to the development of guidelines for referral of patients with suspected CRC, taking account of factors such as age (patients over 60 years are considered to be at increased risk) and symptoms including change in bowel habit, rectal bleeding and anaemia. 4 However, as these symptoms are non-specific and common in the general population, most patients who are investigated will not have the disease. 5,6 This places a considerable burden on diagnostic services and highlights the need for diagnostic tests that are not only sensitive and specific, but widely available, safe and acceptable to patients.…”

Section: Introductionmentioning

confidence: 99%

Computed tomographic colonography compared with colonoscopy or barium enema for diagnosis of colorectal cancer in older symptomatic patients: two multicentre randomised trials with economic evaluation (the SIGGAR trials)

Halligan

Dadswell

Wooldrage

et al. 2015

Health Technol Assess

View full text Add to dashboard Cite

BackgroundComputed tomographic colonography (CTC) is a relatively new diagnostic test that may be superior to existing alternatives to investigate the large bowel.ObjectivesTo compare the diagnostic efficacy, acceptability, safety and cost-effectiveness of CTC with barium enema (BE) or colonoscopy.DesignParallel randomised trials: BE compared with CTC and colonoscopy compared with CTC (randomisation 2 : 1, respectively).SettingA total of 21 NHS hospitals.ParticipantsPatients aged ≥ 55 years with symptoms suggestive of colorectal cancer (CRC).InterventionsCTC, BE and colonoscopy.Main outcome measuresFor the trial of CTC compared with BE, the primary outcome was the detection rate of CRC and large polyps (≥ 10 mm), with the proportion of patients referred for additional colonic investigation as a secondary outcome. For the trial of CTC compared with colonoscopy, the primary outcome was the proportion of patients referred for additional colonic investigation, with the detection rate of CRC and large polyps as a secondary outcome. Secondary outcomes for both trials were miss rates for cancer (via registry data), all-cause mortality, serious adverse events, patient acceptability, extracolonic pathology and cost-effectiveness.ResultsA total of 8484 patients were registered and 5384 were randomised and analysed (BE trial: 2527 BE, 1277 CTC; colonoscopy trial: 1047 colonoscopy, 533 CTC). Detection rates in the BE trial were 7.3% (93/1277) for CTC, compared with 5.6% (141/2527) for BE (p = 0.0390). The difference was due to better detection of large polyps by CTC (3.6% vs. 2.2%;p = 0.0098), with no significant difference for cancer (3.7% vs. 3.4%;p = 0.66). Significantly more patients having CTC underwent additional investigation (23.5% vs. 18.3%;p = 0.0003). At the 3-year follow-up, the miss rate for CRC was 6.7% for CTC (three missed cancers) and 14.1% for BE (12 missed cancers). Significantly more patients randomised to CTC than to colonoscopy underwent additional investigation (30% vs. 8.2%;p < 0.0001). There was no significant difference in detection rates for cancer or large polyps (10.7% for CTC vs. 11.4% for colonoscopy;p = 0.69), with no difference when cancers (p = 0.94) and large polyps (p = 0.53) were analysed separately. At the 3-year follow-up, the miss rate for cancer was nil for colonoscopy and 3.4% for CTC (one missed cancer). Adverse events were uncommon for all procedures. In 1042 of 1748 (59.6%) CTC examinations, at least one extracolonic finding was reported, and this proportion increased with age (p < 0.0001). A total of 149 patients (8.5%) were subsequently investigated, and extracolonic neoplasia was diagnosed in 79 patients (4.5%) and malignancy in 29 (1.7%). In the short term, CTC was significantly more acceptable to patients than BE or colonoscopy. Total costs for CTC and colonoscopy were finely balanced, but CTC was associated with higher health-care costs than BE. The cost per large polyp or cancer detected was £4235 (95% confidence interval £395 to £9656).ConclusionsCTC is superior to BE for detection of cancers and large polyps in symptomatic patients. CTC and colonoscopy detect a similar proportion of large polyps and cancers and their costs are also similar. CTC precipitates significantly more additional investigations than either BE or colonoscopy, and evidence-based referral criteria are needed. Further work is recommended to clarify the extent to which patients initially referred for colonoscopy or BE undergo subsequent abdominopelvic imaging, for example by computed tomography, which will have a significant impact on health economic estimates.Trial registrationCurrent Controlled Trials ISRCTN95152621.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 19, No. 54. See the NIHR Journals Library website for further project information. Funding was also provided by the UK Department of Health, which stipulated a randomised controlled design but had no involvement in the collection, analysis or interpretation of data, in writing the report, or in the decision to submit for publication. This was also the case for manufacturers who donated equipment for the study (Bracco UK Ltd, High Wycombe, UK; Viatronix Inc., Stony Brook, NY, USA; Medicsight plc, London, UK; Barco Ltd, Bracknell, UK).

show abstract

Section: Introductionmentioning

confidence: 99%

Computed tomographic colonography compared with colonoscopy or barium enema for diagnosis of colorectal cancer in older symptomatic patients: two multicentre randomised trials with economic evaluation (the SIGGAR trials)

Halligan

Dadswell

Wooldrage

et al. 2015

Health Technol Assess

View full text Add to dashboard Cite

show abstract

“…Although scientific methodology has been applied, 10,11 the randomised controlled trial (RCT) is usually not feasible for service delivery issues. 6,12 Furthermore, dissemination and implementation of the key findings have not always received sufficient attention in the design.…”

mentioning

confidence: 99%

Pitfalls in the construction of cancer guidelines demonstrated by the analyses of colorectal referrals

Hodder

Ballal²,

Selvachandran³

et al. 2005

Ann R Coll Surg Engl

View full text Add to dashboard Cite

INTRODUCTION The aim of this study was to develop a system to compare and validate cancer referral guidelines, identifying the pitfalls in their development and provide a mechanism to evaluate their efficacy.PATIENTS AND METHODS 3302 patients referred from primary care with colorectal symptoms over a 3-year period were assessed. All participants had a comprehensive history obtained via a questionnaire that incorporated all colorectal symptoms. The questionnaires were completed prior to assessment at the hospital. All patients were then assessed at the Colorectal One Stop Clinic (CROSC), underwent investigation and diagnosis achieved. All data were entered into a databank. Current prioritisation guidelines and tools that are used to assess colorectal referrals were applied to this colorectal databank to test their efficacy for cancer detection and referral prioritisation. Sensitivity and specificity for cancer detection and referral rates were assessed.RESULTS Cancer was detected in 156 patients (4.7%). All prioritisation models (NHS guidelines, Weighted Numerical Score [WNS], Netherlands, Harvard, Mersey, and Somerset) differentiated cancer from non-cancer patients. The use of a few symptoms as risk predictors (e.g. NHS guidelines) causes a decrease in specificity in contrast to a comprehensive risk tool, for example, the WNS at a score of 50 (NHS 54.1%, WNS 62.9%). This results in a significantly higher referral rate (NHS 47.6%, WNS 39.4%) and identifies fewer cancers (NHS 80.1%, WNS 85.9%). Non-evidence based modifications of the NHS guidelines (Somerset and Mersey) caused a further deterioration in specificity, which was reflected in an increased referral rate. Using the WNS, which is objective and a continuous scale, allows adaptation of the referral threshold, balancing sensitivity and specificity to the resources available within a hospital. For example, the WNS of ≥ 40 has a sensitivity of 96.8% for cancer detection.CONCLUSIONS Accurate prospective data collection into a data bank allows testing of referral guidelines as well as providing an adjunct to guideline construction.

show abstract

“…8 Thompson 14 attempted to improve the effectiveness and efficiency of a selection process for the management of low-and high-risk patients, by documenting the predictive and diagnostic values of individual signs and symptoms. Toomey et al 15 demonstrated that in the context of a ''one-stop'' policy, the use of flexible sigmoidoscopy is essential for all patients to avoid missed cases and delayed diagnosis of CRC.…”

Section: Discussionmentioning

confidence: 99%

The Effectiveness of a Rapid-Access Flexible Sigmoidoscopy Clinic in a District Hospital

Sorelli

Iliadis

Payne

2014

International Surgery

View full text Add to dashboard Cite

Historically rapid-access colorectal clinics have had high proportions of nonconforming referrals from primary care physicians, which calls into question the clinics' efficacy. We aim to determine the effectiveness of our rapid-access flexible sigmoidoscopy clinic, and the adherence to the referral guidelines for suspected bowel cancer by general practitioners. We performed a 3-month retrospective audit to evaluate (1) the proportion of patients seen within 2 weeks, (2) the appropriateness of referrals, (3) the proportion of patients with findings, and (4) the proportion of patients who had further tests. A total of 59 patients (19 male, 40 female; age 35-86 years) were included in the study. All were offered an appointment within 2 weeks. Forty-one cases (82%) were appropriate referrals. Twenty-eight patients (47%) had pathology at sigmoidoscopy. Cancer pick-up rate was 6%. Thirty-seven patients (74%) had further investigations. We determined that our rapid-access clinic for symptomatic patients has high diagnostic accuracy and that access to early investigation is being used appropriately by general practitioners. In the current climate of spending cuts and streamlining services, our study confirms we are meeting targets for delivery of our colorectal service. The majority of referrals under the 2-week rule are appropriate. Rapid access to early investigation is being used appropriately by general practitioners contrasting previous studies with high proportions of nonconforming referrals.

show abstract

ACPGBI Referral guidelines for colorectal cancer

Cited by 49 publications

References 66 publications

Computed tomographic colonography compared with colonoscopy or barium enema for diagnosis of colorectal cancer in older symptomatic patients: two multicentre randomised trials with economic evaluation (the SIGGAR trials)

Computed tomographic colonography compared with colonoscopy or barium enema for diagnosis of colorectal cancer in older symptomatic patients: two multicentre randomised trials with economic evaluation (the SIGGAR trials)

Pitfalls in the construction of cancer guidelines demonstrated by the analyses of colorectal referrals

The Effectiveness of a Rapid-Access Flexible Sigmoidoscopy Clinic in a District Hospital

Contact Info

Product

Resources

About