The Department of Health's "two week standard" for bowel cancer: is it working?

Abstract

Objective: To determine the effectiveness and efficiency of the Department of Health's new general practitioner referral guidelines for bowel cancer. Design: One year prospective audit. Setting: District general hospital serving a population of 550 000. Subjects: All patients with bowel cancer; all patients referred on the basis of the two week standard and to a routine colorectal surgical outpatient clinic. Main outcome measures: Proportion of cancers referred on the basis of the two week standard and to other colorectal clinics; the proportion with the higher risk criteria and their diagnostic yields; stage of cancers diagnosed in outpatient clinics; and time to treatment. Results: A total of 249 cancers were diagnosed in the index year. Sixty five (26.1%) were referred to two week standard clinics, 40 (16.1%) to routine colorectal surgical outpatient clinics, 54 (22%) to other clinics, and 88 (35.3%) were emergencies. Thirteen patients per week were referred to the two week standard clinics and 85% (54/65) of cancers so referred were seen within two weeks. The diagnostic yield of cancer in the two week standard clinic was 9.4% (65/695) compared with 2.2% (40/1815) in the routine colorectal surgical outpatient clinic (p,0.0001). Eighty five per cent of patients with cancer referred to outpatients matched the guidelines for the two week standard clinics. Only 46% of this group were so referred. Overall, delay to treatment and Dukes' stage were not improved in patients diagnosed in the two week standard clinics. Conclusions: Most patients with bowel cancer were not referred on the basis of the two week standard although most fulfilled the referral criteria, which had higher diagnostic yields. The two week standard clinics did not shorten the overall time to treatment or improve the stage of disease because the time lags before referral and after the outpatient appointment are the major causes of delay in the bowel cancer patient's journey.

Diagnostic Yield of Flexible Sigmoidoscopy in Symptomatic Population: An Insight to Rapid Access Sigmoidoscopy Clinic

“…5,12,28 Moreover, the 57 % incidence of rectal bleeding and change in bowel habits in bowel cancer was very similar to 58 and 51% in a symptomatic colorectal study. 13 In our study, 92.8% of all cancers were within the reach of the sigmoidoscope and 7.2% were on the right side which is in keeping with previous reports. 29 Unexplained weight loss, peri-anal pain and passing mucus per rectum were the most significant independent predictors of colorectal carcinoma in our symptomatic population.…”

“…19 Most patients referred to secondary centres with colorectal cancers have more than one symptom (85%). 13 Furthermore, these symptoms are subjected to selection bias which affects their predictive value in both the primary and secondary care settings. 20 Rectal bleeding is one of the most widely known and feared symptom.…”

“…12 What is important is that despite all available diagnostic modalities, the vast majority of patients present only after developing worrying symptoms. 13 Therefore, the main objective of this study was to provide an evaluation of symptomatic patients presenting with suspicious symptoms of colorectal cancer to our rapid access colorectal clinic where they had flexible sigmoidoscopy in their index visit. Diagnostic yield, polyps and cancer detection rates, histological grade, anatomical location, presenting symptoms and economic viability were analysed.…”

Referral Letters for 2-Week Wait Suspected Colorectal Cancer do not Allow a ‘Straight-to-Test’ Pathway

“…A study conducted in Portsmouth has shown that 74% of 249 cases of colorectal cancer were diagnosed by a route other than the Two Week Wait Rule clinics. 10 The diagnostic yield for this route is not good either. Although higher than the final diagnostic yield obtained via routine clinics (2%), a systematic review of studies performed in England and Wales showed that, out of 2440 patients referred using the Two Week Wait Rule, only 10.3% were subsequently diagnosed with colorectal cancer.…”

Cancer Diagnostic Assessment Programs: Standards for the Organization of Care in Ontario

“…There were seventeen case series that involved 38-3119 patients, two rcts that included 478 and 791 patients, and one case-control study that included 177 cases and 162 controls 4,7,[15][16][17][18][19][20][21][22][23][24][25][26][31][32][33][34][35][36] . The update of the literature search identified 823 citations in which patient outcomes related to diagnostic assessment units were described for colorectal cancer in four studies [27][28][29][30] , head-and-neck cancer in two studies 37,38 , lung cancer in two studies 39,40 , gynecologic cancers in three studies [41][42][43] , neurologic cancers in one study 44 , lymph node cancers in one study 45 , and upper gastrointestinal cancers in one study 46 . Study designs included one small rct (88 patients), seven prospective cohort studies (359-3637 patients), and six retrospective studies (69-930 patients) [27][28][29][30][37][38][39][40][41][42]…”