The Two-Week Referral System for colorectal cancer—not fit for purpose

Padwick, Robert; Bajwa, Adeel; Shaw, Annabel; Leung, Edmund; Francombe, James; Stellakis, Michael

doi:10.1007/s00384-013-1730-9

Cited by 6 publications

(6 citation statements)

References 13 publications

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“…Of these, 1655 were excluded because they were not conducted in the UK or were not in accordance with NICE guidance. The full texts of the remaining 95 records were reviewed, of which 49 were included in the review . Of the 49 included publications, one reported two datasets from different centres .…”

Section: Resultsmentioning

confidence: 99%

Systematic review with meta‐analysis of over 90 000 patients. Does fast‐track review diagnose colorectal cancer earlier?

Mozdiak

Ghebremichael‐Weldeselassie

McFarlane

et al. 2019

Aliment Pharmacol Ther

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Summary Background National UK data on colorectal cancer (CRC) stage at diagnosis is incomplete. Site‐specific fast‐track (2‐week wait) cancer data are not collected directly by NHS England. Policy making based on these data alone can lead to inaccuracy. Aims To review available data on key outcomes (cancer conversion rate and stage at diagnosis) for the UK's lower gastrointestinal 2‐week wait pathway. Methods A comprehensive literature search was conducted between 2000 and 2017. Primary outcomes were cancer conversion rate and cancer stage at diagnosis. Results were expressed as proportions with 95% CIs. A random effects model was used for meta‐analysis; heterogeneity was assessed by I2. Results Of 95 papers reviewed, 49 were included in analysis with a total study population of 93,655. Cancer conversion rate was 7.7% (95% CI: 6.9‐8.5). The proportion presenting at Dukes A = 11.2% (95% CI 7.4‐15.6), B = 36.7% (95% CI 30.8‐42.8), C = 35.7% (95% CI: 30.8‐40.8) and D = 11.1% (95% CI 7.3‐15.5). No colonic pathology was diagnosed in 54.6% (95% CI: 46.2‐62.8). Conclusions Only 7.7% of patients referred by the 2‐week wait pathway were found to have CRC. No beneficial effect on stage at diagnosis was found compared to non‐2‐week wait referral pathways. Over half of patients had no colonic pathology and detection of adenomas was very low. These results should prompt a reconsideration of the benefits of the 2‐week wait pathway in CRC diagnosis and outcomes, with more focus on strategies to improve patient selection.

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Section: Resultsmentioning

confidence: 99%

Systematic review with meta‐analysis of over 90 000 patients. Does fast‐track review diagnose colorectal cancer earlier?

Mozdiak

Ghebremichael‐Weldeselassie

McFarlane

et al. 2019

Aliment Pharmacol Ther

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“… 10 – 17 Tenesmus is not included in international CRC referral guidelines but has been associated with the detection of CRC, individually or in combination with other obstructive symptoms. 11 , 18 Some of these symptoms seem to be associated with tumor location. Visible rectal blood loss, tenesmus and a change in bowel habits, for example, are considered more common for distal than proximal CRC.…”

Section: Introductionmentioning

confidence: 99%

“…Clinical symptoms potentially indicative for the presence of CRC are visible blood in the stool, a change in bowel habits, unintentional weight loss and abdominal pain, although these symptoms are not very specific 10–17 . Tenesmus is not included in international CRC referral guidelines but has been associated with the detection of CRC, individually or in combination with other obstructive symptoms 11 , 18 . Some of these symptoms seem to be associated with tumor location.…”

Section: Introductionmentioning

confidence: 99%

A large proportion of fecal immunochemical test-positive participants in colorectal cancer screening is symptomatic

Klerk

Vlugt

Bossuyt

et al. 2017

United European Gastroenterology Journal

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BackgroundSymptomatic invitees are advised not to participate in colorectal cancer (CRC) screening but to directly consult their general practitioner (GP), because fecal immunochemical test (FIT) sensitivity for cancer is not optimal. This recommendation may not always be followed in daily practice. We evaluated how many FIT-positive participants had CRC-related symptoms and whether the presence of symptoms was associated with the presence and location of CRC/advanced neoplasia.MethodsWe prospectively collected data on CRC-related symptoms in all FIT-positive participants in the Dutch CRC screening program, referred to our endoscopy centers between 2014 and 2016, and evaluated whether symptoms were associated with detected CRC/advanced neoplasia at colonoscopy.ResultsOf 527 FIT-positive participants, 314 had advanced neoplasia, of which 41 had CRC. Overall, 246 (47%; 95% confidence interval (CI) 0.42–0.51) reported CRC-related symptoms. A change in bowel habits (odds ratio (OR) 2.86, CI 1.23–6.62) and visible blood in stool (OR 8.65, CI 2.34–32.0) were associated with the detection of CRC at colonoscopy. We did not observe significant associations between evaluated symptoms and advanced neoplasia.ConclusionsA large proportion of FIT-positive screening participants have CRC-related symptoms. This suggests that current instructions do not retain symptomatic screening invitees from participation and awareness of CRC-related symptoms is inadequate.

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“…An earlier review [10] found similar results but further identified that the remaining CRC diagnoses were referred as either emergency cases (24.1%) or via other routes (52.4%). From this it is clear the majority of the colorectal cases are diag-nosed outside the fast-track referral system and although studies [7,[11][12][13] have shown a correlation between refer-ral criteria and CRC, clinicians have remained critical of the guidelines; arguing poor specificity as a major factor in their low overall rate of CRC detection [14,15].…”

Section: Methodsmentioning

confidence: 99%

Two Week Rule Compliance: Assessing General Practice Use of the 'Two Week Rule' Referral Pathway for the Suspicion of Colorectal Cancer

Shahzad¹,

Alexander²,

Simon³

et al. 2021

Ann Public Health Reports

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Colorectal cancer (CRC) is a significant and increasing health problem in the western world. In 2012, 42,000 new cases of CRC were diagnosed in the UK, a rate of almost 115 cases per day [1]. Moreover, CRC remains the 4 th most prevalent cancer and 2 nd leading cause of cancer mortality in the UK [1]. It has long been accepted that early diagnosis and treatment improves the chances of survival [2]; yet to date, many patients still present with advanced stages of the disease and only 60% of new diagnoses have a five-year survival rate [3].

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The Two-Week Referral System for colorectal cancer—not fit for purpose

Abstract: Our preliminary results suggest that the current TWR guidelines cannot effectively predict CRC. There is an urgent need for an evidence-based approach to referral criteria for suspected CRC.

Cited by 6 publications

References 13 publications

Systematic review with meta‐analysis of over 90 000 patients. Does fast‐track review diagnose colorectal cancer earlier?

Systematic review with meta‐analysis of over 90 000 patients. Does fast‐track review diagnose colorectal cancer earlier?

A large proportion of fecal immunochemical test-positive participants in colorectal cancer screening is symptomatic

Two Week Rule Compliance: Assessing General Practice Use of the 'Two Week Rule' Referral Pathway for the Suspicion of Colorectal Cancer

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