Straight to test. Results of a pilot study in a hospital serving an inner city population

Objective  The main aims of the study were to determine the frequency with which two-week wait (2ww) referrals for colorectal cancer (CRC) could proceed directly to straight to test (STT), and the potential improvement in time to diagnosis.
Method  A telephone interview was attempted in all 2ww referrals not requiring an advocate and under 80 years. Data were assessed according to a test protocol, and where indicated a potential slot for the appropriate investigation was recorded (virtual test). All patients proceeded to clinic, following which differences in time from GP referral to virtual compared with actual requested test, and any discrepancies between virtual and requested tests were analysed.
Results  Between 8th January and 16th February 2007, there were 42 2ww referrals. Twenty-one patients were contacted, of whom 14 were suitable for STT: 13 virtual colonoscopies and one CT scan were booked. Following out-patient consultation, eight colonoscopies; three flexible sigmoidoscopies, one barium enema, and two CT scans were actually booked. There was a difference of 15.5 days between the median times of the virtual and actual test. During this 6-week period a total of nine patients were diagnosed with CRC, of whom three were referred via the 2ww pathway, but none were suitable for STT.
Conclusions  This 'straight to test' pilot study suggests a potential strategy for reducing the time to diagnosis and therefore first treatment of those identified with CRC, and offers a methodology for individual hospitals to assess their suitability to employ such a strategy.     

The 2-week wait referral system does not improve 5-year colorectal cancer survival

Aim The aim of this study was to compare 5‐year survival rates in colorectal cancer (CRC) patients who underwent potentially curative surgery before and after the introduction of the 2‐week wait (2WW) referral system. Method Data were collected retrospectively from a prospectively maintained cancer database for CRC patients who underwent surgery in 1999 (pre‐2WW group, n = 150) and 2002 (post‐2WW group, n = 126). Patients who presented as an emergency, those who died within 30 days of surgery and those who presented with incurable CRC were excluded. We used the Kaplan–Meier method to plot survival curves and the log rank test to compare survival rates between the two groups. Results The 5‐year survival rates in the pre‐2WW and post‐2WW groups did not differ significantly (71%vs 72%, respectively; P = 0.880). The number of CRC patients who presented via urgent pathways was higher in the post‐2WW group than in the pre‐2WW group (77%vs 38%, P < 0.001). Further, owing to this change in the referral pattern, the overall delay between referral and treatment was significantly lower in the post‐2WW group than in the pre‐2WW group (median 76 days vs 115, P = 0.009). Conclusion The 2WW referral system for patients with symptoms of CRC does not translate into improved survival. However, more patients with symptomatic CRC are being referred via urgent pathways.     

Surgical vs general practitioner assessment: diagnostic accuracy in 2‐week‐wait colorectal cancer referrals

Aim It has been recommended that patients with suspected colorectal cancer should proceed straight to an endoscopic test to increase speed of diagnosis, using only the information in the general practitioner’s referral letter. This study aims to establish whether the diagnostic accuracy of the first surgical outpatient assessment is significantly greater than the general practitioner’s assessment and if so by what means. Method Demographic variables, symptoms and signs were collected from the first surgical outpatient assessment letters and the general practitioners’ referral letters in 2‐week‐wait colorectal cancer referrals made between 2002 and 2005. Multiple logistic regression models derived from both the surgeons’ and the general practitioners’ letters were compared with receiver operator characteristic curves. Results Variables were collected from 978 2‐week‐wait colorectal cancer referrals. The median age was 69 years (range 19–98) and the male to female ratio was 1:2. Seventy‐eight referrals were diagnosed with colorectal cancer. Surgeons’ models demonstrated significantly greater diagnostic accuracy than general practitioners’ models (area under the curve, 0.84 vs 0.73; P < 0.003). General practitioners’ letters contained significantly less information than surgeons’ letters (P < 0.001), but correcting for this did not account for the difference in diagnostic accuracy. The single variable that accounted for the difference in diagnostic accuracy was examination of the rectum by rigid sigmoidoscopy. Conclusion Rigid sigmoidoscopy significantly improves the diagnostic accuracy of clinical assessment in patients with suspected colorectal cancer. If rigid sigmoidoscopy were omitted in a straight‐to‐test pathway, some patients would be denied the opportunity for immediate diagnosis.     

The misuse of the faecal occult blood test under the lower gastrointestinal two week wait rule

Aim  To find the proportion of patients with a faecal occult blood (FOB) performed as part of the referral for the lower gastrointestinal two week wait (2WW) referral system, and whether this correlates with the cancer status.
Method  All patients referred to the colorectal cancer service using the 2WW referral criteria, between August 2005 and August 2007, were identified using the hospital's cancer audit database. Faecal occult bloods and cancer status were recorded for each patient.
Results  Two thousand one hundred and fifty-nine patients (1177 female: 903 male; median age 58; age range 18–98) were referred by general practitioners. The FOBT was only performed on three samples in all cases. In total, 172 of 2159 patients (7.9%) had an FOB performed prior to their referral, with 55 of 172 patients (31.9%) as part of the referral for 2WW. Sixteen of 172 patients (9.3%) had an FOB performed in the presence of overt rectal bleeding. In only 2 of 172 patients (1.1%) the FOB correlated with a colorectal cancer. Unnecessary testing for FOB costs has cost £4072.96 in total.
Discussion  A significant number of faecal occult bloods are being performed and the detection rate, even in this symptomatic group of patients, is very low. It is evident that the test is being performed in the community on three samples and not six. This, combined with the high false positive rate, leads to patients not only undergoing unnecessary psycho-social consequences but could potentially lead to significant risks from unnecessary invasive investigation as well as the added financial burden of test itself.     

Colonoscopic surveillance after curative colorectal resection: Results of an empirical surveillance programme

Introduction Colonoscopic surveillance after colorectal cancer resection is widely practised despite little evidence that it improves survival. The optimum protocol for colonoscopic follow‐up after colorectal cancer resection has not yet been elucidated. We audited the outcome of an empirical colonoscopic follow‐up programme in a cohort of patients who underwent colorectal resection with a minimum of five years follow‐up to establish patterns of metachronous neoplasia and suitable surveillance intervals. Methods The colonoscopic records, biopsy results and follow‐up details of patients diagnosed with colorectal cancer between June1990 and June1996 were reviewed. The number and type of metachronous neoplastic lesions diagnosed was recorded. Rates of development of new neoplasms were estimated by calculating the time from operation to their first discovery. Factors predictive of further development of polyps or cancer were sought. Results were compared to published reports of intensive follow‐up programmes. Results Seven hundred and ninety‐eight patients underwent colorectal resection with curative intent during the study period. 226 patients had one or more follow‐up colonoscopies (mean time post resection 48.8 months). In total 352 colonoscopies, encompassing 1437 patient years of surveillance, were performed. Nine metachronous cancers in eight patients, five of which were asymptomatic were diagnosed by colonoscopy at a mean of 63 months. Three asymptomatic recurrences were diagnosed but all were inoperable. 70 (31%) patients had adenomatous polyps diagnosed after a mean time from operation of 34 months for simple adenomatous polyps and 21 months for those with advanced features. Patients with multiple polyps or advanced polyps at the initial colonoscopy were more likely to form subsequent polyps. Only 5.8% of patients with a single adenoma or a normal colon formed an advanced adenoma over the next 36 months of surveillance. Conclusion The results of an empirical colonoscopic follow‐up programme compared favourably to the results of the intensive programmes reported in the literature. Most patients are at very low risk of developing significant colonic pathology over the first five years after resection. Colonoscopic surveillance intervals need not be less than five years unless the patient has multiple adenomas or advanced adenomas at the first colonoscopy. Three yearly surveillance intervals are most probably adequate in these individuals.     

Is whole colonic imaging necessary for symptoms of change in bowel habit and/or rectal bleeding?

Aim Following the introduction of a 2-week-wait (2ww) cancer pathway, many units are triaging patients with change in bowel habit (CIBH) and/or rectal bleeding (RB) straight to colonoscopy. Evidence suggests that right-sided colonic cancer does not present with these symptoms, hence imaging the left colon only is satisfactory. If this were substantiated, patients could be offered a flexible sigmoidoscopy (FS) alone. This study aimed to review presenting symptoms of patients diagnosed with a right-sided colonic malignancy and assess whether their tumours would be missed based on this practice. Method This is a retrospective analysis of patients who underwent curative resection for a proximal colonic malignancy over a 4-year period. Two-week-wait referral proforma and case notes were analysed for mode of presentation. Results Of 206 elective right hemicolectomies performed, 20/206 (9.7%) patients presented in the absence of either iron deficiency anaemia or palpable abdominal mass. Twelve patients had polyposis identified in the left colon and eight patients had no left-sided colonic pathology. One patient had a strong family history of colon cancer (two first-degree relatives) in the group absent of left-sided pathology. Conclusion Twelve patients who had left-sided polyposis and one patient with a strong family history would have undergone whole colonic imaging based on current colorectal cancer management guidelines. The remaining seven patients with right-sided cancer would have been missed if FS were the only investigation used. Patients presenting on the 2ww with symptoms of a CIBH and/or RB can be adequately investigated with a FS with a 3% chance of missing a proximal cancer.     

What interval between colorectal cancer resection and first surveillance colonoscopy? An audit of practice and yield

Aim Colonoscopic follow‐up after colorectal cancer resection (CRC) is recommended to screen for anastomotic recurrence and metachronous neoplasia, although guidelines vary in the timings of the first investigation. We aimed to quantify current practice and yield of neoplasia at first colonoscopy in relation to time from original resection. Method We conducted a retrospective case note study of all CRCs treated with curative intent within our hospital between two time periods: 2001–2003 and 2006–2007. Variables collected were the extent of preoperative luminal imaging, tumour site, procedure, timing and findings of initial colonoscopy, postoperative CT findings and mortality. The first follow‐up colonoscopy findings including neoplasia formation and recurrence rates were matched with rates of complete preoperative luminal imaging. Two‐year and 5‐year outcomes were sought. Results A total of 863 patients underwent CRC with curative intent within these two time periods (518 vs 345). Colonoscopic follow‐up rates by 2 years were 32.8%vs 54.1%. Within the first cohort 63.5% of patients underwent colonoscopy by 5 years. Significant volumes of neoplasia and resectable recurrences were found before 2 years within these groups. Earlier detection of recurrent malignancy was associated with an improved patient outcome. Complete preoperative screening of the bowel was not associated with a lower incidence of neoplasia at first postoperative colonoscopy. Conclusion Our study demonstrates significant colonoscopic detection rates of neoplasia within 2 years of CRC. Patient outcomes were improved with earlier detection. We would therefore suggest an interval of no more than 2 years between resection and first surveillance colonoscopy.     

Straight to colonoscopy: the ideal patient pathway for the 2-week suspected cancer referrals?

INTRODUCTION

The UK has a higher mortality for colon cancer than the European average. The UK Government introduced a 2-week referral target for patients with colorectal symptoms meeting certain criteria and 62-day target for the delivery of treatment from the date of referral for those patients diagnosed with cancer. Hospitals are expected to meet 100% and 95% of these targets, respectively; therefore, an efficient and effective patient pathway is required to deliver diagnosis and treatment within this period. It is suggested that ‘straight-to-test’ will help this process and we have examined our implementation of ‘straight-to-colonoscopy’ as a method of achieving this aim.

PATIENTS AND METHODS

We carried out a retrospective audit of 317 patients referred under the 2-week rule over a 1-year period between October 2004 and September 2005 and were eligible for ‘straight-to-colonoscopy''. Demographic data, appropriateness of referral and colonoscopy findings were obtained. The cost effectiveness and impact on waiting period were also analysed.

RESULTS

A total of 317 patients were seen within 2 weeks. Cancer was found in 23 patients and all were treated within 62 days. Forty-four patients were determined by the specialist to have been referred inappropriately because they did not meet NICE referral guidelines. No cancer was found in any of the inappropriate referrals. The use of straight-to-test colonoscopy lead to cost savings of £26,176 (£82.57/patient) in this group compared to standard practice. There was no increase in waiting times.

CONCLUSIONS

Straight-to-colonoscopy for urgent suspected cancer referrals is a safe, feasible and cost-effective method for delivery of the 62-day target and did not lead to increase in the endoscopy waiting list.     

Why wait for a colonoscopy? An easy cure

OBJECTIVE: Three thousand five hundred and forty-nine patients are waiting for a colonoscopy in the Kent and Medway cancer network. New guidelines identify those who require surveillance for polyp, cancer, IBD and family history. Our hypothesis was that most of the patients on the waiting list would no longer need a colonoscopy if the new guidelines were applied. PATIENTS AND METHODS: We compared the ACPGBI guidelines for screening/surveillance colonoscopy with the indications in 411 notes of one hospital's waiting list and removed patients as appropriate. In the second part of study we analysed 192 patients attending colonoscopy in seven hospitals in the region and calculated the potential impact of the guidelines on our waiting lists. RESULTS: Of 411 patients on the waiting list in one hospital, only 98 (24%) needed to remain on the list. 142 (34%) were cancelled completely. One hundred and seventy-one (42%) were taken off the 'waiting' list and rebooked for a later date since according to the new guidelines the colonoscopy was not due yet. Of 192 colonoscopies actually performed during the study period in 7 hospitals of Kent and Medway cancer network, 72 (38%) were for surveillance. Two thirds of those were not in line with the guidelines. As a result of implementing the guidelines, waiting times for diagnostic colonoscopy fell from 12 to 4 weeks for urgent, and from 40 to 15 weeks for routine referrals. CONCLUSION: A quarter of the 8000 colonoscopies performed annually in our region are unnecessary when compared to the guidelines. More than three quarters of our waiting list could be removed by reviewing the notes. Implementing the guidelines in one cancer network would save pounds 1 million per year even on conservative estimates of pounds 500 per colonoscopy. It would also reduce the waiting times for diagnostic colonoscopy.     

Prioritization of colorectal referrals: a review of the 2-week wait referral system

OBJECTIVE: The 2-week wait (TWW) fast-track referral system for patients suspected of having colorectal cancer (CRC) has fallen well short of its expectations of streamlining prioritization of colorectal referrals. Our study reviews most of the audits/studies that have been published on the system as its inception. Our aim was to identify where the shortcomings are and also to review the various alternatives that have recently been put forward. METHOD: All articles on the TWW system published in mainstream peer reviewed journals were reviewed, as were all the abstracts on the system presented at the Association of Coloproctology and the British Society of Gastroenterology meetings. Implementation, compliance with guidelines, cancer detection rate, impact on waiting times and the overall effectiveness of the system are evaluated. RESULTS: While the implementation of the system has been generally robust in most centres, the compliance with guidelines has been poor. This coupled with the inherently poor specificity of the system has resulted in a poor (and decreasing) cancer detection rate and a steadily growing volume of the hospital referrals. The system has been shown to have an adverse impact on the waiting times for routine colorectal referrals - a group that contributes significantly to the total number of CRC detected. The various alternatives to the TWW system that have been proposed recently, including our own, are discussed. CONCLUSION: The shortcomings of the TWW system in its original form have now been demonstrated beyond doubt. What is needed is a fresh approach to find a cost effective and viable alternative in a climate of increased expectations and finite resources.     

Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.     

A randomized,controlled trial of narrow‐band imaging vs high‐definition white light for adenoma detection in patients at high risk of adenomas

Aim The study aimed to investigate whether narrow‐band imaging (NBI) can enhance adenoma detection in patients at high risk for adenomas compared with high‐definition white‐light endoscopy (WLE). High risk was defined as three or more adenomas at last colonoscopy, history of colorectal cancer and positive faecal occult blood test. Method Two hundred and fourteen patients were randomized 1:1 to examination with NBI or WLE. The primary outcome measure was the proportion of patients with at least one adenoma detected. Secondary outcomes included total adenomas and polyps, flat adenomas, nonadenomatous polyps, advanced adenomas and patients with three or five or more adenomas. A post hoc analysis to examine the effect of endoscopist and bowel preparation was performed. Results There was no significant difference in the proportion of patients with at least one adenoma: NBI 73%vs WLE 66%, odds ratio 1.40 (95% CI 0.78–2.52), P = 0.26. There was no significant difference for any secondary outcome measure except for the number of flat adenomas which was significantly greater with NBI [comparison ratio 2.66 (95% CI 1.52–4.63), P = 0.001]. Post hoc analysis indicated that one of three endoscopists performed significantly better for adenoma detection with NBI than WLE [comparison ratio 1.92 (95% CI 1.07–3.44), P = 0.03]. Good bowel preparation was associated with significantly improved adenoma detection with NBI [comparison ratio 1.55 (95% CI 1.01–2.22), P = 0.04] but not with fair preparation. Conclusion Overall NBI did not improve detection compared with WLE in a group of patients at high risk for colorectal adenomas, but specific subgroups might benefit.     

Virtual colonoscopy vs conventional colonoscopy in patients at high risk of colorectal cancer – a prospective trial of 150 patients

Objective Virtual colonoscopy (VC)/CT colonography has advantages over the well‐documented limitations of colonoscopy/barium enema. This prospective blinded investigative comparison trial aimed to evaluate the ability of VC to assess the large bowel, compared to conventional colonoscopy (CC), in patients at high risk of colorectal cancer (CRC). Method We studied 150 patients (73 males, mean age 60.9 years) at high risk of CRC. Following bowel preparation, VC was undertaken using colonic insufflation and 2D‐spiral CT acquisition. Two radiologists reported the images and a consensual agreement reached. Direct comparison was made with CC (performed later the same day). Interobserver agreement was calculated using the Kappa method. Postal questionnaires sought patient preference. Results Virtual colonoscopy visualized the caecum in all cases. Five (3.33%) VCs were classified as inadequate owing to poor distension/faecal residue. CC completion rate was 86%. Ultimately, 44 patients had normal findings, 44 had diverticular disease, 11 had inflammatory bowel disease, 18 had cancers, and 33 patients had 42 polyps. VC identified 19 cancers – a sensitivity and specificity of 100% and 99.2% respectively. For detecting polyps > 10 mm, VC had a sensitivity and specificity (per patient) of 91% and 99.2% respectively. VC identified four polyps proximal to stenosing carcinomas and extracolonic malignancies in nine patients (6%). No procedural complications occurred with either investigation. A Kappa score achieved for interobserver agreement was 0.777. Conclusion Virtual colonoscopy is an effective and safe method for evaluating the bowel and was the investigation of choice amongst patients surveyed. VC provided information additional to CC on both proximal and extracolonic pathology. VC may become the diagnostic procedure of choice for symptomatic patients at high risk of CRC, with CC being reserved for therapeutic intervention, or where a tissue diagnosis is required.     

Use of a patient consultation questionnaire and weighted numerical scoring system for the prediction of colorectal cancer and other colorectal pathology in symptomatic patients: A prospective cohort validation study of a Welsh population

Objective There is currently no system in widespread use that accurately prioritizes colorectal referrals in symptomatic patients with an acceptable degree of sensitivity and specificity. We have validated a weighted numerical scoring system for the prioritization of such colorectal referrals in an attempt to rectify this, with detection of colorectal cancer (CRC) the primary outcome. Method We conducted a prospective study of symptomatic patients referred by primary care to the colorectal service in a district general hospital. A computer‐generated weighted numerical score (WNS) was derived from the primary symptoms and symptom combinations. Patients underwent colorectal investigations and a final diagnosis was established. Sensitivity, specificity and accuracy of CRC detection as determined by the WNS, Department of Health (DOH) and National Institute for Health and Clinical Excellence guidelines was determined. Primary Care compliance with guidelines was analysed. Results A definitive diagnosis was established in 3457 patients. One hundred and eighty‐six (5.4%) had CRC. The mean score for the cancer patients (76.9, 95%CI 72–81) was significantly higher than that of non‐cancer patients (52, 95%CI 52–53) P < 0.001. Receiver Operator Curve analysis demonstrates a high discriminatory power for the Patient Consultation Questionnaire (PCQ) with an area under curve of 0.76. Compliance by primary care with the nationally recommended referral guidelines was poor with only 55% and 58% compliance with DOH and National Institute for Clinical Excellence referral guidelines for suspected cancer respectively. Conclusion The PCQ and the WNS is an efficient, objective system that allows the accurate prioritization of colorectal referrals with a high sensitivity for cancer and other serious colorectal pathologies.     

Managing the 2-week wait for breast patients

INTRODUCTION

Published data suggest that the 2-week wait system and triple assessment at one fast-track clinic visit is an out-dated method of capturing disease from a referral population. These studies report up to 32% of breast cancer coming from routine referrals. It has been recommended, therefore, that all breast referrals should be seen within 2 weeks. The sheer volume of referrals are likely to prevent this target being achieved. The aim of this study was to analyse the performance of our fast-track system.

PATIENTS AND METHODS

The Birmingham Heartlands and Solihull fast-track clinics were set up in 1999 with a prospective audit system. The data from this audit were retrospectively analysed and cross-referenced with the cancer data base to determine the referral origin of breast cancers from November 1999 to February 2005.

RESULTS

A total of 14,303 (fast-track, n = 6678; routine referral, n = 7625) patients were seen over a 5-year period. Overall, 1095 cancers (91.8% of the total) came from the fast-track clinics which had a pick-up rate of 16.4% compared with 98 cancers (8.2% of the total) and a pick-up rate of 1.3% for routine referrals (P < 0.001). The appropriateness of fast-track referral was also analysed which showed that 14.4% of cancers were detected if the referral criteria were met compared to 0.55% if they were inappropriate (P < 0.001).

CONCLUSIONS

The traditional fast-track, triple assessment breast clinic is an efficient and well-structured way of diagnosing disease. We recommend that the two system referral pattern should continue.     

Direct photographic documentation of ileal mucosa in routine colonoscopy is not an independent valid or reliable proof of completion: quality assurance issues for the national colorectal cancer-screening programme

Introduction The implementation of bowel cancer screening in the UK requires the maintenance of high standards in colonoscopy. Part of this quality control requires the reliable documentation of complete colonoscopy that can be externally audited and assessed. It has been suggested that terminal ileal biopsy is the only definitive and reliable method of confirming caecal intubation, but it is not cost‐effective and may now be contraindicated because of potential prion infection. Objective To determine how reliable routine terminal ileal images were as an independent predictor of complete colonoscopy and whether their interpretation was aided with water insufflation or indigo‐carmine dye‐spraying. Method Forty‐nine histologically confirmed terminal ileal images were obtained from a single endoscopist’s database; 19 were conventional white‐light images, 15 were taken with water insufflation and 15 were taken using chromoscopy enhancement. The images were transferred onto CD‐ROM and sent as a questionnaire to 42 colonoscopists who were asked to identify the images as terminal ileum or not. Results Twenty questionnaires were returned resulting in a total of 980 responses. Overall, the accuracy of positive identification was 53.4%. Water insufflation and chromoscopy improved the accuracy to 68.3% and 63% respectively. Experience of (> 1000 colonoscopies) did not increase overall accuracy. Less experienced endoscopists had an increased accuracy rate with dye‐spraying (76.7%vs 59.3%, P < 0.05) but experienced endoscopists had an increased accuracy rate with water insufflation (67.4%vs 63.3%, P > .05). Conclusion Currently, terminal ileal imaging is not a reliable mode of documenting complete colonoscopy. Using water insufflation or dye‐spraying coupled with modifications in image acquisition technique may improve its reliability but these methods require further investigation before they can replace the use of caecal landmarks as completion parameters.