Colorectal Cancer Integrated Care Pathway by 39Y4e4

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									    HM Government DoH:


BANES and West Wilts
“GPs not referring enough patients with
bowel symptoms using 2 week wait”
• Any actual association with cancer survival?
• Is it my fault? – banging on for over ten years

• RUH sees all patients referred as 2WW (< 50 % are)
• Unusually high proportion of emergency admissions (30%)

• Are patients presenting to their GPs?
• Are GPs referring these patients?
                    An Audit
• One year of colorectal cancer admissions to the RUH
  who were not 2WW referrals

• Visited GP with symptoms?
• Visited GP with 2WW symptoms?
• GP referral on 2WW or standard pathway?

  PCT cancer lead & RUH cancer managers
                      Problems

• 40,000 new cases a year = 1 per GP
  (Only 1 in 10 GPs likely to see a young patient
   with cancer in whole career – under 30 years of age)

• Cancer symptoms same as those for benign

• We could see more patients but:
  our time / your money / patient’s discomfort +
                             Solution
• Increase number of patients visiting their GP
  (Government advertising campaign - recent pilot in SW but wrong people turned up!
  now new national campaign regardless)

• Increase number of accurate 2WW referrals
• ? Increase number of non-2WW referrals

  = significant improvement in cancer pick-up?
    (also FOB and familial screening)
        “Two week wait” guidelines

• Fe deficiency anaemia without other cause
  Hb < 11 men     Hb < 10 in postmenopausal women
• Definite palpable right-sided abdominal mass
• Definite palpable rectal (not pelvic) mass

• Rectal bleeding with a change of bowel habit towards
  looser stool and/or increased stool frequency persisting
  for 6 weeks or more (over 40 years old)

  (refer those who do not quite fit criteria by prose letter)
      “Two week wait” guidelines

In over 60’s only

• Change of bowel habit to loose or more frequent stool
  for over 6 weeks
• Rectal bleeding persistently with no anal symptoms

If don’t fit criteria but suspicious then wait until they do?
(or refer those who do not quite fit criteria by prose letter)
   CRC risk from bowel symptoms

85% colorectal cancers occur in over 60s



                      Age     < 50 yr      >60 yr

Looser bowel action >6/52     1:100        1:15
     Blood loss from anus     1:300        1:30
      “Two week wait” guidelines

In over 60’s only

• Change of bowel habit to loose or more frequent stool
  for over 6 weeks
• Rectal bleeding persistently with no anal symptoms

BUT – what about under 60s? – still refer over 45 yrs
BUT – what about under 45s then?
      “Two week wait” guidelines

In over 60’s only

• Change of bowel habit to loose or more frequent stool
  for over 6 weeks
• Rectal bleeding persistently with no anal symptoms

BUT – what about under 60s? – still refer over 45 yrs
BUT – what about under 45s then?
       Strategy for PR Bleeding



Please do a
    PR
examination
                  Illustration

• Male 35 years
• Blood spotting after defaecation last two years
   – every few months / especially if strains

• Lumps around anus
• Occasional aching discomfort or itching
                  Illustration

• Male 35 years
• Blood spotting after defaecation last two years
   – every few months / especially if strains

• Lumps around anus
• Occasional aching discomfort or itching


  he could have cancer – but you would be unlucky
                       Illustration

• Female 65 years
• Red rectal bleeding with defaecation for last five years
   – at least monthly but daily for last 6 months

• Prolapse through anus reduced by patient
• Multiple visits to GP – “never examined”
• Referred because Hb 9.6 and low Ferritin from bleeding
  piles was preventing hip surgery
       Strategy for PR Bleeding



Please do a
    PR
examination
             Strategy for PR Bleeding
         Is there a reasonable risk of cancer?
       (How would it look if I missed cancer?)

    Suspicious                     Relaxed

•   over 55 years           •   under 45 years
•   new symptom             •   anal discomfort / itch
•   strong FH               •   no FH
•   progressive             •   infrequent
•   altered blood           •   spots on toilet paper
•   mixed blood             •   drips into toilet pan
           Strategy for PR Bleeding



• Fit 2WW criteria?
• Over 45 yrs very low threshold but standard pathway
• Painless spotting / dripping in young = haemorrhoids
• Pain with spotting / dripping = fissure-in-ano

  Does my patient require treatment anyway?
      Haemorrhoids


Does my patient require treatment?
Does my patient want treatment?

• Frequent or heavy bleeding
• Prolapse
• Discomfort without fissure

• But consider high fibre diet first
  Fissure in ano

               pain / can’t do PR is diagnostic



• Laxatives and analgesia if hx under 6 weeks (“acute”)
• History over 6 weeks = “chronic” and will not heal:

• Prescribe GTN paste (Rectogesic 0.4%)
        • bd / headache

• diltiazem paste (Anoheal) unlicensed
                                                  }   40% cure
                   In Summary

• DoH wants you to refer more patients on 2WW
  (advertising campaign / audit results)
• We want you to refer less ‘weak’ 2WW
  (use single PCT referral form for cancers)


  For non-2WW and especially young patients:
  apply: how would I feel if my patient was later
             diagnosed with cancer?
  Screening For Bowel Cancer


ASYMPTOMATIC NORMAL PEOPLE



 (Surveillance rather than screening if
  previous bowel cancer or adenomas)
Screening - Faecal Occult Blood                   FOB
 • All UK population aged 60 to 70 every two years
 • Independent of GP practices
 • 15% survival advantage in controlled studies
    – but only 15% - at best
 • Most adenomas not picked up

 • Of all the common cancers only CRC has an
   ‘easy’ to cure benign stage – missing a real
   opportunity
    Coming to a town near you
• Flexible sigmoidoscopy (transverse colon)
  – 80%+ adenomas are distal to splenic flexure

• +55 years
• One off vs 5 yearly
• Reduce mortality by up to 50%
• Significantly reduce operations for CRC


• But need: money and endoscopists
Screening for Familial Bowel Cancer


 Recently revised:

 • Broadened the entry criteria
 • But delayed age for first colonoscope
Screening for Familial Bowel Cancer
“Kinship”

Was - first degree relatives only
Now - can include second degree relatives -
 as long as first degree relatives of each other AND
 at least one is a first degree relative of the consultand
       Screening for Familial Bowel Cancer

•   3FDR           1:6-10 (geneticist)       Cx 5 yearly from 50
•   2FDR <60       1:6-10 (?geneticist)      Cx 5 yearly from 50
•   2FDR >60       1:12                      Cx once at 55
•   1FDR <50       1:12                      Cx once at 55



      All others – risk > 1:12 no colonoscopy (pop risk 1:18)
       Take away messages

   Please use PCT 2WW referral form


How would I feel if my patient was later
       diagnosed with cancer?

								
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