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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