Colorectal cancer

This page includes the current referral guidelines and pathways for the management of patients referred with a suspicion of Lower Gastrointestinal (Colorectal) cancer, including highlighting which elements of the pathway will be provided locally by NHS Borders, and which will require to be undertaken in NHS Lothian (Tertiary services).

The Colorectal cancer service is provided by:

• Mr Martin Berlansky, Clinical Director, Consultant General Surgeon and Colorectal Tumour Site Lead
• Dr Luis Ferrando, Clinical Director and Consultant Radiologist
• Dr Jonathan Fletcher, Consultant Gastroenterologist
• Dr Jonathon Manning, Associate Medical Director and Consultant Gastroenterologist
• Mr Karol Pal, Consultant General Surgeon
• Mr Srihari Vallabhajousula, Locum Consultant General Surgeon
• Rebecca Bell, Cancer Nurse Specialist
• Louise Horne, Senior Charge Nurse – Endoscopy Unit
• Rachel Johnson, Cancer Nurse Specialist

Colorectal Cancer: Lower Gastrointestinal Cancers

Lower gastrointestinal symptoms are common presentations in primary care. Rectal bleeding is estimated to affect 14,000 per 100,000 population each year. There are large differences in the predictive value of rectal bleeding for cancer according to its association with other symptoms and signs and the age of the person.

Different management strategies should be adopted according to cancer risk, so that those people with transient low-risk symptoms caused by benign disease avoid unnecessary investigation.

The risk of colorectal cancer is increased if there is a past history of ulcerative colitis, colorectal polyps or cancer, or if there is a family history of colorectal cancer or Lynch syndrome. Guidance for referral to regional genetics centres for those with such a family history is available in SIGN 126.

In people with ulcerative colitis, a plan for follow up should be agreed in line with current national guidelines.

Guidance on the role of qFIT in assessment of new lower gastrointestinal symptoms has now been published and can be found here.

The following provides guidance on the use of quantitative faecal immunochemical test (qFIT) for faecal haemoglobin (f-HB) as an adjunct to clinical acumen so that referral and investigation of patients with colorectal symptoms can be targeted to those with the highest risk of significant colorectal pathology.

Individual symptoms are poor predictors of colorectal cancer. The predictive value of colorectal symptoms can be improved using qFIT. 22% (19-28%) of Scottish patients with colorectal symptoms, will have a f-Hb 10mgHb/g faeces. Up to 95% (84-95%) of patients referred who are then diagnosed with colorectal cancer will have a f-Hb 10mg Hb/g faeces. Referral and management triage applying qFIT in symptomatic patients, shortens time to diagnosis, is cost effective and there is emerging evidence that its application may result in a migration to an earlier cancer stage at diagnosis. qFIT will also prevent harm through the avoidance of investigations in patients who are not likely to have significant pathology.

If a qFIT is requested for asymptomatic, vague acute or non-colorectal symptoms, 12% will still have a f-Hb >10mgHb/g faeces, but the costs and endoscopy demand will not be sustainable, patients will continue to wait for their investigations and the diagnostic yield will be low. There are alternative referral pathways and bowel cancer screening (if eligible) for these patients.

As an adjunct to clinical acumen, a numerical qFIT result should be available whenever possible, before a patient is referred to secondary care for investigation or management of the large bowel symptoms (table overleaf). Where primary care do not have access to qFIT, secondary care will triage the referral taking into account the f-Hb result using their local pathway. Primary care clinicians are also encouraged to request a blood Hb and investigations for iron deficiency anaemia where the Hb is low.