Straight-to-test faecal tagging CT colonography for exclusion of colon cancer in symptomatic patients under the English 2-week-wait cancer investigation pathway: a service review

Faecal immunochemical testing reduces demand and improves yield of Leicester's 2-week pathway for change in bowel habit

AIM

We look at the effect of introducing the faecal immunochemical test (FIT) in the straight-to-test 2-week pathway for change in bowel habit (CIBH).

METHOD

The FIT in primary care triages 2-week wait (2WW) colorectal referrals for patients aged 60 years and above for straight-to-test CT colonography (CTC). We compare the impact of the FIT on numbers of 2WW CTCs, in the year before and after FIT, in both colorectal cancer (CRC) detection and cost-effectiveness at both 4 μg Hb/g faeces and 10 μg Hb/g faeces.

RESULTS

At a threshold of 4 μg Hb/g faeces, the positive predictive value of the FIT for diagnosis of CRC is 5.0% with a negative predictive value of 99.8% and a polyp detection rate of 25.5%. The introduction of the FIT resulted in a reduction in the number of CTCs performed through the CIBH pathway from a mean of 143.9 per month prior to the FIT to 66.8 CTCs per month once the FIT was well established. Given a FIT threshold of 10 μg Hb/g the number of CTCs would be predicted to fall by 70.4% to 42.6 CTCs per month resulting in higher CRC and polyp detection rate, and an estimated annual cost saving of £238 258 in our institution.

CONCLUSION

The FIT use in primary care improves the yield of 2WW referrals for CIBH alone and reduces the burden and cost of investigations to exclude CRC. Improvements may be possible by increasing the cut-off employed, without adversely affecting the risk of missing a cancer.

Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG)

Faecal immunochemical testing (FIT) has a high sensitivity for the detection of colorectal cancer (CRC). In a symptomatic population FIT may identify those patients who require colorectal investigation with the highest priority. FIT offers considerable advantages over the use of symptoms alone, as an objective measure of risk with a vastly superior positive predictive value for CRC, while conversely identifying a truly low risk cohort of patients. The aim of this guideline was to provide a clear strategy for the use of FIT in the diagnostic pathway of people with signs or symptoms of a suspected diagnosis of CRC. The guideline was jointly developed by the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology, specifically by a 21-member multidisciplinary guideline development group (GDG). A systematic review of 13 535 publications was undertaken to develop 23 evidence and expert opinion-based recommendations for the triage of people with symptoms of a suspected CRC diagnosis in primary care. In order to achieve consensus among a broad group of key stakeholders, we completed an extended Delphi of the GDG, and also 61 other individuals across the UK and Ireland, including by members of the public, charities and primary and secondary care. Seventeen research recommendations were also prioritised to inform clinical management.

Computed Tomography Colonography (CTC): Is It Really the Non-Invasive Option We Think It Is? A Patient Experience Study

Aims: Computed tomography colonography (CTC) is seen as a more tolerable alternative to colonoscopy, but patients struggle with the steps required for optimal diagnostic imaging. This prospective study aims to understand the experience of patients undergoing CTC. Methods: A survey was completed by a convenience sample of patients before and after CTC over 7 months. The 13-item questionnaire covered pre-test information, overall and specific experience of the test. The responses were tabulated and analyzed using descriptive statistics. Qualitative free-text responses were coded for content and thematic analysis. Results: At a response rate of 51%, surveys were received from 41 patients. Overall, most patients (54%) found the investigation better than expected. However, 18% stated they were not informed of potential side effects. Side effects were experienced by 49% of patients, including diarrhea (34%) and abdominal pain (24%). About 59% experienced discomfort with gas insufflation, and 86% found turning during the investigation difficult. Conclusion: A significant proportion of patients undergoing CTC experience side effects and difficulties completing the investigation. Patient information is important to improve patient experience of CTC.

"One stop" clinic for upper gastrointestinal cancer-an alternative to "straight to test" referrals?

BACKGROUND

Patients suspected to have upper gastrointestinal (UGI) cancer can be referred directly for investigation; however, at times this may result to inappropriate referrals. This study explores the model of a "one-stop" clinic as an alternative to the direct referral system. The current study aims to assess the feasibility and outcomes of a one-stop UGI clinic and evaluate sensitivity and specificity of "on-the-day" diagnoses.

METHODS

A retrospective analysis of case notes of patients seen in one-stop clinic, between January 2017 and January 2019, was conducted. All General Practitioner (GP) referrals were screened by a specialist nurse.

RESULTS

After completion of the post-GP referral screening process, 252 patients (median age 68 years, IQR 58.8-77.3 years; M:F ratio 118:134) were allocated to the one-stop clinic. OGD was not required, contra-indicated or declined in 27 cases (10.7%). The records of three patients could not be found. One patient did not attend. Overall, 221 patients underwent testing and received "on-the-day" diagnoses. Sensitivity was 94% (range 87-100%), and specificity was 92% (88-96%). Ninety-six percent of patients received a diagnosis on the day.

CONCLUSIONS

The one-stop clinic was feasible and had good specificity and sensitivity. The finding of 10.7% of cases not being suitable for OGD indicates that a patient/specialist consultation is necessary to prevent misuse of endoscopy appointments. The authors recommend widespread adoption of one-stop clinics in UGI surgery.

A colorectal straight-to-test cancer pathway with general-practitioner-guided triage improves attainment of the 28-day diagnosis target and increases outpatient clinic capacity

AIM

This study investigates whether a straight-to-test (STT) colorectal cancer pathway improves attainment of the National Health Service (NHS) England 28-day Faster Diagnosis Standard and the effect of the pathway on reducing face-to-face outpatient clinic appointments. Patient satisfaction and the safety of a novel general practitioner (GP) led patient triage system regarding suitability for colonoscopy are also evaluated.

METHODS

This is an observational study of all patients managed via an STT colorectal cancer pathway between 1 September 2019 and 19 March 2020. Comparison is made with all patients referred on the suspected colorectal cancer pathway prior to implementation of the STT pathway from 1 January 2019 to 30 July 2019. Patient satisfaction with the STT pathway was assessed with a telephone-based questionnaire.

RESULTS

Attainment of the 28-day diagnosis target for all suspected colorectal cancer referrals improved following the establishment of the STT pathway (88% vs. 82%, P < 0.0001). From a potential total of 548 outpatient colorectal clinic appointments for patients on the STT pathway, 504 (92%) were avoided. In those eligible for the STT pathway, GP assessment of patients suitable for colonoscopy agreed with that of the colorectal department in 93% of cases. Of the 50 patients who undertook the satisfaction survey, 86% were satisfied or very satisfied with the pathway. No patient suffered adverse events as a result of their STT investigations.

CONCLUSION

An STT pathway for suspected colorectal cancer referrals with novel GP-led patient triage safely streamlines patients through the suspected colorectal cancer diagnostic pathway and significantly reduces requirement for face-to-face outpatient clinic attendance. This is achieved with high patient satisfaction.

Straight-to-test colonoscopy: Has it improved the detection of colorectal cancer? A 7- year review

AIM

Early diagnosis of colorectal cancer (CRC) improves outcome. Straight-To-Test (STT) pathway was introduced in Whittington Hospital in 2012. The aim was to reduce the time to first oncological treatment and minimise unnecessary outpatient clinic appointments. However, this pathway has added significant burden to the trust in terms of number of procedures to be done.We assessed the diagnostic yield and the effectiveness of this pathway in improving the time to diagnosis of colorectal cancer. We also performed a cost-effective analysis and discussed the current literature along with interventions to further improve the benefits of STT investigations.

METHOD

This is a prospectively collected data of all patients who underwent STT examinations in a single centre from January 2012 till December 2018. The parameters collected were patient details, procedures performed, findings and discharge plan. We also performed a cost-effective analysis.

RESULTS

A total 1648 (90.8%) of patients identified suitable for STT pathway underwent colonoscopy or flexible sigmoidoscopy. From this, 764 (50.2%) patients had diagnosed pathology and CRC was detected in 50(3%) of the patients. We also estimated annual savings of £ 21,599.54 (£151,196.76 in seven years). Patients on the STT pathway took 25 days to obtain results as compared to 40 days in the standard pathway. The decision to take the patient off the cancer pathway was shortened by 3 weeks.

CONCLUSION

STT pathway has proven to be safe and cost-effective means of investigation. However, further improvement is needed in the implementation to make it a sustainable. mode of investigation in long run and increase the pickup rate of colorectal cancer through STT.

COVID-19 recovery: tackling the 2-week wait colorectal pathway backlog by optimising CT colonography utilisation

AIM

To review the indications for computed tomography colonography (CTC) performed on patients referred via the 2-week wait colorectal pathway (2WWCP).

MATERIALS AND METHODS

A retrospective study was performed on all patients referred through the 2WWCP between October 2018 and September 2019. The referrals were audited against the National Institute for Health and Care Excellence (NICE) NG12/DG30 guidelines for referral to the 2WWCP, and against the Royal College of Radiologists (RCR) 2017 guidelines for CTC.

RESULTS

Over the study period, there were 1,707 2WWCP referrals, and 362 (21.2%) of these patients underwent CTC. The median age was 66 years, and 55% were female. Forty-six patients did not meet the NICE NG12/DG30 guidelines for referral to the 2WWCP, and a further 268, although meeting the NICE guidelines, did not meet the RCR 2017 guidelines for CTC. In total, only 13% of CTCs performed complied with both guidelines.

CONCLUSION

This audit demonstrated a significant opportunity to reallocate CTC resources in the recovery stage of the COVID-19 pandemic. To improve outcomes for colorectal cancer (CRC) in the UK, establishing a selective straight-to-test CTC 2WWCP should be considered. Documented consent detailing the risks and benefits of CTC versus colonoscopy should take place in order to assist the patient in making an informed choice.