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REMEDY : BNSSG referral pathways & Joint Formulary

Lower GI - 2WW

Checked: 30-11-2020 by vicky.ryan Next Review: 29-11-2021

Overview

The 2WW lower GI services at NBT, UHB and WGH are for patients who meet the Lower Gastrointestinal Cancer Two Week Wait criteria.

Contact details ADULT 2WW:

NBT - Tel on 0117 414 0522 / 0536 / 0537 / 0538 or email to cancerservices@nhs.net

UHBW - Tel on 0117 342 7641 / 2 / 3 / 4 or email to Ubh-tr.fast-trackreferrals@nhs.net

Before referral

*****NEW PATHWAY FROM 30th November 2020******

Please see the GP communications: Changes to colorectal pathway

From Monday 30th November, for eligible patients, a qFIT result must be included in the TWW referral unless there is a clearly stated reason explaining why it cannot be done. If a referral is sent without this it will be returned requesting the result is included.

This pathway change excludes those in whom a FIT test would not alter their need for investigation i.e. patients with one or more of the following:

  • iron deficiency anaemia in patients aged 60 or over (this is a change to the original pathway released on 5.10.20)
  • abdominal, rectal or anal mass
  • unexplained anal ulceration
  • unexplained rectal bleeding

Please see pathway as a flow diagram

Patients with a negative qFIT are at lower risk of colorectal cancer and evidence suggests they can be managed in the community with appropriate safety netting (1). This will help relieve pressure on colonoscopy provision so that it can be concentrated on patients with higher risk of colorectal cancer.

The direct to test form on ICE and 2WW form have been updated to reflect these changes.

Patients with FIT values ≥ 10ug/g (positive FIT)

These patients should still be referred on the Lower GI (LGI) 2WW pathway for suspected colorectal cancer (CRC). This should be done by direct to test via ICE (if they meet the pre-existing straight to test referral criteria), or via eRS if direct to test is not possible. See local referral pathways in sections below.

Patients with FIT values < 10ug/g (negative FIT)

Patients who do not meet criteria for 2WW referral and who have a negative FIT should be managed in Primary Care with an agreed follow up plan with relevant safety-netting processes in place.    

If the patient has persistent unexplained symptoms and negative qFIT, GPs can seek advice and guidance from secondary care clinicians:

If a GP still has concerns that colorectal cancer is more likely despite a negative FIT then they can still refer in via the 2WW route on e-Referral including an explanation of their concerns. See safety netting advice in FAQs.

FIT Test

There is a risk that patients will not appreciate the importance of carrying out a FIT test and how crucial the result will be to decisions on their management. GPs are therefore encouraged to emphasise the need for the test to be completed and sent off quickly.

To request a test for eligible patients the referral form in EMIS documents will need to be completed and placed back into the pack before handing it to the patient for completion at home

Instructions for use of FIT - Information for GPs - Updated Nov 2020

FAQs

Colorectal 2WW Pathway - Frequently Asked Questions Nov 2020

Referral

Patient Leaflet for 2WW Referral - please issue this leaflet at time of referral.

2WW Patient Information Leaflet. - COVID-19 Edition 

Link to leaflet on CCG website: https://bnssgccg.nhs.uk/library/understanding-two-week-wait-urgent-referrals-and-covid-19/ The leaflet via this link is available in English and 14 additional languages.

Referral to NBT and UHBW - Bristol

If patients meet the 2WW criteria refer Direct to test on ICE.

The following are excluded from direct to test and should be referred direct to clinic, using e_Referral:

    • Patients >75yrs at NBT, or >80yrs UHBW - Bristol
    • Frail patients and those that would not tolerate bowel prep 
    • Patients with FIT <10 where the GP is concerned after 4 weeks follow-up
    • If the patient is unable to carry out the FIT, for example because of a learning difficulty, this is to be clearly stated on the referral

Before starting the ICE referral it is useful to gather the following information to avoid the frustration of having to come out of ICE in order to find it

  • contraindications for colonoscopy
  • capacity to consent to the procedure
  • patient fitness – can the patient turn unaided 
  • co-morbidities - If diabetic or hypertensive a recent eGFR will be required
  • infection – the presence of current infection is a contraindication 
  • current medication - iron tablets should be stopped.
  • anticoagulation 
  • patient contact phone number
  • patient availability in the next two weeks.

Flexible Sigmoidoscopy is the investigation of choice for those patients with rectal bleeding.

Colonoscopy: the clinician will also be asked to agree to be the prescriber of the bowel preparation which will be dispensed by the Hospital. As sedation and analgesia will be used it is essential that the patient has someone at home the evening of the procedure. 

CT Colonoscopy CTC is less invasive and the bowel prep less aggressive so this is a more appropriate investigation for frail or elderly patients. However, note that this investigation is not sensitive to picking up lesions at the ano-rectal junction and so please ensure that a rectal PR examination has been carried out. If polyps are identified another referral will be needed to arrange their removal.

If patients are not suitable for direct to test should be referred to the 2WW clinic via e-referral using the Lower GI Cancer referral form (word doc).  Please free text concerns on the 2WW form making it clear why ICE referral is not possible or not appropriate.

The NBT lower GI team ask that when making a referral please be sure to give the patient the  NBT suspected bowel cancer patient information leaflet regards the referral process.

Referral to UHBW - Weston

For Lower GI suspected Cancer at WGH referrals must be raised using the Lower GI Cancer referral form (word doc).  The up to date form should be embedded in your EMIS system.

There is no Direct to test available at Weston.

Resources

NICE lower GI tract cancer guidelines(2015) 

CKS Summary (2017).

SWAG Cancer Alliance Primary and Secondary Care Guidance Lower GI 2WW Pathway during COVID-19 (Aug 2020)

Advice to local systems on triaging patients with lower gastrointestinal symptoms (NHSE / NHSI)