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REMEDY : BNSSG referral pathways & Joint Formulary

Lower GI - 2WW

Checked: 03-08-2021 by Rob.Adams Next Review: 02-08-2022


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

UHBW - Tel on 0117 342 7641 / 2 / 3 / 4 or email to


****New FIT test guidelines are coming - Update May 2022***

The BSG (1) have released guidance supporting a qFit being requested to guide management of all patients with symptoms that warrant investigation on a 2ww colorectal pathway (apart from anal mass/ulceration).

Local referral forms and pathways have not yet been updated but should change in the coming weeks. Until then you can select another 2ww symptom on the qFit test request with text to explain the situation.

Pathways for the ongoing management of these patients are under review with the local Colorectal teams and until these are agreed patients can continue to be sent on a 2ww pathway for further assessment irrespective of the qFit result.

(1) Faecal Immunochemical Testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC) - The British Society of Gastroenterology

See also the FIT test page for details or the 'FIT test required' section below.

Who to Refer

Patients who do not require a FIT test

Patients with the following symptoms should be referred directly via 2WW and do not require a FIT test prior to referral:

  • Rectal or abdominal mass (patients with a pelvic mass should be referred via the gynaecology 2WW pathway)
  • Aged 50 and over with unexplained rectal bleeding
  • Aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, iron-deficiency anaemia
  • Aged 60 and over with Iron-deficiency anaemia
  • Unexplained anal mass or unexplained anal ulceration


Patients where a FIT test is indicated and is positive (>10)

In patients where a FIT test is indicated, this should be performed and if positive then a 2WW referral should be made. Please see section below or go to the FIT test page for further details.


Patients where a FIT test is not possible, or a GP has significant concerns about malignancy, but cannot refer via ICE

In the scenarios above, a 2WW referral can be submitted via e-RS 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.

 If advised to refer into MDT, then please submit a 2WW referral to the relevant secondary care team who will ensure that all the required information is available to enable an effective MDT discussion. 


At time of referral please issue the relevant BNSSG 2WW Patient Information Leaflet - COVID-19 edition, which is available in English and 14 additional languages.  There is also an Easy Read version of the leaflet.

Referrals to NBT or UHBW 

Patients with symptoms meeting the 2WW criteria should be referred direct to test on ICE unless exclusions apply.

  • NBT - 2WW direct to test is now available for colonoscopy, CT colonoscopy and CT Abdomen and Pelvis. The ICE form will direct you towards the most appropriate test for you patient.
  • UHB - 2WW direct to test is available for colonoscopy, CT colonoscopy and CT Abdomen and Pelvis. The ICE form will direct you towards the most appropriate test for you patient.
  • WESTON – 2WW direct to test is not available on ICE but there is work continuing for this to align with the ICE requesting process currently operation at UHB, until that date please continue to refer by ERS.

The following are excluded from direct to test and should be referred direct to the suspected cancer clinic via eRS, using the 2WW referral form:

  • 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.

Patients who require a FIT test

The new 2WW form and ICE direct to test form state that FIT tests should be performed in the following patients:

  •  Aged 40 and over with unexplained weight loss and abdominal pain
  •  Aged 60 and over with changes in their bowel habit

In addition, patients without rectal bleeding who have unexplained symptoms but do not meet the 2WW criteria should have a FIT test:

  • Aged under 60 with iron deficiency anaemia
  • Aged 60 and over with non-iron deficiency anaemia
  • Aged 50 or over with abdominal pain or weight loss
  • Aged less than 60 with change in bowel habit


For these groups of 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.

Please see pathway as a flow diagram

Please see the GP communications: Changes to colorectal pathway (30.11.20)

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


Colorectal 2WW Pathway - Frequently Asked Questions Nov 2020


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 (March 2021)

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