scholarly journals EP.TU.333FIT stratification in the COVID era - Is it safe for rectal bleeding?

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Jaspreet Seehra ◽  
James Bailey ◽  
Caroline Chapman ◽  
Joanne Morling ◽  
David Humes ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Rectal Bleeding ◽  
Digital Rectal Examination ◽  
Final Analysis ◽  
Bowel Habit ◽  
Hospital System ◽  
Testing Protocol ◽  
Low Threshold ◽  
Electronic Hospital

Abstract Aims Faecal Immunochemical Tests (FIT) are increasingly used for stratification of colorectal cancer risk in symptomatic patients. FIT is not currently recommended for use in patients with rectal bleeding, but recent studies have reported its safe use. We report our experiences of FIT in patients presenting with rectal bleeding during the COVID-19 pandemic. Methods Patients referred to NUH NHS Trust with rectal bleeding from 15/04/20-15/08/20 were invited to complete a postal-based FIT (OC-Sensor). Demographics, symptoms, investigations and results were recorded. Outcomes were retrospectively reviewed using an electronic hospital system. Result 344 patients were invited to participate, with 301 (87.5%) returning FITs in accordance with testing protocol. 36 patients declined to be seen, 4 were considered not fit for investigation, and 4 had incomplete records. 257 patients were included in the final analysis with 10 CRC detected (3.9%). Rectal bleeding (257, 100%) was the most common presenting symptom followed by change in bowel habit (133, 51.8%). 10 CRC were diagnosed (3.9%). 2 CRC were detected with FIT <4 µg Hb / g faeces (2/137, 1.5%) and 8 were detected >100 µg Hb / g faeces (8/45, 17.8%). FIT result was significantly associated with CRC diagnosis (p < 0.0001). 4 with CRC had anaemia (4/53, 7.5%), 1 had thrombocytosis (1/12, 8.3%). Conclusions FIT missed 20% of CRC in this patient group with the application of a very low threshold (<4 µg Hb / g faeces). Both cancers missed by FIT were detectable on digital rectal examination, emphasising the importance of this examination in primary care.

Removing hospital-based triage from suspected colorectal cancer pathways: the impact and learning from a primary care-led electronic straight-to-test pathway

2020 ◽  
pp. bmjqs-2019-009975
Author(s):  
Philippa Orchard ◽  
Nitin Arvind ◽  
Alison Wint ◽  
James Kynaston ◽  
Ann Lyons ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Dramatic Improvement ◽  
Hospital System ◽  
Cancer Data ◽  
Cancer Pathways ◽  
Referral Criteria ◽  
Nice Guidance ◽  
Referral Form ◽  
The Impact

BackgroundThe 2-week wait referral pathway for suspected colorectal cancer was introduced in England to improve time from referral from a general practitioner (GP) to diagnosis and treatment. Patients are required to be seen by a hospital clinician within 2 weeks if their symptoms meet the criteria set by the National Institute for Health and Care Excellence (NICE) and to start cancer treatment within 62 days. To achieve this, many hospitals have introduced a straight-to-test (STT) strategy requiring hospital-based triage of referrals. We describe the impact and learning from a new pathway which has removed triage and moved the process of requesting tests from hospital to GPs in primary care.MethodAn electronic STT pathway was introduced allowing GPs to book tests supported by a decision aid based on NICE guidance eliminating the need for a standard referral form or triage process. The hospital identified referrals as being on a cancer pathway and dealt with all ongoing management. Routinely collected cancer data were used to identify time to cancer diagnosis compared with national dataResults11357 patients were referred via the new pathway over 3 years. Time from referral to diagnosis reduced from 39 to 21 days and led to a dramatic improvement in patients starting treatment within 62 days. Challenges included adapting to a change in referral criteria and developing a robust hospital system to monitor the pathway.ConclusionWe have changed the way patients with suspected colorectal cancer are managed within the National Health Service by giving GPs the ability to order tests electronically within a monitored cancer pathway halving time from referral to diagnosis

scholarly journals Colorectal cancer and rectal bleeding in primary care: Rectal bleeding needs attention in primary care

BMJ ◽  
2006 ◽  
Vol 333 (7560) ◽  
pp. 201.3
Author(s):  
Christopher M Newman ◽  
Guy F Nash ◽  
Tom Armstrong ◽  
Kieren Darcy
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Rectal Bleeding

scholarly journals Colorectal Cancer in Different Age Groups in a Tertiary Hospital in Nepal

2017 ◽  
Vol 56 (206) ◽  
Author(s):  
Nandu Silwal Poudyal ◽  
Sitaram Chaudhary ◽  
Bhupendra Kumar Basnet ◽  
Bidhan Nidhi Poudel ◽  
Barun Shrestha ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Rectal Bleeding ◽  
Older Patients ◽  
Histological Grade ◽  
Medical Attention ◽  
Bowel Habit ◽  
P Value ◽  
Younger Patients ◽  
Altered Bowel Habit ◽  
Clinical Presentations

Introduction: Some studies have suggested that colorectal cancer at a younger age had distinct biological characteristics: different clinical presentations, more advanced stage at time of diagnosis and poorly differentiated carcinoma. The aim of the study is to analyze clinical and histopathological differences between younger (≤40 years of age) and older (>40 years of age) colorectal cancer patients.Methods: A cross-sectional analysis was conducted amongst the colorectal cancer patients who visited Bir Hospital between July 2015 and April 2017. All colonoscopically diagnosed and histopathologically proven cases of colon cancer were included. Chi-square test and independent t – test was performed to analyze the difference between clinical presentations and histopathological findings among two groups of patients and p value of <0.05 was considered as significant.Results: Thirty younger patients and thirty older patients were enrolled without any differences in gender proportion. There were no statistical differences between clinical presentation and histological grade and type in younger and older patients. The younger patients had more complaints of altered bowel habit (p <0.001) while older patients mostly presented with per rectal bleeding (p< 0.008).Conclusions: In this study, colorectal cancer at younger ages showed similar characteristics to those of older patients except altered bowel habit was more common in younger patients while per rectal bleeding was more common in older patients. Although colorectal cancer incidence increases with age, younger patients with altered bowel habits, weight loss, anemia and anorexia should also be given due medical attention and undergo evaluation promptly.  Keywords: carcinoma; colon; per rectal bleeding; younger group. [PubMed]

scholarly journals Faecal immunochemical test to triage patients with abdominal symptoms for suspected colorectal cancer in primary care: review of international use and guidelines

2020 ◽  
Vol 37 (5) ◽  
pp. 606-615 ◽  
Author(s):  
Marije van Melle ◽  
Samir I S Yep Manzano ◽  
Hugh Wilson ◽  
Willie Hamilton ◽  
Fiona M Walter ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Primary Care Patient ◽  
Care Patient ◽  
Bowel Habit ◽  
Level Of Evidence ◽  
Primary Care Population ◽  
Abdominal Symptoms ◽  
Primary Care Patients ◽  
The Uk

Abstract Background Recently, faecal immunochemical tests (FITs) have been introduced for investigation of primary care patients with low-risk symptoms of colorectal cancer (CRC), but recommendations vary across the world. This systematic review of clinical practice guidelines aimed to determine how FITs are used in symptomatic primary care patients and the underpinning evidence for these guidelines. Methods MEDLINE, Embase and TRIP databases were systematically searched, from 1 November 2008 to 1 November 2018 for guidelines on the assessment of patients with symptoms suggestive of CRC. Known guideline databases, websites and references of related literature were searched. The following questions were addressed: (i) which countries use FIT for symptomatic primary care patients; (ii) in which populations is FIT used; (iii) what is the cut-off level used for haemoglobin in the faeces (FIT) and (iv) on what evidence are FIT recommendations based. Results The search yielded 2433 publications; 25 covered initial diagnostic assessment of patients with symptoms of CRC in 15 countries (Asia, n = 1; Europe, n = 13; Oceania, n = 4; North America, n = 5; and South America, n = 2). In three countries (Australia, Spain and the UK), FIT was recommended for patients with abdominal symptoms, unexplained weight loss, change in bowel habit or anaemia despite a low level of evidence in the symptomatic primary care patient population. Conclusions Few countries recommend FITs in symptomatic patients in primary care either because of limited evidence or because symptomatic patients are directly referred to secondary care without triage. These results demonstrate a clear need for research on FIT in the symptomatic primary care population.

scholarly journals Symptoms and signs of colorectal cancer, with differences between proximal and distal colon cancer: a prospective cohort study of diagnostic accuracy in primary care

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Knut Holtedahl ◽  
Lars Borgquist ◽  
Gé A. Donker ◽  
Frank Buntinx ◽  
David Weller ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Rectal Bleeding ◽  
Occult Blood ◽  
Distal Colon ◽  
Supplementary Information ◽  
Free Text ◽  
Persistent Symptoms ◽  
Abdominal Symptoms ◽  
Symptoms And Signs

Abstract Background In an abdominal symptom study in primary care in six European countries, 511 cases of cancer were recorded prospectively among 61,802 patients 16 years and older in Norway, Denmark, Sweden, Netherlands, Belgium and Scotland. Colorectal cancer is one of the main types of cancer associated with abdominal symptoms; hence, an in-depth subgroup analysis of the 94 colorectal cancers was carried out in order to study variation in symptom presentation among cancers in different anatomical locations. Method Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. Follow-up data were provided by the GP after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. Fisher’s exact test was used to analyse differences between groups. Results Almost all symptoms recorded could indicate colorectal cancer. ‘Rectal bleeding’ had a specificity of 99.4% and a PPV of 4.0%. Faecal occult blood in stool (FOBT) or anaemia may indicate gastrointestinal bleeding: when these symptoms and signs were combined, sensitivity reached 57.5%, with 69.2% for cancer in the distal colon. For proximal colon cancers, none of 18 patients had ‘Rectal bleeding’ at the initial consultation, but three of the 18 did so at a later consultation. ‘Abdominal pain, lower part’, ‘Constipation’ and ‘Distended abdomen, bloating’ were less specific and also less sensitive than ‘Rectal bleeding’, and with PPV between 0.7% and 1.9%. Conclusions Apart from rectal bleeding, single symptoms did not reach the PPV 3% NICE threshold. However, supplementary information such as a positive FOBT or persistent symptoms may revise the PPV upwards. If a colorectal cancer is suspected by the GP despite few symptoms, the total clinical picture may still reach the NICE PPV threshold of 3% and justify a specific referral.

scholarly journals Risk in primary care of colorectal cancer from new onset rectal bleeding: 10 year prospective study

BMJ ◽  
2006 ◽  
Vol 333 (7558) ◽  
pp. 69-70 ◽  
Author(s):  
Jennifer du Toit ◽  
William Hamilton ◽  
Kevin Barraclough
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Prospective Study ◽  
Rectal Bleeding ◽  
New Onset

scholarly journals Clinical features of bowel disease in patients aged <50 years in primary care: a large case-control study

2017 ◽  
Vol 67 (658) ◽  
pp. e336-e344 ◽  
Author(s):  
Sally A Stapley ◽  
Greg P Rubin ◽  
Deborah Alsina ◽  
Elizabeth A Shephard ◽  
Matthew D Rutter ◽  
...  
Keyword(s):  
Primary Care ◽  
Clinical Features ◽  
Rectal Bleeding ◽  
Bowel Disease ◽  
Inflammatory Markers ◽  
Case Control Study ◽  
Case Control ◽  
Colorectal Disease ◽  
Bowel Habit ◽  
Control Study

BackgroundIncidences of colorectal cancer (CRC) and inflammatory bowel disease (IBD) are increasing in those aged <50 years.AimTo identify and quantify clinical features in primary care of CRC/IBD in those aged <50 years. This study considered the two conditions together and aimed to determine which younger patients, presenting in primary care with symptoms, would benefit from investigation for potentially serious colorectal disease.Design and settingMatched case-control study using primary care records from the Clinical Practice Research Datalink, UK.MethodIncident cases (aged <50 years) of CRC (n = 1661) and IBD (n = 9578) diagnosed between 2000 and 2013 were each matched with up to three controls (n = 3979 CRC; n = 22 947 IBD). Odds ratios (OR) and positive predictive values (PPV) were estimated for features of CRC/IBD in the year before diagnosis.ResultsTen features were independently associated with CRC/IBD (all P<0.001): rectal bleeding, change in bowel habit, diarrhoea, raised inflammatory markers, thrombocytosis, abdominal pain, low mean cell volume (MCV), low haemoglobin, raised white cell count, and raised hepatic enzymes. PPVs were >3% for rectal bleeding with diarrhoea, thrombocytosis, low MCV, low haemoglobin or raised inflammatory markers; for change in bowel habit with low MCV, thrombocytosis or low haemoglobin; and for diarrhoea with thrombocytosis.ConclusionThis study quantified the risk of serious bowel disease in symptomatic patients aged <50 years in primary care. Rectal bleeding and change in bowel habit are strongly predictive of CRC/IBD when combined with abnormal haematology. The present findings help prioritise patients for colonoscopy where the diagnosis is not immediately apparent.

scholarly journals Predictive values for different cancers and inflammatory bowel disease of 6 common abdominal symptoms among more than 1.9 million primary care patients in the UK: A cohort study

PLoS Medicine ◽  
2021 ◽  
Vol 18 (8) ◽  
pp. e1003708
Author(s):  
Annie Herbert ◽  
Meena Rafiq ◽  
Tra My Pham ◽  
Cristina Renzi ◽  
Gary A. Abel ◽  
...  
Keyword(s):  
Primary Care ◽  
Abdominal Pain ◽  
Rectal Bleeding ◽  
Bowel Habit ◽  
Composite Outcome ◽  
Predictive Values ◽  
Abdominal Bloating ◽  
Abdominal Symptoms ◽  
Specialist Referral ◽  
Inflammatory Bowel

Background The diagnostic assessment of abdominal symptoms in primary care presents a challenge. Evidence is needed about the positive predictive values (PPVs) of abdominal symptoms for different cancers and inflammatory bowel disease (IBD). Methods and findings Using data from The Health Improvement Network (THIN) in the United Kingdom (2000–2017), we estimated the PPVs for diagnosis of (i) cancer (overall and for different cancer sites); (ii) IBD; and (iii) either cancer or IBD in the year post-consultation with each of 6 abdominal symptoms: dysphagia (n = 86,193 patients), abdominal bloating/distension (n = 100,856), change in bowel habit (n = 106,715), rectal bleeding (n = 235,094), dyspepsia (n = 517,326), and abdominal pain (n = 890,490). The median age ranged from 54 (abdominal pain) to 63 years (dysphagia and change in bowel habit); the ratio of women/men ranged from 50%/50% (rectal bleeding) to 73%/27% (abdominal bloating/distension). Across all studied symptoms, the risk of diagnosis of cancer and the risk of diagnosis of IBD were of similar order of magnitude, particularly in women, and younger men. Estimated PPVs were greatest for change in bowel habit in men (4.64% cancer and 2.82% IBD) and for rectal bleeding in women (2.39% cancer and 2.57% IBD) and lowest for dyspepsia (for cancer: 1.41% men and 1.03% women; for IBD: 0.89% men and 1.00% women). Considering PPVs for specific cancers, change in bowel habit and rectal bleeding had the highest PPVs for colon and rectal cancer; dysphagia for esophageal cancer; and abdominal bloating/distension (in women) for ovarian cancer. The highest PPVs for abdominal pain (either sex) and abdominal bloating/distension (men only) related to non-abdominal cancer sites. For the composite outcome of diagnosis of either cancer or IBD, PPVs of rectal bleeding exceeded the National Institute of Health and Care Excellence (NICE)-recommended specialist referral threshold of 3% in all age–sex strata, as did PPVs of abdominal pain, change in bowel habit, and dyspepsia, in those aged 60 years and over. Study limitations include reliance on accuracy and completeness of coding of symptoms and disease outcomes. Conclusions Based on evidence from more than 1.9 million patients presenting in primary care, the findings provide estimated PPVs that could be used to guide specialist referral decisions, considering the PPVs of common abdominal symptoms for cancer alongside that for IBD and their composite outcome (cancer or IBD), taking into account the variable PPVs of different abdominal symptoms for different cancers sites. Jointly assessing the risk of cancer or IBD can better support decision-making and prompt diagnosis of both conditions, optimising specialist referrals or investigations, particularly in women.

scholarly journals Qualitative faecal immunochemical tests (FITs) for diagnosing colorectal cancer in patients with histories of rectal bleeding in primary care: a cohort study

2020 ◽  
Vol 35 (11) ◽  
pp. 2035-2040
Author(s):  
Cecilia Högberg ◽  
Ulf Gunnarsson ◽  
Olof Cronberg ◽  
Hans Thulesius ◽  
Mikael Lilja ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Rectal Bleeding ◽  
Predictive Value ◽  
Primary Care Physicians ◽  
Occult Blood ◽  
Health Records ◽  
Alarm Symptom ◽  
History Of ◽  
Patient’S History

Abstract Background Rectal bleeding is considered an alarm symptom for colorectal cancer (CRC) but it is common and mostly caused by benign conditions. Qualitative faecal immunochemical tests (FITs) for occult blood have been used as diagnostic aids for many years in Sweden when CRC is suspected. The study aimed to evaluate the usefulness of FITs requested by primary care physicians for patients with and without histories of rectal bleeding, in the diagnosis of CRC. Methods Results of all FITs requested in primary care for symptomatic patients in the Örebro region during 2015 were retrieved. Data on each patient’s history of rectal bleeding was gathered from electronic health records. Patients diagnosed with CRC within 2 years were identified from the Swedish Cancer Register. The analysis focused on three-sample FITs, the customary FIT in Sweden. Results A total of 4232 patients provided three-sample FITs. Information about the presence/absence of rectal bleeding was available for 2027 patients, of which 59 were diagnosed with CRC. For 606 patients with the presence of rectal bleeding, the FIT showed sensitivity 96.2%, specificity 60.2%, positive predictive value 9.8% (95% CI 6.1–13.4) and negative predictive value 99.7% (95% CI 99.2–100) for CRC. For 1421 patients without rectal bleeding, the corresponding figures were 100%, 73.6%, 8.3% (95% CI 5.6–10.9) and 100% (95% CI 99.6–100). Conclusion The diagnostic performance of a qualitative three-sample FIT provided by symptomatic patients in primary care was similar for those with and without a history of rectal bleeding. FITs seem useful for prioritising patients also with rectal bleeding for further investigation.

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