The two-week rule colorectal cancer pathway: an update on recent practice, the unsustainable burden on diagnostics and the role of faecal immunochemical testing

Introduction Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services. Methods A prospectively maintained database of patients referred under the two-week rule pathway for April 2017–2018 was sub-analysed and the data cross-referenced with all diagnostic reports. Findings There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding. Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.

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Sensitivity and positive predictive value of the registration of self-expanding metal stent treatment for obstructive colorectal cancer in two Danish nationwide registries

Clinical Epidemiology ◽

10.2147/clep.s174867 ◽

2018 ◽

Vol Volume 10 ◽

pp. 1411-1415 ◽

Cited By ~ 2

Author(s):

Tue Højslev Avlund ◽

Rune Erichsen ◽

Lene Hjerrild Iversen

Keyword(s):

Colorectal Cancer ◽

Positive Predictive Value ◽

Predictive Value ◽

Metal Stent ◽

Obstructive Colorectal Cancer ◽

Stent Treatment

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Symptom or faecal immunochemical test based referral criteria for colorectal cancer detection in symptomatic patients: a diagnostic tests study

BMC Gastroenterology ◽

10.1186/s12876-018-0887-7 ◽

2018 ◽

Vol 18 (1) ◽

Cited By ~ 14

Author(s):

Jesús-Miguel Herrero ◽

Pablo Vega ◽

María Salve ◽

Luis Bujanda ◽

Joaquín Cubiella

Keyword(s):

Colorectal Cancer ◽

Cancer Detection ◽

Diagnostic Tests ◽

Faecal Immunochemical Test ◽

Referral Criteria ◽

Immunochemical Test

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Use of a Sentinel Lymph Node Biopsy Algorithm in a South African Population of Patients With Cervical Cancer and High Prevalence of Human Immunodeficiency Virus Infection

International Journal of Gynecological Cancer ◽

10.1097/igc.0000000000001310 ◽

2018 ◽

Vol 28 (7) ◽

pp. 1432-1437 ◽

Cited By ~ 1

Author(s):

Leon Cornelius Snyman ◽

Emma P. Bryant ◽

Elize I. Wethmar ◽

Tom de Greve ◽

Florette Reyneke ◽

...

Keyword(s):

Cervical Cancer ◽

Human Immunodeficiency Virus ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Positive Predictive Value ◽

Predictive Value ◽

Detection Rate ◽

Immunodeficiency Virus ◽

High Prevalence ◽

Sensitivity Specificity

ObjectivesCervical cancer is common in resource-poor settings with high prevalence of tuberculosis, pelvic inflammatory disease, and human immunodeficiency virus (HIV) infection. There are no data regarding the sentinel lymph node (SLN) algorithm in these high-risk cancer populations. Our objectives were to establish the sensitivity, specificity, positive predictive value, and negative predictive value of the SLN algorithm in cervical cancer and to compare the detection rate of indocyanine green (ICG) versus blue dye versus technetium Tc 99m nanocolloid (99mTc).MethodsThis prospective study was conducted at the University of Pretoria. 99mTc-nanocolloid tracer, ICG dye, and methylene blue (MB) were used to detect SLNs. Pathological ultrastaging was performed on hematoxylin-eosin– negative nodes.ResultsResults of 72 women were analyzed. The mean age was 47.2 years, 5.5% had a history of tuberculosis, 18.1% had pelvic inflammatory disease, and 65.3% were HIV positive. The SLN detection rate was 65.3%. Detection rate of MB was 56.9%; 99mTc, 69.4%; ICG, 87.5%; and the combination of MB and 99mTc, 91.7%. Pelvic nodal metastases occurred in 26.4%. The sensitivity, specificity, negative predictive value, and positive predictive value of SLN biopsy were 85.7%, 100%, 100%, and 98.33%, respectively. The false-negative rate was 14.3%, and it was 0% if the algorithm was applied.ConclusionsThe SLN algorithm is a feasible option for use in cervical cancer women with a high prevalence of HIV infection. The detection rate is generally lower, but in select subgroups of women, it was comparable to that reported elsewhere. This is the first report of the use of SLN biopsy in a substantial group of HIV-infected women.

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Does Screening Colonoscopy at an Earlier Age in Asymptomatic Patients With Family History of Colorectal Cancer (CRC) Improve Polyp and Colon Cancer Detection Rate?

Gastroenterology ◽

10.1016/s0016-5085(11)62321-4 ◽

2011 ◽

Vol 140 (5) ◽

pp. S-560-S-561

Author(s):

Naeem Aslam ◽

Marc F. Catalano ◽

Robbie Taha ◽

Nalini M. Guda ◽

Joseph E. Geenen

Keyword(s):

Colorectal Cancer ◽

Colon Cancer ◽

Family History ◽

Cancer Detection ◽

Detection Rate ◽

Cancer Detection Rate ◽

Screening Colonoscopy ◽

Asymptomatic Patients ◽

History Of

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Positive predictive value of breast MRI in cancer detection.

10.1158/0008-5472.sabcs-4007 ◽

2009 ◽

Author(s):

SC Gavenonis ◽

JM Lee ◽

EF Halpern ◽

EA Rafferty

Keyword(s):

Positive Predictive Value ◽

Cancer Detection ◽

Predictive Value ◽

Breast Mri

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Utility of the methylated SEPT9 test for the early detection of colorectal cancer: a systematic review and meta-analysis of diagnostic test accuracy

BMJ Open Gastroenterology ◽

10.1136/bmjgast-2019-000355 ◽

2020 ◽

Vol 7 (1) ◽

pp. e000355 ◽

Cited By ~ 5

Author(s):

Rohit Hariharan ◽

Mark Jenkins

Keyword(s):

Colorectal Cancer ◽

Systematic Review ◽

Early Detection ◽

Positive Predictive Value ◽

Negative Predictive Value ◽

Diagnostic Test ◽

Predictive Value ◽

Meta Analysis ◽

Test Accuracy ◽

Sensitivity Specificity

BackgroundCirculating tumour DNA from colorectal cancer (CRC) is a biomarker for early detection of the disease and therefore potentially useful for screening. One such biomarker is the methylated SEPT9 (mSEPT9) gene, which occurs during CRC tumourigenesis. This systematic review and meta-analysis aims to establish the sensitivity, specificity and accuracy of mSEPT9 tests for the early diagnosis of CRC.MethodsA systematic search of the relevant literature was conducted using Medline and Embase databases. Data were extracted from the eligible studies and analysed to estimate pooled sensitivity, specificity and diagnostic test accuracy.ResultsBased on 19 studies, the pooled estimates (and 95% CIs) for mSEPT9 to detect CRC were: sensitivity 69% (62–75); specificity 92% (89–95); positive likelihood ratio 9.1 (6.1–13.8); negative likelihood ratio 0.34 (0.27–0.42); diagnostic OR 27 (15–48) and area under the curve 0.89 (0.86–0.91). The test has a positive predictive value of 2.6% and negative predictive value of 99.9% in an average risk population (0.3% CRC prevalence), and 9.5% (positive predictive value) and 99.6% (negative predictive value) in a high-risk population (1.2% CRC prevalence).ConclusionThe mSEPT9 test has high specificity and moderate sensitivity for CRC and is therefore a potential alternative screening method for those declining faecal immunochemical test for occult blood (FIT) or other screening modalities. However, it is limited by its poor diagnostic performance for precancerous lesions (advanced adenomas and polyps) and its relatively high costs, and little is known about its acceptability to those declining to use the FIT.

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Intraoperative Radioimmunolocalization of Colorectal Cancer: A Review

The International Journal of Biological Markers ◽

10.1177/172460089300800306 ◽

1993 ◽

Vol 8 (3) ◽

pp. 166-171

Author(s):

C. Aprile

Keyword(s):

Colorectal Cancer ◽

Positive Predictive Value ◽

Detection Rate ◽

Clinical Results ◽

Clinical Approach ◽

Clinical Use ◽

Current State ◽

Combined Use ◽

High Positive Predictive Value ◽

Detector Type

Although intraoperative radioimmunolocalization (IORIL) is gaining wider acceptance, several limits inhibit a more extensive clinical use. In this paper the following topics will be discussed: 1) the clinical approach, that is, the combined use of immunoscintigraphy and IORIL after a single MAb administration or the use of non-imaging 125 I MAb; 2) the detector type and its collimation and shielding; 3) the nuclides employed, and 4) the background problem. The clinical results of our and other groups show a sensitivity that is generally higher than 0.75 with a high positive predictive value. The detection rate of occult lesions is in the order of 20% of all explored sites. However, the current state of detector and MAb technology do not allow to achieve better results; probably the results can be improved by the use of bispecific MAb or the avidin-biotin system.

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