Introduction Previous studies have found that in the UK iron deficiency anaemia (IDA) is often inadequately investigated resulting in a delayed diagnosis of gastrointestinal (GI) cancer. The presence of an IDA therefore has been included in the “2WW” referral criteria for urgent GI investigation introduced in England in 2000. Over this period there has been a >50% increase in use of blood tests in primary care and an increase in the prescribing of low dose aspirin which we have shown to be associated with a 2.5-fold increase in the prevalence of IDA.1

Methods We examined the “2WW” referral forms for upper and lower GI cancer sent to Nottingham University hospitals over 4 months in 2007 and identified all referrals with mention of anaemia. Clinical details were then extracted from hospital electronic records, case records and where necessary by contacting the GP. IDA criteria were a haemoglobin <13 g/dl in males or <12 in females and an MCV <84, or MCH <28, or serum ferritin <25.

Results Between June-September 2007 there was a total of 981 referrals in which anaemia was mentioned in 204 (20%); in 60 (29%) this was the sole criterion for referral. Mean age was 71 years (122F/82M) and 40% were taking low dose aspirin. In 144 the presence of upper or lower GI symptoms was also mentioned on the referral form. An IDA was present in 133/204 (65%) 42 of whom had no GI symptoms reported. Investigation identified a cause for the anaemia in 83 of whom 26 had a GI cancer (9 oesophago-gastric, 15 colorectal and 2 hepato-pancreatic). In 6 of the patients found to have GI cancers the presence of an IDA was the sole indication for referral. Non-GI malignancies were detected in 6; an ovarian and a lung cancer were found in 2 referrals with an IDA and haematological malignancies were present in 4 with non-IDA. In 17, the GP stated that the IDA had been detected during a routine “MOT” check up for CV disease or diabetes and in none of these cases was a GI or other malignancy detected; 8/17 were taking low dose aspirin.

Conclusion Presence of anaemia is a common referral criterion but in only two-thirds is this an IDA. Yield of GI cancer is 16% in those with an IDA and was similar in those with or without GI symptoms. However cancer yield is low in those investigated on account of a mild IDA detected at routine check-ups. Alternative management strategies need to be developed for this group.