Introduction Public expectation, media scrutiny and political posturing around early cancer diagnosis continue to escalate. Primary and secondary care face increasing demands to diagnose and treat cancer earlier and more quickly. Nottingham Colorectal Service receives 2WW referrals at 2 sites: Nottingham University Hospitals and a private Diagnostic Treatment Centre. To address increasing referrals and failure to treat within 62 days we introduced a “Direct to test (DTT)” initiative as part of our 2WW pathway.
Method We amended our 2WW referral form to include ECOG performance status and Charlson co-morbidity. GPs were asked to provide eGFR and FBC/Ferritin. 2WW referrals received between 1/8/14 and 30/11/14 were vetted by a Colorectal Consultant and selected for DTT according to a pre-defined protocol. DTT patients were telephoned by a Nurse Specialist (NS) to confirm suitability and explain the process. Those not deemed suitable for DTT were offered outpatient assessment (OPA). All referrals were logged in a database and outcomes of investigation and treatment were analysed. (Statistical comparisons: GraphPad Prism).
Results 553,2WW referrals were received - mean age at time of referral 67.6 y (Range 18.9–93.7y). 355 patients (64.1%) were deemed suitable for DTT but 64 (11.6%) failed telephone assessment. 11 (2.0%) failed to complete the pathway.
291 patients were sent DTT: 222 patients for colonoscopy, 45 OGD/colonoscopy, 4 colonoscopy/CT scan, 13 flexible sigmoidoscopy and 3 flexible sigmoidoscopy/CT scan, and 4 CT scan only.
280 patients successfully completed a DTT pathway (50.6%). 233 (42.1%) completed OPA/investigation. 40 patients (7.2%) excluded due to inappropriate referral, patient choice/DNA, or OPA that investigation was not appropriate.
The DTT group (mean age 64.9y) was significantly younger (p < 0.0001) than the OPA group (71.0y). In the OPA group, 105 (19%) were seen by a consultant and 128 (23.1%) by a NS.
37 colorectal cancers (CRC), including anal SCC, were detected from all 2WW referrals (6.7%). 15 CRC were detected in the DTT group (5.4%) and 22 CRC in the OPA group (9.4%). The lower CRC detection rate in DTT did not reach statistical significance (Fisher’s Exact Test p = 0.087). Notably our local BCSP hub had a CRC detection rate of 8.5% in patients with positive FOBT.
Conclusion DTT was safe and effective at selecting out a group of symptomatic patients who could proceed straight to test – usually involving endoscopy (98.6%). Unsurprisingly, this group was younger and fitter and yielded a lower CRC detection rate. In fact, CRC detection rate in all of our symptomatic 2WW referrals was lower than BCSP patients with a positive FOBT. Is it time to re-evaluate our symptomatic 2WW screening programme?
Disclosure of interest None Declared.
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