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MARK COLEMAN MBChB FRCS (Gen Surg) MD hon FRCPSG Consultant Colorectal Surgeon www.bowelcancerwest.org .uk
MARK COLEMAN
MBChB FRCS (Gen Surg) MD hon FRCPSG
Consultant Colorectal Surgeon
www.bowelcancerwest.org.uk
www.bowelcancerwest.org.uk
bowelcancerwest.org.uk
www.bowelcancerwest.org.uk
2 Week Criteria2 Week Criteria
‘‘everyone with everyone with suspected cancer suspected cancer
will be able to see a will be able to see a specialist within 2 specialist within 2 weeks of their GP weeks of their GP deciding that they deciding that they need to be seen need to be seen
urgently and urgently and requesting an requesting an appointment’appointment’
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Where were the delays?Where were the delays?
rectal sigmoidcancers
others
pt / GP 65% 35%
out-patient 15% 19%
diagnosistreatment
20% 46%
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Colorectal cancer 2WW criteriaColorectal cancer 2WW criteria Rectal bleeding WITH a change in bowel habit to Rectal bleeding WITH a change in bowel habit to
loosened stool and/or increased frequency of loosened stool and/or increased frequency of defaecation persistent for 6 weeks (all ages)defaecation persistent for 6 weeks (all ages)
Change in bowel habit above WITHOUT rectal Change in bowel habit above WITHOUT rectal bleeding and persistent for 6 weeksbleeding and persistent for 6 weeks
Rectal bleeding persistently WITHOUT anal Rectal bleeding persistently WITHOUT anal symptomssymptoms
A definite right sided abdominal massA definite right sided abdominal mass A definite palpable rectal mass (not pelvic)A definite palpable rectal mass (not pelvic) Iron deficiency anaemia Iron deficiency anaemia Below 10gms post-menopausal womenBelow 10gms post-menopausal women
Below 11gms all menBelow 11gms all menAnal symptoms include soreness, discomfort, itching, lumps and prolapse as well as painAnal symptoms include soreness, discomfort, itching, lumps and prolapse as well as pain
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Aims – 2 Week StandardAims – 2 Week Standard
80-90% of bowel cancer patients 80-90% of bowel cancer patients identified by GPs, referred and seen identified by GPs, referred and seen within two weekswithin two weeks
The total number of patients referred The total number of patients referred kept to a minimum and easily kept to a minimum and easily accommodated within existing accommodated within existing resourcesresources
100% 100% effectiveeffective
high efficiencyhigh efficiency
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symptoms age cumulative % of cancers
diagnostic yield (%)
+C +B –PS –AP 60+ 17.2 38.9 +C +B –PS +AP 60+ 27.1 22.4 +C +B +PS –AP 60+ 36.8 15.3 +C +B –PS –AP –60 39.9 12.5 –C +B –PS 60+ 49.8 11.5 +C +B +PS +AP 60+ 57.4 10.9 +C –B 60+ 77.3 7.5 +C +B –PS +AP –60 80.0 6.1 +C +B +PS –AP –60 83.0 5.4 –C –B +AP 60+ 85.5 3.2 –C +B +PS 60+ 90.8 3.0 +C –B –60 93.9 2.6 +C +B +PS +AP –60 95.6 1.9 –C –B +AP –60 96.4 1.4 –C –B –AP +PS 60+ 96.8 0.9 –C +B +PS –60 99.4 0.7 –C +B –PS –60 99.7 0.5 –C –B –AP +PS –60 100 0.4
sensitivity specificity effectiveness efficiency
Age and Symptom ProfilesAge and Symptom Profiles
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Diagnostic YieldDiagnostic Yield
0
20
40
60
80
100
120
140
1 2 3 4 5 6
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Correct ReferralCorrect Referral
0
20
40
60
80
100
120
1 2 3 4 5 6
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How to Improve GPs Effectiveness How to Improve GPs Effectiveness and Efficiencyand Efficiency
criteria referral correcton all elements
element least wellobserved
1 +B +C 52% not new symptomstoo short history
2 +C –B >60 50% too short history
3 +B –PS >60 20% anal symptoms presenttoo short history
4 abdo mass 32% single element
5 rectal mass 25% single element
6 IDA 93% single element
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Proportion of Cancer Patients Proportion of Cancer Patients Identified by Higher Risk CriteriaIdentified by Higher Risk Criteria
Overall Overall 76 / 83 76 / 83 92% 92%
TWCTWC 36 / 3836 / 38 95% 95%
Non-TWCNon-TWC 40 / 4540 / 45 89% 89%
Guidelines valid
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Only send patients with:Only send patients with: New symptomsNew symptoms Persistent symptomsPersistent symptoms Need to be aware of the Need to be aware of the
importance of anal symptoms importance of anal symptoms in patients with rectal bleeding in patients with rectal bleeding
Take Home Message Take Home Message
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the referral criteria are effective and the referral criteria are effective and reasonably efficientreasonably efficient
By appropriate use, most cancers By appropriate use, most cancers cancan be diagnosed in the 2WW clinic be diagnosed in the 2WW clinic
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Key Points for GP EducationKey Points for GP Education
Must identify patients with new symptomsMust identify patients with new symptoms Importance of only referring patients with Importance of only referring patients with
symptoms persistent for at least 6 weekssymptoms persistent for at least 6 weeks Importance of the absence of anal Importance of the absence of anal
symptoms in patients with rectal bleedingsymptoms in patients with rectal bleeding
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IntroductionIntroduction
NAEDI Bowel Awareness NAEDI Bowel Awareness Campaign 2011 Campaign 2011
Department of Health’s Department of Health’s National Awareness and Early National Awareness and Early Diagnosis Initiative (NAEDI)Diagnosis Initiative (NAEDI)
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Colorectal 2ww referrals received between 1st January and 31st June - 2009, 2010, 2011
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
2ww referrals 2009
2ww referrals 2010
2ww referrals 2011
In 2011 there were approximately 30% more colorectal 2ww referrals than the equivalent period in 2010.
30% increase in 2WW referrals
Colorectal 2WW Referrals Received between 1st January and 31st June 2009, 2010 and 2011
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Colonoscopy's performed between 1st January and 31st June - 2009, 2010 and 2011
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Colon 2009
Colon 2010
Colon 2011
In 2011 approximately 35% more colonoscopy's were performed
than the equivalent period in 2010
35% increase in colonoscopies
Colonoscopy's Performed between 1st January and 31st June2009, 2010 and 2011
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Flexi-sigmoidoscopy's performed between 1st January and 31st June - 2009, 2010 and 2011
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Flexi sig 2009
Flexi sig 2010
Flexi sig 2011
In 2011 approximately 17% more flex-sig's were performed than the equivalent period in 2010
17% more flexi sigs
Flexi-signmoidoscopy`s Performed between 1st January and 31st June 2009, 2010 and 2011
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Barium Enemas performed between 1st January and 31st June - 2009, 2010 and 2011
0
2
4
6
8
10
12
14
16
18
20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
BE 2009
BE 2010
BE 2011
In 2011 approximately 8% more BA were performed
than in the equivalent period in 2010
8% more Barium enemas
Barium Enem as performed between 1st January and 31st June2009, 2010 and 2011
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No increase in CT
CT's performed between 1st January and 31st June - 2009, 2010 and 2011
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
CT 2009
CT 2010
CT 2011
In 2011 approximately 1% less CT's were performed than in the equivalent period in 2010.
CTs Performed between 1st January and 31st June 2009, 2010 and 2011
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Colorectal cancers diagnosed between 1st January and 31st June - 2009, 2010 and 2011
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Diagnosed cancers 2009
Diagnosed cancers 2010
Diagnosed cancers 2011
In 2011 approximately 4% less cancers were diagnosed than in the equivalent period in 2010
No increase in cancers diagnosed
Colorectal Cancers Diagnosed between 1st January and 31st June2009, 2010 and 2011
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0
50
100
150
200
250
october november december january feburary
OPD
flexi sig
2WW
2011-12
PHNT
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Take Home MessagesTake Home Messages
Refer persistent new onset Refer persistent new onset symptoms to 2WWsymptoms to 2WW
Family history is usefulFamily history is useful We have (relatively) short waiting We have (relatively) short waiting
times for non 2WWtimes for non 2WW Don’t hesitate to call us! Don’t hesitate to call us!
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ANY QUESTIONS?ANY QUESTIONS?
