Lower Gastrointestinal Cancer
Lower gastrointestinal symptoms are common presentations in primary care. Rectal bleeding is estimated to affect 14,000 per 100,000 population each year. There are large differences in the predictive value of rectal bleeding for cancer according to its association with other symptoms and signs and the age of the person.
Different management strategies should be adopted according to cancer risk, so that those people with transient low-risk symptoms caused by benign disease avoid unnecessary investigation.
The risk of colorectal cancer is increased if there is a past history of ulcerative colitis, colorectal polyps or cancer, or if there is a family history of colorectal cancer or Lynch syndrome. Guidance for referral to regional genetics centres (see Appendix 5) for those with such a family history is available in SIGN 126.8
In people with ulcerative colitis, a plan for follow up should be agreed in line with current national guidelines.
Guidance on the role of qFIT in assessment of new lower gastrointestinal symptoms has now been published and can be found here
The following provides guidance on the use of quantitative faecal immunochemical test (qFIT) for faecal haemoglobin (f-Hb) as an adjunct to clinical acumen so that referral and investigation of patients with colorectal symptoms can be targeted to those with the highest risk of significant colorectal pathology.
Individual symptoms are poor predictors of colorectal cancer. The predictive value of colorectal symptoms can be improved using qFIT. Twenty-two percent(19-28%) of Scottish patients with colorectal symptoms, will have a f-Hb >10mgHb/g faeces. Up to 95% (84-95%) of patients referred who are then diagnosed with colorectal cancer will have a f-Hb >10mg Hb/g faeces. Referral and management triage applying qFIT in symptomatic patients, shortens time to diagnosis, is cost effective and there is emerging evidence that its application may result in a migration to an earlier cancer stage at diagnosis. qFIT will also prevent harm through the avoidance of investigations in patients who are not likely to have significant pathology.
If a qFIT is requested for asymptomatic, vague, acute or non-colorectal symptoms, 12% will still have a f-Hb >10mgHb/g faeces, but the costs and endoscopy demand will not be sustainable, patients will continue to wait for their investigations and the diagnostic yield will be low. There are alternative referral pathways and bowel cancer screening (if eligible) for these patients.
As an adjunct to clinical acumen, a numerical qFIT resultshould be available whenever possible,before a patient is referred to secondary care for investigation or management of the large bowel symptoms (see table below). Where primary care do not have access to qFIT, secondary care will triage the referral taking into account the f-Hb result using their local pathway. Primary care clinicians are also encouraged to request a blood Hb and investigation for iron deficiency anaemia where the Hb is low c.
Urgent suspicion of cancer referral - high-risk features
| Mass (No qFIT required) |
|
| Patient Factors |
|
| qFIT > 10 |
|
Indications for qFIT (when available in primary care) or Urgent – Suspicion of Cancer referral (when qFIT is secondary care only test according to local protocols
| Bleeding |
|
| Bowel habit |
|
| Pain |
|
| Iron deficiency anaemia |
|
An abdominal and rectal examination plus blood tests to assess renal function (in case of triage straight to CT colonography), liver function tests and to identify iron deficiency anaemia and thrombocytosis should be performed on all people with symptoms suggestive of colorectal cancer. Thrombocytosis is a risk marker for underlying cancer, including colorectal, and this can facilitate appropriate triage in secondary care. A negative rectal examination, or a recent negative bowel screening test, should not rule out the need to refer. The carcinoembryonic antigen (CEA) test should not be used as a screening tool
Good practice points
- Recommend qFIT testing, where available, for patients with persistent new colorectal non-USOC symptoms where referral to secondary care is being considered
- In patients <40 years old with persistent diarrhoea, a calprotectin should be considered where available
- Where a patient has persistent symptoms and a qFIT < 10µgHb/g faeces, a second qFIT is recommendedd. A secondary care referral is recommended if the second QFIT is ³ 10µgHb/g. If the second qFIT is <10µg Hb/g faeces please see primary care management below.
- Consider the possibility of ovarian cancer as per gynaecological cancers guideline
Primary care management
- Low risk features:
- transient symptoms (less than four weeks) – NO qFIT required
- patients under 40 years in absence of high risk features
- Watch and wait (four weeks)
- Assessment and review
- Consider bowel diary
- Appropriate information, counselling and agreed plan for review with GP
- Patients with a qFIT < 10µgHb/g faeces should only be referred if (please specify in the referral)
- symptom management support from secondary care is required OR
- you have ongoing clinical concerns that the patient has significant colorectal pathology, despite two f-Hb <10µgHb/g faeces e.g. severe persistent symptoms
- For genetics queries, please refer to regional guidance (see appendix 5).
a qFIT is not appropriate for investigation of an acute change in bowel habit (<4 weeks) or vague non colorectal symptoms.
b In patients <40 years old with persistent diarrhoea, a calprotectin should be considered where available.
c Iron deficiency anaemia is defined in the national pathway: a low Hb by local lab criteria AND either a ferritin <30mg/L OR a ferritin 30-100<30mg/L AND a low serum iron with a transferrin >3g/L.
d The sensitivity of 2 qFIT tests for colorectal cancer is 97%