Lower Gastrointestinal Cancer

Lower Gastrointestinal Cancer
Urgent suspicion of cancer referral - high-risk features

Mass (No qFIT required)
  • Unexplained abdominal mass
  • Palpable ano-rectal mass
Patient Factors
  • In patients with high risk symptoms where qFIT is indicated (see table below)  AND an incapacity that prevents the completion of the qFIT test,
  • patient declines or is unlikely to complete a qFIT  (this information must be provided in the referral))
qFIT > 10
  • Any patient with colorectal symptoms and 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
  • Repeated rectal bleeding without an obvious anal cause
  • Any blood mixed with the stool
 Bowel habit
  • Persistent (more than four weeks) change in bowel habit especially to looser stools - not simple constipation
 Pain
  •  Abdominal pain with weight loss (also consider upper GI cancer)
Iron deficiency anemia
  •  Unexplained iron deficiency anaemia
  • Normal qFiT still requires investigation. Refer according to local pathways.

 

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 recommended (link to full guidance) 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).
Full Guideline