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Analysis

Have large increases in fast track referrals improved bowel cancer outcomes in UK?

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3273 (Published 10 November 2020) Cite this as: BMJ 2020;371:m3273
  1. Michael Thompson, consultant colorectal surgeon1,
  2. Daniel O’Leary, consultant colorectal surgeon1,
  3. Iona Heath, retired general practitioner2,
  4. Lynn Faulds Wood, patient representative2,
  5. Brian Ellis, general practitioner1,
  6. Karen Flashman1,
  7. database manager Portsmouth outpatient database,
  8. Neil Smart, associate professor of colorectal surgery3,
  9. John Nicholls, emeritus consultant surgeon professor of colorectal surgery4,
  10. Neil Mortensen, president of the Royal College of Surgeons of England5,
  11. Paul Finan, professor of colorectal surgery6,
  12. Asha Senapati, consultant colorectal surgeon1,
  13. Robert Steele, chair UK National Screening Committee7,
  14. Peter Dawson, senior lecturer of colorectal surgery4,
  15. James Hill, professor of colorectal surgery8,
  16. Brendan Moran, consultant colorectal surgeon9
  1. 1Queen Alexandra Hospital, Portsmouth, UK
  2. 2London, UK
  3. 3University of Exeter Medical School, Exeter, UK
  4. 4Imperial College, London, UK
  5. 5John Radcliffe Hospital, Oxford, UK
  6. 6St James’s University Hospital, Leeds, UK
  7. 7University of Dundee, Dundee, UK
  8. 8Manchester University, Manchester, UK
  9. 9North Hampshire Hospital, Basingstoke, UK
  1. Correspondence to: M R Thompson michaelrthompson{at}me.com

More precise risk stratification is required to enable timely diagnosis of bowel cancer while avoiding unnecessary investigation, argue Michael Thompson and colleagues

UK Department of Health policies to improve survival from bowel cancer through GP referral guidelines and public awareness campaigns have increased urgent referrals to hospitals. This has led to an unsustainable demand for colonoscopy and CT colonography without evidence of significant clinical benefit. These policies could be improved by more precise stratification of the risk of having bowel cancer to achieve prompt, rather than earlier, diagnosis while avoiding over-referral and investigation of patients with transient symptoms from benign conditions.

Development of GP referral guidelines and fast track clinics

The first UK cancer plan was developed in 2000 to improve outcomes for patients. The plan introduced the concept of the “two week wait,” from urgent GP referral to the first outpatient appointment. In 2000, the committee developing the referral criteria for bowel cancer1 advised that only those with symptoms persisting for 6 weeks should be referred. The 2005 National Institute for Health and Care Excellence (NICE) review of the guidelines largely endorsed the referral criteria, which identified nine out of 10 bowel cancers (box 1) and had a 9-14% predictive value for cancer34 (table 1). Fast track clinics reduced time to diagnosis but not to treatment.34 Over the following nine years the number of referrals increased by 45% (table 1) while the predictive value for cancer decreased from 14% to 8%34567 (table 1). A review of several articles was carried out in 2001-04, with one study reporting a 14% predictive value for cancer and another, by 2009, before the introduction of the public awareness campaign, reporting a predictive value of 7.9%.

Box 1

Seven typical characteristics of bowel cancer2

These characteristics identified over 92% of bowel cancers referred to outpatient departments.

Adding two age thresholds: >40 …

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