Why is a new care pathway for investigating rectal bleeding needed ?
Why is a new care pathway for investigating rectal bleeding needed ?
The number of cancer referrals to colorectal teams is vastly increasing . The Cancer Reform Strategy ( Department of Health , 2007 ) sets out the pathway that patients suspected of cancer should be seen within 2 weeks of the GP referral and treated within 62 days of the GP referral . It was previously recommended that rectal bleeding with a change in bowel habit in a person aged over 60 should be referred on a fast-track pathway ( Royal College of Surgeons , 2013 ). However , a change in NICE ( 2015 ) guidelines shows that patients having rectal bleeding at any age with or without associated symptoms can be referred on the cancer 2 week wait ( 2WW ) pathway . As the previous NICE guidelines were aimed at those aged 60 and over , this extended criteria has put added pressure on hospitals to see an increased number of patients along this timed pathway . Compared to the rest of Europe , England falls below in cancer survivorship therefore , such government guidelines ; like that set out by Public Health England ( 2016 ), emphasise the importance of early detection in bowel cancer to improve better outcomes ( Sykes , 2017 ; Coleman et al 2011 ). A one stop rectal bleeding clinic can be used to address these government agendas to treat early and streamline a colorectal service to help cope with the added pressures of referrals for suspected cancer .
There are concerns that rapid access along the cancer pathway is unrealistic . The time frame in which patients are seen and then treated , with the added pressure of outpatient areas and surgery or oncology treatment , to be delivered does not reflect the current state of the NHS ( Department of Health , 2007 ; Sykes , 2017 ). It is also reported that the rapid access process might be over or inconsistently used therefore patients with cancer are actually waiting longer due to the high number of referrals ( Redaniel et al , 2015 ). Despite this high number of referrals it has also been reported that only around 2 % of patients referred on a cancer pathway were found to have cancer ( McCoubrey et al , 2012 ). However , Barrett et al ( 2006 ) found that 28 % of cancers were found on the 2WW pathway . This may have been affected by the introduction of the NHS Bowel Cancer Screening Programme . Therefore , a one stop rectal bleeding clinic may reduce the pressures of the rapid referral system .
Straight- to -test is becoming recognised as important to improving the speed in which cancer is diagnosed . A ‘ straight to test ’ is a strategy in which patients under the 2WW rule undergo an investigation prior to outpatient assessment in order to streamline the service and improve time to diagnosis ( Banerjea , 2017 ). 2WW continues to diagnose the highest number of cancers compared to such things as the Bowel Cancer Screening Programme ( NHS England , 2016 ). NHS England ( 2016 ) recognises straight – totest can reduce wait times for first diagnostic test by between 7 and 14 days , by eliminating the outpatient appointment . It further reduces the need for outpatient space , nursing staff , medical staff and administration time . The one- stop rectal bleeding clinic would be classed as a straightto test service as it misses the prior outpatient assessment . However , the diagnostic test must be performed within the 2WW period as this is classed as the patient being first seen therefore still putting stress in the time component on the first part of the pathway ( NHS England , 2015 ).
Rectal bleeding is seen as a red flag for bowel cancer and therefore seen in the 2WW clinics . This is in line with NICE ( 2015 ) guidelines . It is important to establish whether the bleeding is altered or dark , as this can be associated with proximal bowel abnormalities or bright red blood , as this is associated with lower distal colon and rectal abnormalities ( Hibberts , 2011 ). Both are seen in the referral guidelines as urgent and patients with these symptoms are generally referred on the 2WW referral pathway . Bright red blood is usually investigated via a flexible sigmoidoscopy for the fear of missing a left sided cancer ( Mathew et al , 2004 ; Hibberts , 2011 ; NICE , 2015 ; Sykes , 2017 ). However , the yield of finding a left sided cancer has been reported as generally low ( Astin et al , 2011 ; Bekkink et al , 2009 ; Toit et al , 2006 ). Surprisingly Barrett et al ( 2006 ) found that only 28 % of colorectal cancers were found in 2WW clinics . Robertson et al ( 2006 ) attempted to predict colorectal cancer risk in patients with rectal bleeding and found that the most contributing factor was age group , rectal