The NICE guideline for referral to specialist services with suspected colorectal cancer (CRC) was last updated in June 2015, with expansion of the criteria. This study aimed to compare referral patterns and clinical practice, in terms of the investigations performed, over two years before (01/06/2013–31/05/2015) and after (01/06/2015–31/05/2017) introduction of the updated guideline.Methods
A retrospective study of all patients referred to our unit with a suspected CRC in the two years before and two years after introduction of the updated guideline compared referral rates, the number of colorectal and non-colorectal (non-CRC) cancers, the TNM stage of CRC and the investigations performed.Results
The total number of referrals increased from 6075 to 7951, with the rate of CRC decreasing from 5.14% to 5.01% (p=0.08). The number of non-CRCs increased from 1.17% to 1.61% (p=0.02). There was no significant difference in the TNM stage of CRC (figure 1).Results
The use of flexible sigmoidoscopy (17.01% vs. 28.52%, p=0.002) and CTC (9.54% vs. 17.78%, p=0.007) increased and the use of colonoscopy decreased (81.33% vs. 67.78%, p=0.0006). The use of CT (91.29% vs 92.59%) and MRI scanning was not significantly different between groups (figure 2).Conclusions
CTC was more common in the later cohort, likely related to increasing availability of this imaging modality. This may also explain the increase in flexible sigmoidoscopy, as left sided lesions on CTC require flexible sigmoidoscopy only, rather than full colonoscopy.Conclusions
Expansion of the referral criteria has not significantly impacted on the number of new CRCs, but has increased the number of non-CRCs. In those presenting with symptoms such as anaemia, abdominal pain and weight loss, with an absence of specific lower gastrointestinal symptoms, CT would be a more appropriate initial investigation than luminal investigations. This will aid in the diagnosis of other significant pathologies, including the many non-CRCs detected via this referral pathway, whilst minimising exposure to invasive luminal investigations with their associated morbidity.