This protocol should only be used where there is no suspicion of malignancy
If there is a degree of suspicion please see the guidelines below and refer through the Lanarkshire Cancer Referral Centre
Colorectal Cancer Referral Guideline
Risk-Based guidelines for Investigating Patients with Colorectal Symptoms
Patients with any of the following symptoms and associated symptoms should be referred urgently through the Lanarkshire SCI Gateway Cancer Referral Services. This will ensure that a patient pathway co-ordinator tracks the referral from the day it is sent..
Patients over 75 will be seen at the clinic first and will not be appointed straight to test.
| Main Symptom | Associated Symptom | Age | Patient will be booked for |
|---|---|---|---|
| Rectal bleeding for > 6 week | Frequent and/or loose stools for 6 weeks Constipation Constipation in isolation in isolation | >75 <75 >50-74 <50 >50-74 <50 | Outpatient clinic Colonoscopy Flexible Sigmoidoscopy and Barium Enema Please refer using Routine Colorectal Guideline (below) Flexible Sigmoidoscopy and Barium Enema Please refer using Routine Colorectal Guideline (below) |
| Diarrhoea 3 or more loose or liquid stools/day for > 4 weeks | >75 >50-74 <50 | Outpatient clinic Colonoscopy Please refer using Routine Colorectal Guideline (below) |
|
| Palpable mass, right sided Abdominal mass or Rectal mass | Any | Outpatient clinic appointment | |
| Iron deficiency Anaemia. Unexplained | Upper GI symptoms in isolation male or postmenopausal female in isolation male or postmenopausal female Pre-menopausal female | <75 >75 | Please refer using the Upper GI Suspected Cancer Guidelines Colonoscopy and gastroscopy Outpatient clinic Please refer using Routine Colorectal Guideline (below) or to Gastroenterology |
Routine Colorectal Referral Guideline
Patients with any of the following symptoms and associated symptoms should be referred routinely through the Lanarkshire SCI Gateway to the colorectal specialty in the appropriate hospital.
Patients over 75 will be seen at the clinic first and will not be appointed straight to test
| Main Symptoms | Associated symptom | Age | Patient will be booked for: |
|---|---|---|---|
| Rectal bleeding for > 6 weeks | Constipation in isolation | <50 <50 | Flexible Sigmoidoscopy Flexible Sigmoidoscopy |
| Diarrhoea 3 or more loose or liquid stools/day for > 4 weeks | <50 | Outpatient clinic | |
| Constipation recent change of bowel habit | >75 >50-74 <50 | Outpatient clinic Flexible Sigmoidoscopy and Barium Enema Outpatient clinic |
|
| Iron deficiency Anaemia. Unexplained | In isolation | Premenopausal female | Gastroenterology or Colorectal Outpatient Clinic |
All patients who require direct referral to test should be:
- Physically fit for bowel preparation
- No Anal symptoms (pain, discomfort, itching, lump and prolapse)
- No Large bowel investigations carried out in the last 2 years
Investigations
No examinations or investigations (other than abdominal and rectal examination ,Uamp;E (for patient safety with bowel prep) and FBC are recommended).
Chronic diarrhoea – recommended investigations are Uamp;E, FBC, CRP, TFT and faeces culture
FOB or CEA is not indicated and should not influence decision making in symptomatic patients.
Key Points:
Patients with the following symptoms are at very low risk of cancer and could be managed initially within Primary Care or referred non-urgently for assessment:
- Rectal bleeding with anal symptoms
- Change in bowel habit to decreased frequency of defaecation and harder stools.
- Abdominal pain without clear evidence of intestinal obstruction.
Colorectal Cancer and Family History
Individuals who have a family history of colorectal cancer but who are asymptomatic may warrant investigations if their history meets the criteria outlined in the following table. If any of the criteria are fulfilled patients should be referred for risk assessment to:
Regional Genetics Service
Management of High Risk Groups
| Risk | Criteria for Screening | Screening | Age of Screening |
|---|---|---|---|
| High | At least three family members affected by CRC and one with endometrial cancer in at least two generations; one affected relative must be age ?50 years at diagnosis; one of the relatives must be a first degree relative of the other two Gene carriers (HNPCC genes) Untested primary relatives of gene carriers | Colonoscopy every 2 years Discuss gynaecological screening for endometrial and ovarian cancer Offer 2 yearly upper GI endoscopy for gastric cancer Consideration needs to be given to other screening for other cancers which may occur in specific families and are part of the HNPCC spectrum | From 30 to 70 years (or 5 years younger than the youngest affected relative) For stomach cancer from 50 to 70 years or 5 years younger than the youngest stomach cancer |
| Medium | One first degree relative affected by colorectal cancer when aged < 45 years; or Two affected first degree relatives (one less than 55 years); or Two (one CRC less than 55 years) or three affected individuals with colorectal or endometrial cancer who are first degree relatives of each other and one a first degree relative of consultand. | Single colonoscopy if normal findings Single repeat colonoscopy | At 30-35 years and again at 55 years |
| Low | Anyone not fulfilling medium or high risk criteria | Reassure and encourage healthy lifestyle GP to monitor | N/A |
Hereditary Nonpolyposis Colorectal Cancer (HNPCC)
Sign revised edition – in press
HNPCC is an autosomal dominant condition caused by a mismatch repair gene mutation. Individuals carrying a mismatch repair gene mutation or fulfilling high risk criteria for HNPCC should be offered endoscopic screening starting in the twenties if possible and repeated every 2-3 years taking into account the patient’s general condition and uptake. Diagnosis requires:
At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)
At least two consecutive generations should be affected
At least one should be diagnosed before age fifty years
Referral should be made to the Regional Genetics Service for consideration of Mismatch Repair Gene mutation analysis
Familial adenomatous polyposis (FAP)
Sign Revised edition – in press
FAP is an autosomal dominant condition caused by an APC gene mutation and characterised by the development of multiple adenomatous colorectal polyps and the subsequent development of one or more colorectal cancers. In patients with FAP, referral should be made to the Regional Genetics Service for consideration of APC Gene mutation analysis. For those at risk of FAP, determined either by a positive family history or on the basis of mutation analysis should be offered:
At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)
Colonoscopy every 2-3 years and yearly sigmoidoscopy
Patients should be offered proctocolectomy with or without ileoanal reconstruction or total colectomy with ileorectal anaastomsis once adenomas have developed. Subsequent management should include lifelong survey
Other High Risk Groups
A number of chronic conditions require structured surveillance. These include:
Chronic Inflammatory Bowel Disease
Acromegaly
Peutz-Jeghers Syndromme
Juvenile Polyposis Coli
Reference: Scottish Referral Guidelines for Suspected Cancer. Scottish Executive 2007
SIGN Guideline 67 -Management of Colorectal Cancer
Lead Clinician Mr Alistair Brown, NHS Lanarkshire
Review Date Dec 2010