Colorectal, Suspicion of Cancer Referral – NHS Lanarkshire LanRefHelp

Lower Gastrointestinal Cancer

Lower gastrointestinal symptoms are common presentations in primary care. Rectal bleeding for instance is estimated to affect 14,000 individuals per 100,000 population each year. There are large differences in the predictive value of rectal bleeding for cancer according to its association with other symptoms and signs and the age of the patient. For example, the positive predictive value of rectal bleeding alone is 2.4%, which rises to 8.5% in combination with an abnormal rectal examination.

Different management strategies should be adopted according to cancer risk so that those patients with transient lowrisk symptoms caused by benign disease avoid unnecessary investigation. The following guideline is recommended for managing patients with features associated with a possible diagnosis of colorectal cancer. Guidance for referral to regional genetics centres for those with a family history of colorectal cancer is available available at Scottish Government Health and Social Care website. In patients with ulcerative colitis, a plan for follow up should be agreed.

An abdominal and rectal examination and a full blood count should be performed on all patients with symptoms suggestive of colorectal cancer. These findings can facilitate appropriate triage in secondary care. A negative rectal examination, or a recent negative faecal occult blood result, should not rule out the need to refer. The carcinogenic embryonic antigen (CEA) test should not be used as a screening tool.

High-risk features Urgent suspicion of cancer referral
Bleeding	Repeated rectal bleeding without an obvious anal cause Any blood mixed with the stool
Bowel Habit	Persistent change in bowel habit especially to looser stools (more than 4 weeks)
Mass	Right-sided abdominal mass Palpable rectal mass
Iron deficiency anaemia In men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11g/100ml or below. In non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10g/100ml or below.	Unexplained iron deficiency anaemia
Other	Past history of lower gastrointestinal cancer with any of the symptoms above

Primary care management

Low-risk features

Transient symptoms (less than 4 weeks)
Patients under 40 years in absence of high-risk features

Watch and wait (4 weeks)

Assessment and review
Consider bowel diary
Appropriate information, counselling and agreed plan for review with GP

Refer if symptoms persist or recur

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 126 – Diagnosis and Management of Colorectal Cancer
Lead Clinician Mr A Brown, NHS Lanarkshire
Review Date March 2017