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Colon Ca referral chaos

A study has uncovered 'marked variability' in GPs' use of

referral guidelines for colorectal cancer, with many

apparently unaware of the

two-week rule.

The analysis of GPs at 49 practices in four primary care trusts found nearly a quarter did not know about the urgent referral guidelines.

Just 8 per cent could correctly recall the number of urgent referral criteria, and 53 per

cent of practices did not diagnose any colorectal cancers through the fast-track system.

Study leader Mr Solomon John, a colorectal surgeon at the Royal Bournemouth Hospital, insisted there was a need to target education at those practices who were not using guidance appropriately.

'Our study suggests the guidelines can be used more

effectively and we believe they have not been given the opportunity to work. It also highlights the fact that in many general practices, there is little or no utilisation of this pathway. GP education is needed to improve the implementation of the existing referral guidelines.'

Last week, two studies reported in Pulse found the two-week rule was not improving survival or the quality of referrals for

colorectal cancer – partly because guidelines were frequently not followed.

In the new study, only 26

per cent of GPs said they had

received training in interpretation of guidance.

Dr Nick Clements, senior medicolegal adviser at the

Medical Protection Society, said the society would be 'very much in favour' of training for GPs to avoid the medicolegal consequences of missed diagnoses.

'If GPs use the guidelines

and keep good notes they should be able to justify their decisions. Where they don't have a defence is when the guidelines have been breached.'

But Dr William Hamilton, a senior clinical research fellow in cancer diagnosis at the

University of Bristol and a GP in Exeter, said: 'Simply saying GPs need education is facile.

'GPs will have different thresholds for referral depending on their personal experience. Guidelines are particularly tricky in colorectal cancer. This is where the GP saying "I just don't think this patient is right" is actually quite an accurate tool. So, I'd always expect considerable variation.'

The study was published

in the latest issue of Colorectal Diseases.

• Expert advice on cancer diagnosis at our Clinical Challenges seminar – full details on page 58

When to refer for colorectal Ca

• Bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting six weeks or more

• Aged 60 years and older, with rectal bleeding persisting for six weeks or more without a change in bowel habit and without anal symptoms

• Aged 60 years and older, with a change in bowel habit to looser stools and/or more frequent stools persisting for six weeks or more without rectal bleeding

• Men with unexplained iron deficiency anaemia and a haemoglobin of 11g/100ml or below, or non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10 g/100ml

or below

Screening cuts colonoscopies

Offering immunochemical tests to patients who test positive for faecal occult blood can streamline colorectal screening and cut the demand for endoscopy, a study concludes.

Use of faecal immunochemical tests has already been incorporated into the Scottish Bowel Screening Programme, and researchers predicted it could cut the need for colonoscopy by about 30 per cent.

The 'two-tier' system, which offers immunochemical tests to patients before colonoscopy if they have tested positive for guaiac faecal occult blood tests, proved sensitive and reasonably specific.

A trial of 1,124 patients aged 56 to 69 detected colorectal cancer with 96 per cent sensitivity and 59 per cent specificity, and high-risk polyps with 88 per cent sensitivity and 65 per cent specificity.

Study leader Professor Callum Fraser, chair of the screening centre laboratory group in Dundee, wrote online in the journal Gut that detection rates for the two-tier system meant it was 'an efficient and effective disease detection strategy that simultaneously reduced need for screening colonoscopy'.

Professor Fraser told Pulse he expected a 30 per cent reduction in demand for colonoscopy in Scotland. 'Our findings have informed the Scottish Bowel Screening Programme – our two-tier strategy will be used.'

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