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Colon cancer referral alert

GPs should refer every patient over 45 with any rectal bleeding for urgent colorectal cancer investigation, a new study by a Government adviser concludes.

The NHS-funded research warned that current practice was missing 'an important proportion' of cancer cases and urged NICE to overhaul its referral guidance.

The recommendations came as the Government revealed plans to radically expand the number of patients eligible for referral under the two-week rule – prompting fears that secondary care would be swamped.

The study, to be published in the BMJ, found rectal bleeding on its own carried a sufficiently high risk of cancer to warrant investigation – while additional symptoms did not help to pick out cancer cases.

Of 4,426 GP patients, 265 presented with rectal bleeding over 10 years, 5.7 per cent of whom had colorectal cancer. Only two had accompanying diarrhoea.

Dr William Hamilton, a researcher on the study who is piloting a colorectal cancer diagnostic algorithm for the Dep- artment of Health, said: 'It is increasingly clear the risk of neoplasia from rectal bleeding is high enough to warrant investigation.'

Dr Hamilton, senior research fellow at the University of Bristol and a former GP, said GPs should begin referring all patients with new rectal bleeding right away. Current NICE guidance recommends referral in the absence of anal symptoms only if bleeding persists for six weeks (see box, left).

Dr Jonathan Green, vice-president of the British Society of Gastroenterology, said: 'My anxiety is that all these guidelines do miss a number of younger patients, so any study suggesting a lower age limit is welcome.'

But Dr Paul Roblin, secretary of Berkshire and Buckingham-shire LMC, said: 'I might be saving some lives if I referred all these people, but what is the cost? It might stop other patients getting what they need.'

Meanwhile, the department told Pulse that by 2008 all patients with unexplained bowel symptoms should be seen by a specialist within two weeks.

'We are considering what changes are needed to ensure all cancer patients are identified at the earliest possible stage,' a spokesperson said.

Dr Hamilton said the plan went too far: 'We'd prefer a more focused approach. We need to avoid swamping secondary care.'

Who to refer?

NICE guidance

Urgent referral for:

– patients aged over 40 with six weeks of rectal bleeding accompanied by diarrhoea

– patients aged 60 or more with rectal bleeding for six weeks without anal symptoms or diarrhoea

Study recommendations

All patients aged 45 or over with new-onset rectal bleeding should have urgent investigation of their bowel, whether or not they have other symptoms

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