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Two week wait colorectal referral missing patients

NICE is coming under renewed pressure to rewrite the rulebook on referral for colorectal cancer after publication of a study showing its guidance on anaemia is missing large numbers of patients.

Anaemia was strongly associated with colorectal cancer even in patients with no other features of iron deficiency, the researchers found.

The University of Bristol team called for NICE rules to be simplified to ignore features of iron deficiency entirely and recommend urgent referral of all patients over 60 with unexplained anaemia based on the haemoglobin value alone.

NICE guidelines require the presence of iron deficiency as well as anaemia, but the study, published online by the British Journal of Cancer, found this missed men in particular.

Researchers quantified the risk of cancer for current referral guidance and found that around 13% of men with colorectal cancer with a haemoglobin of less than 11g/dl and features of iron deficiency would not meet criteria for an urgent referral. The figure for women with a haemoglobin of less than 10mg/dl and iron deficiency was 8%.

Under the researchers' suggested revisions to guidance - based on a study of more than 6,400 UK colorectal cancer patients and 45,000 controls – current haemoglobin thresholds of 11g/dl for men and 10 g/dl for women to be retained.

Study leader Dr Willie Hamilton - clinical research fellow in the department of primary health care at the University of Bristol and a GP in the city - said lower risk thresholds had to be accepted if more patients were to be detected through the two-week pathway: ‘Our point is that the GP shouldn't be misled by absence of iron deficiency once there is moderately severe anaemia.'

He added that simplifying the guidance to focus on anaemia alone would pick up ‘large numbers' of people in whom a diagnosis would be delayed leading to worse prognosis. ‘With bowel symptoms I think you must do a haemoglobin test,' he said.

Dr Richard Stevens, a GP in Oxford and chair of the Primary Care Gastroenterology Society, said there was no reason why GPs should not take anaemia more seriously, but that many initial investigations could be done in the surgery. ‘Anyone with these figures warrants further investigation but the GP is in the best position to do the initial work-up.'

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