Colorectal Straight to Test Service

If bowel cancer is suspected, a GP or a medical professional should refer patients to our Rapid Colorectal Cancer Diagnosis Pathway.

A team of Nurse Practitioners, Colorectal Fellows and Colorectal Consultants aim to assess patients with suspected bowel cancer for colorectal investigations. These should be arranged within 14 days from the referral and patient should receive a diagnosis within 28 days.

Patients may attend an outpatient clinic appointment for further discussion with a doctor or have a telephone assessment by a member of the Straight to Test Team to evaluate their symptoms and discuss the suitability of investigations.

The tests we offer are mainly Colonoscopy, Flexible sigmoidoscopy, CT Colonography or CT Abdomen and Pelvis scan. These tests should help to identify whether patients have colorectal cancer or not.

 

Colorectal Nurse Practitioner Team

We are a team composed of:

• 4 Colorectal Nurse Practitioners
• 1 Trainee Senior Colorectal Practitioner
• 7 Senior Colorectal Nurse Practitioners (including 5 Nurse Endoscopists)
• 3 Patient Pathway Administrators

We work in close contact with the Colorectal Consultants and several services such as Endoscopy, Radiology department and multidisciplinary teams from other specialities at NUH. We run the Straight to Test (STT) Service, Colorectal Nurse Led Clinics, OSCARS lists and ORBIT clinic.

In 2022, the nurse practitioner team received approximately 5800 RCCD referrals and 1205 routine/urgent colorectal referrals, giving a total of 7005 referrals.  We provided 215 clinic sessions where 1205 patients were seen and also provided 597 endoscopy sessions.

 

OSCARS: One stop Colonoscopy and Radiological Staging

We invite patients with the highest results or suspected bowel cancer onto dedicated endoscopy lists after assessing their fitness. If we find something of note during a colonoscopy, the endoscopist who perform the procedure (this might be a doctor, surgeon or a nurse endoscopist) informs the patient and relatives about the findings and organises scans ( CT Chest Abdomen Pelvis / CT Colonography) usually for the same day.

We run these dedicated lists at Nottingham Treatment Centre – next to QMC.

Some patients might be offered a scan at first, depending on the presenting clinical symptoms and general health conditions.

In some cases, we may ask patients to attend a 2 week wait consultant led clinic to discuss symptoms and possible investigations.

 

ORBIT : One-stop Rectal Bleeding Investigation & Treatment

We prioritise patients referred with a rectal mass and rectal bleeding. We book them into a dedicated clinic and, if appropriate, we offer a same day flexible sigmoidoscopy.

Patients can also have access to same day or next day CT Chest Abdomen Pelvis / CT Colonography scan, if necessary. Elderly or frail patients with rectal bleeding can be reviewed by one of our colorectal doctors, before any camera investigation or scan.

We run this clinic at Nottingham Treatment Centre – next to QMC.

 

2WW Clinic

Some patient are unable to attend straight to test investigations for a variety of reasons. We have a dedicated two-week-wait (2ww) clinics delivered by Colorectal Consultants and Colorectal Fellows to assess patients prior 2ww colorectal investigations.

Our aim is to send as many patients as possible straight to test.

We run this clinic at Nottingham Treatment Centre – next to QMC.

 

Colorectal Nurse Led Clinics

These clinics are run by Senior Colorectal Nurse Practitioners, who went through an extended training to be able to see colorectal patients independently.

We offer outpatient face-to-face or telephone consultations to patients referred to the colorectal routine and urgent pathway.

We provide a clinical assessment with a holistic approach to our patients. We follow patients up from the initial assessment to diagnosis and treatment. Some of the nurses are also qualified non-medical prescribers and nurse endoscopists.

These clinics have helped to reduce the colorectal service waiting time and improved patients’ quality of life.

We mainly see patients with acute or chronic colorectal diseases and perform Abdominal & Rectal examination, Proctoscopy, Rigid Sigmoidoscopy and Haemorrhoid Banding, and also send patients for investigations if appropriate (blood tests, microbiology tests, endoscopy procedures, scans, minor operations under general or local anaesthesia).

We currently run 5 clinic sessions a week at Nottingham Treatment Centre, Gateway I.

FIT is a home test kit and check for hidden blood in “poo”.

Many things can cause hidden blood in motions but we know that high levels of hidden blood can indicate a higher risk of serious causes such as cancer.

Most people with high FIT results will still have nothing serious in their large bowel (colon & rectum).

Nottingham University Hospitals NHS Trust was the first place in England to make use of FIT in patients with symptoms. Our results have been shared widely and used to develop new guidelines. FIT helps us to identify those who most need investigation and also helps us to reassure those with very low levels of hidden blood in poo.

 

Faecal Immunochemical Test (FIT)

• Please follow the instructions that come with your test kit (please instructions below)
• If you need help or instructions in another language please call or email
• Please return the kit as soon as possible
• Please do not store your kit for a long time or in hot areas (eg above fires/radiators) as the result will be wrong
• If the lab does not receive your kit within 14 days from the request, they will not analyse it but will send you a new one

 

Test instructions:

When you're ready to do the test

• Write the date on the sample pot
• Use the layers of the toilet paper to catch your poo
• Twist cap to open sample bottle
• Collect sample by scraping the green stick along the poo until all the grooves are covered
• Put stick back in bottle and click the green cap to close it
• Do not repeat collection
• Wash hands after use
• Check you have written the date on the sample bottle
• Seal the sample bottle inside the return envolope 
• Post envolope without the delay

 

Watch this video on how to take a FIT, with translated subtitles or British Sign Language on Vimeo https://vimeo.com/showcase/6663813 

 

Bowel cancer: Self-testing kit 'saved my life' - Nottingham University Hospitals

Please read the article here - www.bbc.co.uk/news/uk-england-nottinghamshire-47792829

 

FAECAL IMMONUCHEMICAL TEST

FIT is a test that looks for hidden traces of blood in the stool. It helps to identify which patients are most likely to benefit from urgent investigation. We use blood tests to minimise the risk if missing bowel cancer.

A digital rectal examination is mandatory irrespective of FIT results. A “negative” FIT may sometimes miss a palpable rectal mass.

FIT <4

There is no quantifiable blood and the risk of CRC is less than 1 in 1000.

PATIENTS under 40 YEARS OLD

For patients under 40 years old referred to the RCCD (Rapid Colorectal Cancer Diagnosis) pathway, the FIT threshold is ≥ 100.

If FIT is < 100 with abnormal blood results, patients should be referred on the routine colorectal pathway and provided with safety netting in Primary Care.

Patients under 40 years should have a faecal calprotectin (FCP) test if GP is concerned about IBD (Inflammatory Bowel Disease). Calprotectin level > 250 should be referred on an “urgent” non- 2WW basis.

Patients with a palpable rectal mass should be referred on the RCCD pathway without a FIT result.

 

PATIENTS over 40 YEARS OLD

• Rectal bleeding and normal bloods

The current FIT threshold for RCCD referral is ≥ 10.

• Rectal bleeding and abnormal bloods

The current FIT threshold for RCCD referral is ≥ 4.

• No rectal bleeding and normal bloods

The current FIT threshold for RCCD referral is ≥ 20. Patients with FIT < 20 and normal bloods can be referred routinely. A repeat FIT is advised if GP remains concerned about colorectal cancer.

• No rectal bleeding and abnormal bloods

The current FIT threshold for RCCD referrals is ≥4

• Non-return

Patients repeatedly fail or decline FIT: GP to send a Routine referral.

• FIT Negative and Palpable Abdominal Mass

GP to consider USS (Ultrasound Scan), FBC (Full Blood Count), Ca125, Glucose and urine dip for haematuria (blood in urine) prior to referring onto the following pathways:

• 2WW Upper GI (includes HPB)  if Upper GI risk factors/symptoms
• 2WW Urology if haematuria / raised PSA
• 2WW Gynaecology if raised Ca125 or abnormal pelvic USS or PV bleeding

Other options:

If lower abdominal mass then 2WW Gynaecology in females

If upper abdominal mass then 2WW Upper GI (Includes HPB)

Or 2WW Non-specific/Vague symptoms

 

• FIT Negative and Unexplained Weight Loss ( >3kg per month) OR FIT Negative and Iron Deficiency Anaemia (IDA)

GP to consider CXR, FBC, Ca125, PSA, Glucose, ESR, TFT, UE, LFT, CRP, Bone/Calcium, Myeloma screen, TTG and urine dip for haematuria prior to referring onto the following pathway:

• 2WW Upper GI if Iron Deficiency Anaemia AND weight loss
• 2WW Lung if abnormal CXR, chest symptoms or risk factors
• 2WW Urology if haematuria / raised PSA
• 2WW Gynae if low abdominal mass; or raised Ca125 or abnormal pelvic USS
• 2WW Haematology if myeloma screen positive

Note : If platelets >400 2WW lung or 2WW Upper GI more likely

 

Repeat FIT

A repeat FIT may reduce the risk of missed colorectal cancer, if FIT result is between 4 and 19.9 with normal bloods.

If cancer concern persists but alternate pathways are not appropriate, GP to consider 2WW Non-specific symptoms pathway.

If all of the above are normal and evidence of IDA – Iron Deficiency Anaemia (new or recurrent)- and not seen in secondary care in last 3 years: GP to refer patient to the Gastroenterology team routinely.

If IDA persists without an obvious source of blood loss, a repeat FIT testing may be reasonable. 

 

RCCD definition of abnormal blood results

Abnormal blood results considered in the RCCD pathway:

• HB <130 males,<120 females
• Platelets ≥400
• Ferritin <25 or ≥350

If a patient has abnormal bloods, GP may repeat their FIT test once if CRC (Colorectal Cancer) remains a concern, but there is limited evidence to support this. Alternate cancer pathways or routine gastrointestinal referral are alternate options – please note non-colorectal cancers are more common causes of altered bowel habit, weight loss, abdominal mass and abdominal pain in this group.

 

New guidelines

• GP will always need to perform a finger examination (Digital rectal examination).
• GP can still refer patient if FIT result is negative but this is done on a different pathway
• GP can also repeat the FIT test if symptoms do not settle or blood tests are getting worse
• Our data shows that this system misses fewer people with bowel cancer (reduced by 25%)
• The risk of FIT below 20 missing a bowel cancer is very low but not zero (0.3% or 3 in 1000)
• The risk of bowel cancer in people who do not return their FIT test is 3 or 4 times higher overall (1%) and much higher when the result is high.

 

Further info for GPs

Further info for GPs

FIT group	No. results	CRC	Detection %	Miss rate below lower limit	CRC Detection rate above lower limit
<4	22734	26	0.1	-
4-9.9	5190	36	0.7	0.1	4.3
10-19.9	2176	26	1.2	0.2	6.8
20-29.9	1031	22	2.1	0.3	9.1
30-39.9	646	23	3.6	0.4	10.8
40-49.9	477	21	4.4	0.4	12.2
50-59.9	315	10	3.2	0.5	13.4
60-69.9	252	19	7.5	0.5	14.6
70-79.9	192	10	5.2	0.6	15.3
80-89.9	164	8	4.9	0.6	16.2
90-99.9	152	9	5.9	0.6	17.0
100+	1960	351	17.9	0.6	17.9
DNR	3631	38	1.0

 

Colorectal Cancer Risk depending on FIT score

 

RCCD Pathway