Colorectal cancer

The Urgent Suspicion of Cancer (USC) Primary Care referral pathway should be used for patients who meet the Scottish Referral Guidelines (SRG) for Suspected Cancer criteria.

Patients will also be referred, who meet the screening threshold, through the Scottish Bowel Screening Programme which invites those aged between 50 and 74 to participate in bowel screening every 2 years.

Primary care should inform the patient that they are being referred as USC at the point of referral, while reassuring them that the majority of referrals result in a non-cancer diagnosis.

Primary care should also make the patient aware of their responsibility to make themselves available for tests and appointments in the coming days/weeks, as they may be invited at short notice. 

Including as much relevant information and supporting materials in the initial referral from primary care is key to enabling active clinical triage to ensure the patient is on the right pathway at the right time. As per the Scottish Referral Guideline, if lower gastrointestinal cancer is suspected:

• Perform an abdominal and rectal examination;
• Arrange blood tests for renal function, liver function and full blood count plus ferritin/iron studies if anaemic.

Active Clinical Referral Triage (ACRT)

Clinical triage can be done by a suitably experienced clinician – preferably by a consistent group, regularly and should be complete within 3 days of the patient being referred (allowing for the weekend).

A national consensus was reached by the clinical community across NHS Scotland regarding the use of qFIT for prioritisation of patients with new lower gastrointestinal symptoms and should be adopted in all Health Boards - National Quantitative Faecal Immunohistochemical Testing (qFIT) for Patients with New Lower Gastrointestinal Symptoms 2024. Where possible, the referrer should provide details of any weight loss and the numerical value of the qFIT when referring to secondary care to allow effective triage.

If a USC referral is regraded at the point of vetting, the USC National Regrading Guidance should be adopted with the initial referrer and patient informed.

Pre-assessment (screen detected)

Patients referred through the National Bowel Screening Programme should have a pre-assessment to assess their suitability for diagnostic testing. How the pre-assessment is undertaken is for Health Boards to determine.

The patient should have their first diagnostic test with a verified report, by day 14.

The majority of patients will have a colonoscopy as their initial diagnostic test, however there will be instances where this is not suitable for the patient. As such, alternatives could include CT abdomen pelvis, CT colonography, Colon Capsule Endoscopy or Flexible-Sigmoidoscopy.

If cancer is suspected or diagnosed during the diagnostic test, staging investigations should be booked as soon as possible. Allowing and supporting staff such as nurse endoscopists to request staging investigations can help speed up the process.

Where possible, a navigator or Single Point of Contact (SPOC) should be identified to provide consistent contact, build trust and generally support the patient throughout the diagnostic pathway.

Patients should be informed about cancer being ruled out, or diagnosed, at the earliest opportunity using the preferred method of communication agreed with the patient, this could be face to face or via telephone/virtual.

In cases where cancer is likely, the patients should meet the Cancer Nurse Specialist (CNS), be considered for a prehabilitation referral and further tests arranged.

In cases where cancer is excluded, USC patients can be removed from tracking on a 62 day pathway and referred back to Primary Care where appropriate.

Prehabilitation (prehab)

When prehab is effectively embedded it can improve a patient’s chance of positive clinical outcomes, helping them to recover more quickly from surgery, chemotherapy and radiotherapy, and reduce the chance of developing other problems during and after treatment.

All patients should be screened to identify level of prehabilitation need (universal, targeted or specialist intervention) to ensure they are supported by the right people, at the right place, at the right time.

Those who are identified with higher level of support needs (targeted and specialist) should be referred for onward assessment.

Useful first steps to delivering prehab are included in the NHS Scotland prehab website and the Maggies website.  

Standard imaging protocols should be applied for all CT, MRI and ultrasound and these should comply with Royal College of Radiologists’ recommendations or equivalent. Where MRI is required for suspected rectal cancer, reporting should be completed by day 21.

Reports for tissue sampling should be available in advance of the multi-disciplinary team (MDT) meeting by day 28.

All histopathology should have a clear indicator which clarifies the urgency and date that the report is required by, this will ensure that the timescales for MDT reporting is not lost between different clinicians or teams. Genomic results, though needed, should not result in a delay to the MDT meeting taking place, these results can be considered after MDT meeting has taken place.

The MDT meeting is the culmination of patient examinations/consultations and diagnostic investigations.

The MDT meeting provides a professional forum to discuss patients’ results and explore and agree the most effective treatment options available.

It is crucial that all MDT meetings are coordinated and managed effectively to ensure there’s clinical agreement on the next step of the patient’s pathway and a decision to treat is not delayed. Recommendations on delivering effective MDT meetings can be found in the Framework for Effective Cancer Management. The patient should be informed of their diagnosis by day 28, following the MDT meeting.

Personalised care and support planning should be based on the patient and clinician(s) completing a holistic needs assessment (HNA), shortly after diagnosis.

The HNA ensures conversations focus on what matters to the patient and considers wider health, wellbeing and practical support required. This helps enable shared decision-making regarding treatment and options.

Useful resources include the nutrition and psychological therapies and support frameworks. 

Improving the Cancer Journey (ICJ) Teams across NHS Scotland have shown that they are particularly good at engaging and supporting those in lower SIMD quintiles which could help address inequalities among colorectal cancer patients. Patients are invited to engage with ICJ as early as possible and the ICJ Team can help to address all non-clinical needs.

Treatment

Within weeks 5 to 6, patients should jointly agree their treatment plan (decision to treat) with their clinical team.

To ensure that the referral for treatment happens as efficiently as possible, prompt notification to the treating specialist is required. This should include the results of pre-operative tests already performed such as biopsy reports and genetic testing.