The Royal Marsden

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Lower GI Cancer Key facts

Dr Sheela Rao

Medical Oncologist

The Royal Marsden

Distribution of Colorectal Cancer

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2 ww lower GI referral –NICE Colorectal cancer

1.3.1 Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal

cancer if:

they are aged 40 and over with unexplained weight loss and abdominal pain or

they are aged 50 and over with unexplained rectal bleeding or

they are aged 60 and over with:

iron-deficiency anaemia or

changes in their bowel habit, or

tests show occult blood in their faeces. [new 2015]

1.3.2 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in

adults with a rectal or abdominal mass. [new 2015]

1.3.3 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in

adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings:

abdominal pain

change in bowel habit

weight loss

iron-deficiency anaemia. [new 2015]

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2ww model

Traditional 2WW model Outpatient clinic within day 14 days 20 minute appointment but usually only confirms the need for further investigations

Rigid sigmoidoscopy (no prep, limited value) and then further tests usually colonoscopy booked - by day 28 but often later

Creates ‘carve out’ of capacity resulting in routine patients waiting longer and if surgery needed, risk of breaching 18 week RTT targets.

This group is often where the patients with cancer are sitting

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Straight-to-test for the two-week-wait colorectal cancer

pathway under the updated NICE guidelines reduces time

to cancer diagnosis and treatment. J Christopher1, et al.

Introduction: The 2015 National Institute for Health and Care Excellence guidelines widened the referral

criteria for the two-week-wait pathway for suspected lower gastrointestinal cancer. We implemented a

straight-to-test protocol to accommodate the anticipated increase in referrals. We evaluated the

impact of these changes for relevant pathway metrics and clinical outcomes using a retrospective

cohort study with historic controls.

Materials and methods: We analysed data from all patients referred to a teaching hospital via the two-

week-wait pathway for suspected lower gastrointestinal cancer under the previous guidelines

between 1 March and 31 August 2015 compared with the same period in 2016, when the updated

guidelines and straight-to-test protocol had been implemented.

Results: In the 2015 cohort, there were 64 cancer diagnoses from 664 referrals (9.6% pick-up) compared

with 58 cancer diagnoses from 954 referrals in the 2016 cohort (6.1% pick-up). Our straight-to-test

protocol reduced the median time to cancer diagnosis by 12.5 days (P < 0.001) and reduced the

median time to cancer treatment by 7.5 days (P < 0.05) An increased proportion of non-colorectal

cancers were diagnosed in 2016 compared with 2015, (37.9% vs 17.2%, P < 0.05) and more

adenomas were removed in 2016 compared with 2015 (377 vs 193).

Discussion and conclusion: Our straight-to-test protocol has resulted in a reduction in times to cancer

diagnosis and cancer treatment, despite an increase in the number of referrals. The new referral

criteria have considerable resource implications, but their implementation did not result in an increase

in the total number of cancers diagnosed.

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Molecular Differences depending on site of primary

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Right versus Left

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Immunotherapy

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Immunotherapy in Colorectal Cancer

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Royal Marsden GI Unit

Integrated multidisciplinary team approach

Patient driven care-support groups /focus

groups/patient advocates

Extensive portfolio of Clinical trials –investigator led

and pharmaceutical sponsored

National and international collaborations

Commitment to translational research -new state of

the art molecular pathology labs to be based at

Sutton