Information for GPs – click this link for Referral Guidelines Download
|What to consider in Primary Care before referring
- Up to 9% of an average population will have at least one first degree relative (FDR i.e. sibling, parent or child) and over 20% a second degree relative (SDR i.e. Grandparent, uncles, aunts, half siblings) with bowel cancer.
- For most of these there is no proven benefit for increased surveillance above that of the rest of the population i.e. the bowel cancer screening programme (BCSP).
- However a significant proportion may benefit from outpatient assessment for screening interventions and/or genetic testing.
- There is no direct access colonoscopy service, patients should be referred for outpatient assessment for the appropriateness of this procedure.
- Information about the BCSP for GPs including referral guidelines in contained in the link above. Currently this is still a faecal occult blood (FOB) test based screening test from the age of 60 years only, although in a few years this may become a flexible sigmoidoscopy based screening programme.
|Approach to assessing patients with a family history of bowel cancer – Full historywith reference to the following points
- Full family history detailing all family members affected
- Age of diagnosis of relative (s) with bowel cancer
- Extracolonic cancer(s): Age of diagnosis and site
- Specific details of previous genetic testing (with written documentation if possible)
- Patients other risk factors e.g.
- Body mass index
- Physical activity
- Smoking and alcohol consumption
- Symptoms – often these patients will be asymptomatic, but consideration of any alarm symptoms should be included and referred irrespective of family history according to NICE referral guidelines
Examination should specifically include
- Palpable masses on external, or digital rectal examination.
- Superficial lesions including moles, buccal pigmentation, etc.
|PRIMARY CARE Low risk groups: Although many of these patients may seek reassurance, according to national guidelines they do not require screening above and beyond the rest of the population (i.e. BCSP).
- 1 FDR over age 50 years at diagnosis.
- 2 SDRs.
- Family history of any relative with < 10 polyps found on colonoscopy.
They may be offered lifestyle modification advice in addition to reassurance. Lifestyle interventions proven to reduce risk of bowel cancer include
- Regular physical activity
- Weight loss if obese (to a normal BMI)
- Diet: High fibre, low red meat, 5 pieces of fruit & veg per day
- Smoking cessation
- Moderate or low alcohol consumption (any alcoholic beverage)
|Referral ThresholdModerate risk groups should be referred for assessment for screening from the age of 50 years onwards and not before in the absence of other indications.
- 1 FDR under age 50 years at diagnosis.
- ≥ 2 FDRs any age.
- 1 FDR and 1 SDR same side of the family any age.
High risk groups should be referred at any age. They account for approximately 5% of all bowel cancer.
- 3 FDR with bowel cancer – one diagnosed under age 50 (e.g. Lynch Syndrome or Hereditary non-polyposis colorectal cancer (HNPCC)).
- A family history with multiple affected members in more than one generation
- A previously characterised high risk patient or relative (i.e. with a known cancer syndrome such as Familial Adenomatous Polyposis Coli (FAP)) not currently undergoing surveillance.
- The presence of a germline pathogenic mutation in a colorectal cancer susceptibility gene if previously tested.
There is strong evidence that screening moderate and high risk groups reduces colorectal cancer mortality, with much lower than expected incidence in screened populations compared to expected ONS data
|Secondary care resource:Refer to Gastroenterologist if moderate or high risk
- West Middlesex University Hospital
West Middlesex Hospital
Twickenham Road, Isleworth, TW6 7AF
Phone: 020 8321 5351
Fax: 020 8321 5152