West Yorkshire & Harrogate Cancer Alliance (plus York) Guidelines for the Management of Colorectal Cancers - Version 4.0
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West Yorkshire & Harrogate Cancer
Alliance (plus York)
Guidelines for the Management
of Colorectal Cancers
Version 4.0
1Contributors to current version 4.0
Contributor Author/Editor Section/Contribution
Review led by Praminthra
Chitsabesan, Consultant
Individual Colorectal Surgeon, York Colorectal lead
Teaching Hospitals NHS
Foundation Trust
Dr Nathalie Casanova
Clinical Oncology Group Prof Sebag-Montefiore Anal Cancer
Dr Rachel Cooper
Non-Surgical Oncology
Dr Sam Chan Chemotherapy
Group
Individual Praminthra Chitsabesan Surgery
Individual Richard Baker Rectal Cancer
Colorectal Anaesthetic team Simon Davies Anaesthetic Workup
Individual Diane Burwell Colorectal Nurse Specialist
Y&H Regional Palliative and
Lead Team Palliative Care Section
EoL Group
Page 2 of 93
Version number: 4.0
Valid at date of publicationi Document Control
West Yorkshire & Harrogate Cancer Alliance
Title
Guidelines for the Management of Colorectal Cancers
Colorectal MDT Lead Clinicians across West Yorkshire & Harrogate
Author(s)
Cancer Alliance (plus York)
Owner West Yorkshire & Harrogate Cancer Alliance
Version Control
Version/ Draft Date Revision summary
1.0 2005 First publication
2.0 2007 Review and re-write
3.0 2010 Major re-write and formatting
Final comments on version 3
Clarification on indications/contraindications for
3.1 Aug 2010
laparoscopic surgery (section 13.1 p.53)
Clarification of straight to test policy” (section 2.2 p.12)
Removal of genetics guideline (chapter 19) awaiting new
3.2 Aug 2010
local policy based on revised national guidance
Primary Care Referral Guidelines
3.3 Aug 2011 Policy for Referrals for Patients Outside the Agreed
Primary Care Referral Process
Palliative Care and End of Life
3.4 Oct 2011 Management of Early Rectal Cancer
Anaesthetic advice re cardiac disease and bowel cancer
surgery
Updated Calderdale table in Palliative Care and End of
3.5 Feb 2012
Life Guidelines
3.6 Mar 2012 Updated Stenting Personnel table
Updated section 14.1 on colorectal liver metastases and
section 10.3 on referral pathways / MDT management of
3.7 Aug 2012
anal cancer. Added some additional laparoscopic
surgeons in Section 13.2
Full review and update September 2017. Further review &
Sept 2017-
4.0 updates in January 2018 and April 2018 following
April 2018
comments received from the Colorectal MDT Leads
Page 3 of 93
Version number: 4.0
Valid at date of publicationContributors to previous YCN Guidelines August 2010
Contributor Author/Editor Section/Contribution
Dr D Sebag-Montefiore & Dr
Individual Anal Cancer
R Cooper.
Individual Dr CL Kay Stents
Individual Dr JA Guthrie Radiology
Mr I Botterill & Mr J Davies Mr I Botterill & Mr J Davies Surgery
Mr J Griffith & Mr J Davies Mr J Griffith & Mr J Davies Laparoscopic surgery
Liver Resection &
Individual Mr G Toogood
Metastases
Non-Surgical Oncology
Dr J Dent Chemotherapy
Group
Dr A Buxton & Dr O Rotimi Dr A Buxton & Dr O Rotimi Pathology
Management of anterior
Individual Mrs M Jennings
resection syndrome
Individual Mr D Leinhardt Laparoscopic guideline
Individual Mr RB Khan Laparoscopic and follow-up
Sub Regional Palliative and Palliative Care and End of
Group
EoL Group Life
Anaesthetic advice re cardiac
I Botterill and Dr Berridge I Botterill and Dr Berridge disease and bowel cancer
surgery
Mr M Steward & Mr J Mr M Steward & Mr J
Early Rectal Cancer
Robinson Robinson
Page 4 of 93
Version number: 4.0
Valid at date of publicationii Information Reader Box
West Yorkshire & Harrogate Cancer Alliance Guidelines for the
Title
Management of Colorectal Cancer
Author(s) Colorectal MDT Leads across WY&H (Plus York)
September 2017, then updated January and April 2018 following
Reviewed and updated comments from the colorectal MDT Leads across the Cancer
Alliance
Date signed off 2018
Published May 2018
Next Review Date May 2021, or earlier if new guidance becomes available
West Yorkshire & Harrogate (plus York)
Proposed Target Acute Trust Colorectal MDT Teams
Audience for
Acute Trust Colorectal Lead Nurses
Consultation / Final
Statement Acute Trust Lead Cancer Managers
CCG Lead Cancer Commissioners
All WY&H CA Colorectal Group guidelines will be made available
Proposed Circulation electronically at the West Yorkshire & Harrogate Cancer Alliance
List for Final website
Statement
No hard copies will be circulated by the Group.
West Yorkshire & Harrogate Cancer Alliance
NHS Wakefield CCG
Contact details White Rose House
West Parade
Wakefield
WF1 1LT
Page 5 of 93
Version number: 4.0
Valid at date of publicationiii Table of Contents
I DOCUMENT CONTROL........................................................................................................... 3
II INFORMATION READER BOX ................................................................................................ 5
III TABLE OF CONTENTS ........................................................................................................... 6
IV BASIS BEHIND THE UPDATE ................................................................................................ 9
1 INTRODUCTION..................................................................................................................... 10
1.1 PURPOSE AND SCOPE OF THESE GUIDELINES ............................................................................. 10
1.2 COLORECTAL CANCER SERVICES W EST YORKSHIRE & HARROGATE............................................ 10
1.3 NETWORK CLINICAL PATHWAYS ................................................................................................. 10
1.4 PATIENT INFORMATION .............................................................................................................. 11
1.5 BOWEL SCREENING PROGRAMME .............................................................................................. 11
2 REFERRAL GUIDELINES ...................................................................................................... 12
2.1 GP GUIDELINES FOR REFERRAL FROM PRIMARY CARE-2 WEEK REFERRALS ................................... 12
2.2 CLINICAL RESPONSIBILITY .......................................................................................................... 13
2.3 OTHER ROUTES OF REFERRAL .................................................................................................... 14
2.4 ONWARD REFERRAL FROM DIAGNOSTIC SERVICE TO MDT ........................................................... 15
2.5 REFERRAL GUIDELINES FOR LIVER METASTASES .......................................................................... 16
2.6 REFERRAL OF PATIENTS FROM LOCAL COLORECTAL MDTS TO ANOTHER MDT ............................. 16
3 MULTIDISCIPLINARY TEAM MEETING ................................................................................ 17
4 DIAGNOSIS AND LOCAL STAGING .................................................................................... 20
4.1 INVESTIGATION OF PATIENTS WITH SUSPECTED COLORECTAL CANCER .......................................... 20
4.2 POLICY FOR REFERRALS FOR PATIENTS OUTSIDE THE AGREED PRIMARY CARE - REFERRAL
PROCESS. ................................................................................................................................. 21
4.3 CLINICAL RESPONSIBILITY .......................................................................................................... 21
4.4 COMMUNICATION ....................................................................................................................... 23
5 IMAGING GUIDELINES ......................................................................................................... 24
5.1 DIAGNOSIS ................................................................................................................................ 24
5.2 STAGING ................................................................................................................................... 24
5.3 RADIOLOGICAL FOLLOW-UP ....................................................................................................... 25
5.4 PET ......................................................................................................................................... 26
5.5 DETECTION OF RECURRENT OR METASTATIC DISEASE ................................................................ 26
6 PRIMARY TREATMENT ........................................................................................................ 27
6.1 INTRODUCTION .......................................................................................................................... 27
6.2 ANAESTHETIC ASSESSMENT....................................................................................................... 27
6.3 ADJUVANT PRE-OPERATIVE RADIOTHERAPY ................................................................................ 27
6.4 SURGERY.................................................................................................................................. 28
6.5 ADJUVANT POST-OPERATIVE CHEMORADIOTHERAPY / CHEMOTHERAPY......................................... 32
6.6 PALLIATIVE TREATMENTS ........................................................................................................... 32
6.7 LOCAL RECURRENCE ................................................................................................................. 33
7 NON-SURGICAL ONCOLOGY .............................................................................................. 34
7.1 INTRODUCTION .......................................................................................................................... 34
7.2 NEO-ADJUVANT TREATMENT GROUPS ........................................................................................ 34
7.3 ADJUVANT TREATMENT GROUPS – COLORECTAL ONLY ............................................................... 35
7.4 METASTATIC TREATMENT GROUPS – COLORECTAL ONLY ............................................................ 36
8 FOLLOW-UP .......................................................................................................................... 38
8.1 STRATIFIED FOLLOW-UP ............................................................................................................. 38
8.2 MINIMUM FOLLOW-UP SCHEDULE ................................................................................................ 38
Page 6 of 93
Version number: 4.0
Valid at date of publication8.3 SURVEILLANCE .......................................................................................................................... 38
9 MANAGEMENT OF EARLY RECTAL CANCER................................................................... 41
9.1 INTRODUCTION .......................................................................................................................... 41
9.2 REFERRAL ................................................................................................................................ 42
9.3 BRADFORD PATHWAY ................................................................................................................ 43
9.4 BRADFORD FOLLOW-UP ............................................................................................................. 44
10 EMERGENCY MANAGEMENT OF COLORECTAL CANCER ............................................. 45
11 ANAL CANCER ...................................................................................................................... 46
11.1 INTRODUCTION .......................................................................................................................... 46
11.2 EVIDENCE BASE......................................................................................................................... 46
11.3 REFERRAL PATHWAYS ............................................................................................................... 47
11.4 PRE-TREATMENT ASSESSMENT .................................................................................................. 48
11.5 SUMMARY OF TREATMENT PROTOCOLS ...................................................................................... 50
11.6 GENERAL ASPECTS OF MANAGEMENT (ALL PATIENTS) .................................................................. 51
11.7 FOLLOW UP ............................................................................................................................... 53
11.8 SALVAGE SURGERY ................................................................................................................... 54
11.9 TREATMENT PROTOCOLS (IN DETAIL) .......................................................................................... 55
11.10 ANAL CANCER REFERRAL FORM ................................................................................................ 60
12 POLYP CANCER .................................................................................................................... 61
13 COLORECTAL STENTS ........................................................................................................ 63
13.1 STENTING PERSONNEL............................................................................................................... 65
14 LAPAROSCOPIC SURGERY ................................................................................................ 67
14.1 ELIGIBILITY ................................................................................................................................ 67
14.2 AUTHORISED SURGEONS............................................................................................................ 68
15 MANAGEMENT OF RECURRENT AND ADVANCED DISEASE ......................................... 69
15.1 LIVER METASTASES ................................................................................................................... 69
15.2 SYNCHRONOUS LIVER METASTASES........................................................................................... 71
15.3 SURGICAL RESECTION OF LOCAL RECURRENCE ........................................................................... 72
15.4 CHEMOTHERAPY ....................................................................................................................... 73
15.5 SYMPTOM CONTROL .................................................................................................................. 73
15.6 HEPATOBILIARY MDT AT LEEDS ................................................................................................. 73
16 PATHOLOGY GUIDELINES .................................................................................................. 74
16.1 INTRODUCTION .......................................................................................................................... 74
16.2 SPECIMEN TYPES ...................................................................................................................... 74
16.3 SPECIMEN EXAMINATION............................................................................................................ 75
16.4 MINIMUM DATASET FOR REPORTING........................................................................................... 75
16.5 GRADING AND STAGING CONVENTIONS ...................................................................................... 77
16.6 USE OF ANCILLARY LABORATORY TECHNIQUES .......................................................................... 78
16.7 AUDIT ....................................................................................................................................... 79
16.8 REFERRAL FOR REVIEW OR SPECIALIST OPINION ........................................................................ 79
16.9 REFERENCES ............................................................................................................................ 80
17 MANAGEMENT OF ANTERIOR RESECTION SYNDROME ................................................ 81
18 PALLIATIVE & END OF LIFE CARE ..................................................................................... 82
18.1 DEFINITIONS.............................................................................................................................. 82
18.2 W HO PROVIDES PALLIATIVE / END OF LIFE CARE? ...................................................................... 82
18.3 SPECIALIST PALLIATIVE CARE .................................................................................................... 83
18.4 FURTHER LINKS AND INFORMATION ............................................................................................ 84
18.5 DIRECTORY OF W EST YORKSHIRE & HARROGATE CANCER ALLIANCE SPECIALIST PALLIATIVE CARE
SERVICES ................................................................................................................................. 84
Page 7 of 93
Version number: 4.0
Valid at date of publication19 AUDIT AND RESEARCH. ...................................................................................................... 87
19.1 INFORMATION/DATA SUBMISSION ................................................................................................ 87
20 GENETICS – ........................................................................................................................... 88
21 APPENDIX 1: DIAGNOSTIC & ASSESSMENT SERVICES ................................................. 89
22 APPENDIX 2: NAMED LIST OF COLORECTAL MDT’S INCLUDING THOSE DEALING
WITH RECTAL & ANAL CANCER ........................................................................................ 91
23 APPENDIX 3: NETWORK “STRAIGHT TO TEST” POLICY ................................................ 92
24 APPENDIX 5: MRI RECTUM STAGING PROFORMA .......................................................... 93
Page 8 of 93
Version number: 4.0
Valid at date of publicationiv Basis behind the update
These guidelines have been updated based on the latest national guidance. It also includes
the “SERVICE SPECIFICATION FOR COLORECTAL CANCER” which is the bowel cancer
pathway commissioned by CCG’s and NHSE.
The aim is for a unified pathway that all users will sign up to. The key priorities for
commissioning services for people with suspected and confirmed bowel
cancer - 2016-2017 include:
1. Data submission – a high quality service requires and provides good quality data.
This will only be possible if commissioners and providers work together to ensure
comprehensive, timely and accurate data submission. These data will permit
better assessment of interventions to improve outcomes and patient experience.
Local commissioners need to know how the stage and mode of presentation
differs from the national average.
2. Encouraging earlier diagnosis of bowel cancer – over 93% of people survive for
at least five years if diagnosed at stage one, compared to 7% at stage four.
Achieving earlier diagnosis will require improvements in participation in screening
by harnessing the ability of GPs to promote the NBCSP, a lower threshold for
referral for investigating patients with colorectal symptoms and expanding and
making better use of diagnostic capacity. This may require the establishment of
specific diagnostic services for patients presenting with bowel symptoms
including straight to test.
3. Reducing unwarranted variation in diagnosis & treatment – the NHS atlas of variation in
healthcare for 2015 shows early diagnosis varied between 13.5% from the CCG with the
lowest rate to a highest rate at 54.4%. Planned access to adult critical care following
emergency excision colorectal surgery by CCG 2013/14. Varied between 0% for the
CCGs with the lowest rate to a highest rate of 96.6%. Commissioners have been asked
to use the service specification outlined in this document to contract high quality
services for colorectal cancer. They should identify where providers are not currently
compliant and reduce unjustifiable variations in quality and outcomes. They should do
this in a pragmatic way as not all suggestions will be practical to introduce.
4. Delivering improvements in the patient experience – a positive experience of
treatment and care for patients with bowel cancer is related to ease of access to
Clinical Nurse Specialists (CNS). Commissioners need to ensure contracts
stipulate adequate levels of CNS support for patients throughout their treatment
pathway and during follow-up. Services must be commissioned to ensure
equitable access to care for people living with and beyond bowel cancer aligned
with the National Cancer Survivorship Initiative.
Within England, there are also regional variations in stage at diagnosis, provision of
diagnostic and treatment services and outcome. Local commissioning for much of the
colorectal cancer pathway may permit local provision more responsive to local need, but risks
increased national variation if evidence based standards are not applied.
91 Introduction
Colorectal cancer is the second most common cancer occurring mainly in the elderly and is
increasing in incidence in the UK, accounting for more than 39,000 new cases per year.
Approximately half of these patients can expect to die of the disease, with one third of
patients having metastatic disease evident at the time of diagnosis. Given the disease
usually arises in a benign polyp and that the cure rate with current treatment modalities in
early stage disease approaches 90% overall, there is considerable scope for improving the
outcome for patients with colorectal cancer.
Unfortunately, the survival prospects for patients diagnosed with colorectal cancer in England are not
as good as in other countries with a developed heath care system. Net survival has been reported to
be up to 15% less in England compared with, for example, Australia. These differences in outcomes
are most likely due to late presentation. In England there is an increased rate of emergency
presentation with about 25% of patients diagnosed following admission to Accident and Emergency
(A&E) departments.
Although population screening can expect to improve the overall survival by approximately
15% and ultimately reduce the incidence, current circumstances demand the prompt
recognition of symptomatic disease with rapid access to effective diagnostic services and
modern treatment modalities under the guidance of the multidisciplinary team.
1.1 Purpose and Scope of these Guidelines
These guidelines are based on the national Improving Outcomes in Colorectal Cancers
guidance, and accompanying research evidence, with appropriate interpretation for our local
service. Based on the National Service Specification, it sets out the key evidence based
priorities for providing high quality, patient-centred services for people wherever they live.
This evidence based approach will ensure the best value interventions. An effective bowel
cancer service depends on local services working seamlessly with specialist services that are
commissioned directly by NHSE.
Contained in this document are guidelines for the management of rectal, colon and anal
cancers. The guidelines will be reviewed and updated on a regular basis. The guidelines will
be available online.
1.2 Colorectal Cancer Services West Yorkshire & Harrogate
The West Yorkshire & Harrogate Cancer Alliance (WY&H CA) has a resident population of
approximately 2.6 million and there are 11 Clinical Commissioning Groups and 6 Acute
Hospital Trusts within the Network. The Cancer Centre is based at Leeds Teaching Hospitals
NHS Trust.
1.3 Network Clinical Pathways
The former YCN Colorectal Group developed Network clinical timed pathways for the
following tumour sites:
Anal Cancer Pathway
Colon Cancer Pathway
10 Rectal Cancer Pathway
Early Rectal Cancer Pathway
Colorectal Emergency Admission Pathway
In addition a Teenage and Young Adults (TYA) with cancer pathway has been developed.
1.4 Patient Information
Clinical teams offer all newly diagnosed cancer patients information specific to their site,
treatment and relevant to their individual need. Patients can also access NHS choices for an
information prescription and clinical teams will offer help to do this, if required.
1.5 Bowel Screening Programme
The national bowel screening programme is well underway with faecal occult blood (FOB)
testing as the screening tool. Patients with positive FOBs are offered colonoscopies at all
hospitals within the Network. However, there are plans to change this to
immunohistochemistry testing of faeces. There is also the offer of a one off flexible
sigmoidoscopy at the age of 55.
Table updated 05.05.17
Screening Centre Trust
Bradford and Airedale NHS Foundation Trust Not fully rolled out as yet but
Airedale Screening aiming to do so.
Bradford Teaching Hospitals
Centre
NHS Foundation Trust
Calderdale, Kirklees Calderdale & Huddersfield NHS Fully rolled out here.
and Wakefield Bowel Foundation Trust
Cancer Screening
Mid Yorkshire Hospitals NHS
Centre
Trust
Harrogate, Leeds Harrogate and District NHS Only offered at Harrogate at
and York Bowel Foundation Trust present with the aim to offer at
Screening Centre York and Leeds within 12
Leeds Teaching Hospitals NHS
months.
Trust
York Teaching Hospitals NHS
Foundation Trust
112 Referral Guidelines
2.1 GP guidelines for referral from primary care-2 week referrals
All localities should follow the NICE Suspected cancer: recognition and referral (2015)
https://www.nice.org.uk/guidance/ng12 and adapt this for local use. Patients referred
through the urgent referral for suspected cancers follow a local common path for diagnosis
and assessment.
The former YCN Colorectal NSSG has agreed that their Network agreed policy is to use
individual Trust proformas. Each Trust pro forma complies with NICE Guidance. They
include which type of presentation (in terms of specific symptoms and patient characteristics)
should be referred with which level of priority (with regard to how quickly they should be dealt
with); as well as the single referral contact point for each trust hosting a colorectal diagnostic
service in the network (see next page).
The investigation protocol (Chapter 4) describes the pathway and clinical responsibility for
onward referral and communication with GP and the patient.
Referral based on Nice Guidance 2015 o should be using the regionally agreed two-week
wait referral pro-forma. The form ensures all referrals are sent to a designated Trust
diagnostic service with a single decision point for prioritising appointments. All such referrals
should be made within 24 hours usually through a dedicated fast track system. The patient
will be offered an appointment date within 2 weeks of referral.
The criteria are (NICE 2015):
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]
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]
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
12•iron‑deficiency anaemia. [new 2015]
4. The diagnostics guidance recommends tests for occult blood in faeces, for people
without rectal bleeding but with unexplained symptoms that do not meet the criteria
for a suspected cancer pathway referral in recommendations 1-3 above...
•All symptomatic patients who do not fulfil the two week wait criteria, should be considered
for referral to a consultant colorectal surgeon or gastroenterologist using the routine referral
point (18 week pathway) or using available straight to test services.
Patients without ‘red flag’ symptoms for colorectal cancer should be referred using the
Choose and Book service. GPs must attach the referral letter to the Choose and Book
documentation.
All patients with new onset colorectal symptoms over 40 years of age should be referred for
further investigation.
CCG’s should expect feedback on the appropriateness and/or timeliness of GP
referrals. The feedback should include the stage and route of presentation.
2.2 Clinical responsibility
Patients diagnosed with cancer should go straight to staging and be referred to the Colorectal MDT
Patients with non-malignant disease diagnosed as part of the MDT process remain the
responsibility of the referring clinician, most commonly by GP.
Patients with investigations that do not reveal cancer, but have a symptomatic condition
manageable in primary care should be sent back to the referring GP with a full report of
the investigation results including histopathology, and with advice on self-care and
primary care medical management. If symptoms persist, patients should be referred via
18 week pathway to an appropriate outpatient clinic
Patient diagnosed with Polyps should be entered into surveillance managed at the acute trust
level in accordance with the BSG guidelines
The named hospitals and their referral contact details Table updated 05.05.17
Trust Name Contact
Airedale NHS Foundation Trust Fast Track Office Tel: 01535 292613
Fax: 01535 294340
13Bradford Teaching Hospitals NHS Fast track office Tel: 01274 382542
Foundation Trust
Fax: 01274 382543
01274 365361
Calderdale & Huddersfield NHS Fast track office Tel : 01484 355394
Foundation Trust
Fax:01484 347295
Appointment Centre
0800 0158222
Harrogate and District NHS Foundation Appointment Centre Tel: 01423 553373
Trust
Fax: 01423 554455
Leeds Teaching Hospitals NHS Trust Referral and Booking Tel: 0113 2065141
Service (RBS)
Fax: 0113 206 4508
leedsth-
tr.FastTrackTeam@nhs.net
Mid Yorkshire Hospitals NHS Trust Fast Track Office Tel: 01924 212507
Clayton Hospital Fax: 01924 542746
York Teaching Hospitals NHS Patient Access Office Tel: 01904 726241
Foundation Trust
Tel: 01904 725817
Fax: 01904 726888
Scarborough Fast Track Referrals Tel: 01723 346160
2.3 Other routes of referral
All symptomatic patients who do not fulfil the two week wait criteria, should be considered for
referral to a consultant colorectal surgeon or gastroenterologist using the routine referral point
(18 week pathway) or using available straight to test services. All patients with new onset
colorectal symptoms over 40 years of age should be referred for further investigation.
Low-risk referral criteria
Patients with the following symptoms and no abdominal or rectal mass are at very low risk of
cancer and are therefore of lower priority:
Rectal bleeding with anal symptoms such as soreness, discomfort, itching, lumps and
prolapse as well as pain
Rectal bleeding with obvious external cause, e.g. prolapsed piles or anal fissure
Change in bowel habit to decreased frequency of defecation and harder stools
Abdominal pain without clear evidence of intestinal obstruction, iron-deficient anaemia or
palpable abdominal or rectal mass.
14Urgent referral to normal clinic
Patients with persistently low-risk symptoms, but with other worrying factors, such as a
positive family history
Patients who do not meet the urgent criteria but about whom there remain concerns.
Patients referred via other referral mechanisms have their individual referral assessed by a
relevant clinician and escalated to the two week wait pathway, based on expert clinical
opinion. Patients who describe symptoms which don’t entirely fulfil the criteria but are a
source of concern to the GP can be referred urgently to the colorectal service out with the
fast track system.
There should be no direct referral of newly presenting patients for large bowel investigations
from primary care to individual colorectal surgeons or gastroenterologists.
The former YCN had agreed a Network ‘straight to test’ policy (Appendix 23) that describes
the investigation pathway for suspected colorectal cancers. However, other alternative
models of clinical assessment within the network are acceptable, as long as local audit can
demonstrate that the timeliness of diagnosis and treatment is not compromised
Endoscopy is the preferred initial investigation for making the definitive diagnosis of
colorectal cancer.
Patients will be stratified into investigative pathways on the basis of the symptoms detailed in
the referral document. The precise nature of the investigation will depend on the patient’s
symptoms, co-morbidity and the capacity of investigative resources within each trust or
diagnostic centre.
Any patient with symptoms and signs of large bowel obstruction should be referred as an
emergency to the surgical admissions unit.
2.4 Onward referral from diagnostic service to MDT
A member of a clinical team informed that a patient under their care has or is highly likely to
have colorectal cancer will be responsible for the urgent referral of the patient to the local
colorectal cancer service or named core member of the MDT.
The referral to the core MDT member should be within one complete working day of the
diagnosis being made. The local service leads will ensure that clinicians likely to encounter
patients in their practice with colorectal cancer are informed of this responsibility. Such
clinical groups include upper GI surgeons, gynaecologists, gastroenterologists and
physicians with an interest in medicine for the elderly, and radiologists. The contact details
will be familiar to each diagnostic service. It will be the responsibility for each colorectal MDT
Lead to inform these key groups of this process on an annual basis.
The endoscopist, radiologist and pathologist making the initial diagnosis of colorectal cancer
will send a copy of the report to the local MDT co-ordinator. This will provide a back-up
mechanism for ensuring that patients enter the next phase of the patient pathway rapidly,
facilitating expedient histological confirmation, staging and treatment.
To avoid unnecessary delays, patients with suspected or proven colorectal cancer should be
reported to the MDT co-ordinator by staff in radiology, endoscopy and pathology.
15These guidelines also apply to patients diagnosed from biopsies or scans undertaken in the
private sector or in GP treatment centres (such as Fountains Medical Centre, Leeds or
Eccleshill Treatment Centre, Bradford).
2.5 Referral guidelines for liver metastases
Not infrequently certain aspects of a specific case will need discussion at either a specialty
MDT (e.g. lung or gynaecology) within the local trust or at a tertiary centre MDT (e.g. anal
cancer, local resection of early rectal cancer and hepatobiliary).
The MDT for referral for patients with liver metastases is located at St James’s University
Hospital, Leeds serving a population of 3.8 million. Whilst hepatobiliary surgeons attend
some MDT’s within the network, making this a mechanism of referral, a single central point of
referral is present and the preferred route.
Catchment
Type of Population
Name Location Contact Details
Team
Approx.
Mr Giles Toogood
Consultant Surgeon
St James’s University Hospital,
Hepatobiliary HpB St James’s University
Leeds Teaching Hospitals NHS 3.8 Million*
MDT Team Hospital
Trust
Leeds Teaching Hospitals
NHS Trust
* This figure includes patients referred from Humber Coast & Vale Cancer Alliance
The Network will adopt the new national guidelines for referrals when these are published.
Where there is doubt concerning suitability for referral, clinicians are advised to contact the
HPB MDT for advice. It is also recognised that a proportion of patients with synchronous
large bowel cancer primary with liver metastases will be suitable for synchronous resection of
both sites of disease. These cases should also be discussed with the HPB MDT.
Please also see Chapter 15.1
2.6 Referral of patients from local colorectal MDTs to another MDT
Anal cancer Referral to Anal cancer MDT at Leeds (see Ch.10)
Referral to Colorectal MDT at Leeds or Bradford if
Early rectal cancer
not available locally (see Ch. 8).
Liver metastases Referral to HPB MDT at Leeds (see Ch. 14.1)
16Consider referral to local Lung MDT (York patients
Lung metastases are assessed and managed by Hull and East
Yorkshire Hospitals NHS Trust as appropriate).
Specialist palliative care Referral to local Specialist palliative care team
3 Multidisciplinary team meeting
3.1 MDT membership
All members have a specialised interest in colorectal cancer, with one member taking
managerial responsibility for the service as a whole (the Lead Clinician).
Core team includes:
At least two colorectal surgeons are required, to comply with National Peer Review.
Clinical oncologist with responsibility for radiotherapy for rectal carcinoma
Medical oncologist with responsibility for chemotherapy
Radiologist with an interest in colorectal imaging and intervention
Specialist Gastrointestinal Histopathologist
Colonoscopist with expert skills from any the following disciplines: surgeon,
physician or specialist nurse
A gastroenterologist
At least two Colorectal Clinical Nurse Specialists (CNS) to provide cover for the smaller
units.Larger departments will require more.
MDT Co-ordinator
An NHS-employed member of the core or extended team should be nominated as
havingspecific responsibility for users’ issues and information for patients and carers.
At least one of the clinical core members, with direct clinical contact, should
have completed the training necessary to enable them to practice at level 2
for the psychological support of cancer patients and carers.
One of the core MDT members should be nominated as being responsible for
the integration of service improvement.
One of the core MDT members should be nominated as being responsible for
the recruitment of patients into clinical trials.
For medically qualified core members of the MDT, the cover should be provided
by a consultant in the same specialty.
The extended team includes:
It would be hoped that an Anaesthetist with an interest in the perioperative management
of patient with colorectal cancer (including pre-operative assessment) will be able to
attend the MDT to discuss high risk patients who have a potential to go for surgery.
Psychologist/liaison Psychiatrist
Liver surgeon who is a member of a liver resection MDT
Thoracic Surgeon who has a practice in lung metastasectomy, and is a member of a
Lung MDT
A member of the palliative care MDT (doctor or nurse)
An expert in insertion of lower intestinal stents
Consultant in elderly care
17 Dietitian
Clinical geneticist/genetics counsellor
Social Worker
Clinical trials co-ordinator or research nurse
Bowel Cancer Screening Nurse
Stoma care CNS
Physiotherapist/Occupational Therapist
Onward Referral to appropriate services as the clinical situation e.g. Urology
Management of colorectal emergencies
This issue is to be discussed through a Cancer Alliance Task and Finish Group
3.2 Purpose of the MDT
The aim of the MDT is to ensure a co-ordinated approach to the diagnosis, treatment and
care services for all patients diagnosed with colon, rectal and anal cancer. The MDT will
ensure that it discusses at least 60 new patients per year, and that each of the colorectal
surgeons performs at least 20 colorectal resections per year.
The MDT has the combined function of diagnosis (to rapidly assess and achieve
histopathological confirmation of cancer), treatment (discussing the management of all newly
diagnosed cancers) and communication (with the appropriate agencies e.g. primary care
teams, hospice etc.). Furthermore, the MDT is committed to achieving the highest standards
of care and patient outcomes by:
• collection of high quality data
• analysis of such data in audit cycles
• involvement in local, national and international research studies
• incorporation of new research and best practice into patient care
• providing comprehensive information to patients and their relatives
• involving patients in assessment and redesign of the services
“All consultants responsible for the delivery of any of the main treatment modalities should
be a core member of the MDT. The role of the imaging specialist can be met by a group of
named specialists. The role of the histopathologist can be met by a group of named
histopathologists provided each meets the workload and EQA requirements.” [14-2D-101]
(Page 18).
The MDT Co-ordinator will record the attendance of the core membership. Each core
member (or cover) should attend at least two-thirds of MDT meetings. Attendance should be
in person, though members such as a clinical oncologist can attend via an audio-visual link.
Meetings should be scheduled every week unless the meeting falls on a public holiday. The
attendance at each individual scheduled treatment planning meeting should constitute a
quorum, for 95% or more, of the meetings. The quorum for the MDT meeting is made up of
the following core members: one colorectal surgeon, one clinical oncologist, one medical
oncologist, one radiologist, one histopathologist, one Colorectal CNS and an MDT Co-
ordinator.
The MDT will discuss the following groups of patients:
18• all newly diagnosed cancer patients
• all postoperative patients
• all patients with newly-diagnosed recurrent disease
• any other cancer-related cases needing discussion
Treatment planning takes into account the holistic needs assessment (HNA) of the patient.
Following discussion of the case, the agreed management plan is recorded on Medical
Review Lists in real time by an audio typist in conjunction with the MDT Co-ordinator. This is
displayed on a screen for all attendees to see, thus providing a contemporaneous record of
the discussion. In addition, a letter is also dictated for each patient by the responsible
clinician at the end of the MDT meeting. This is typed by a dedicated MDT audio typist that
day, and subsequently verified by the respective clinician. It is then transmitted electronically
to the GP, with a copy filed in the patient’s notes and on CPD.
Where possible the MDT meeting will be used to collect information relevant to the agreed
Network minimum dataset. The MDT Co-ordinator has the responsibility for reporting
information regarding 14-day, 31-day and 62-day targets to the MDT and other appropriate
agencies, and recording the minimum dataset electronically.
If a patient requires referral to another MDT, this will be organised by the MDT Co-ordinator,
who should liaise with his/her counterpart in the MDT to which the referral has been made.
The Colorectal CNS should also liaise with their equivalent CNS.
Where a patient with colorectal cancer is deemed to require an urgent treatment planning
decision, which needs to be made prior to the next scheduled colorectal MDT meeting, the
following procedure should be followed:
• Telephone discussion with the relevant consultant or their deputy
• Formal written letter to follow telephone discussion as a permanent record
• The case will be discussed retrospectively at the next scheduled MDT meeting
The MDT will meet annually to discuss operational matters, audit data and service
improvement matters.
3.3 Leadership and responsibilities
Responsibilities of the Lead Clinician
Lead the clinical activity of the MDT, working to agreed guidelines, and ensuring a
high quality integrated service which meets local, regional and national standards
Ensure the MDT engages with the relevant clinical alliance
Ensure that clinical management guidelines are produced and revised regularly
Ensure the collection of the appropriate cancer minimum dataset, working with the
team’s audit co-ordinator.
Produce an Annual Report with the support of the Cancer Management Team and
review processes
194 Diagnosis and local staging
4.1 Investigation of patients with suspected colorectal cancer
On receipt of a two week wait referral, patients must receive an appointment within 14 days
of referral. Patients who do not attend their appointment must be offered a second
appointment, with the referring clinician informed that they failed to attend the first
appointment.
There are a range of diagnostic endoscopic and radiological investigations which are of value
in making the diagnosis of colorectal cancer. The optimal investigative pathway will depend
on the patient’s symptom complex. The preferred method of establishing a definitive
diagnosis is through endoscopy.
Symptom Test
Iron deficiency Anaemia Upper & Lower GI tract investigation
Preferred combination is gastroscopy &
colonoscopy.
For patients who have incontinence or
who are frail it is likely that they will be
better served by a combination of
gastroscopy and colonography.
Due to the recent SIGGAR study
(Lancet 2013) It should be noted that barium
enema is not considered to be an appropriate
first diagnostic test.
Persistent fresh rectal bleeding without anal Flexible sigmoidoscopy/colonoscopy and
symptoms & without a rectal mass treatment of local causes. If bleeding
continues - colonoscopy
Dark or altered blood+/- blood stained
mucous – colonoscopy.
Blood in the lumen of the rectum at rigid
sigmoidoscopy usually indicates
significant colorectal pathology
Rectal mass Urgent biopsy with colonoscopy or CT
colonography
Abdominal mass Colonoscopy & CT or CT colonography
Altered bowel habit with rectal bleed Flexible sigmoidoscopy/colonoscopy or
CT colonography
Altered bowel habit without rectal bleed Colonoscopy or CT colonography
Altered bowel habit with diarrhoea Colonoscopy
Bowel obstruction CT to allow staging
A water soluble contrast enema or
colonoscopy may be necessary in some
cases
20We would advise that the choice of Colonoscopy/CT Colonography is a decision based on
the patient’s general health / fitness for bowel prep and possible sedation. An alternative in
some trusts would be an “unprepared” CT scan.
All biopsies should undergo analysis as outlined in the pathology guidelines (Chapter 15).
The diagnosis of colorectal cancer will usually be made by endoscopic, histopathological or
radiological methods, either alone or in combination. All patients who are considered for
treatment should undergo the appropriate staging investigations as a matter of urgency.
The imaging investigations are described in the imaging guidelines (see Chapter 5).
Specific staging tests should include CEA, abdominal and thoracic CT and pelvic MRI in
rectal cancer. Ferritin should be checked if possible as data exists that IV iron infusion can
increase Hb levels without the need for a packed cell transfusion prior to an operation.
Rectal lesions that are potentially suitable for trans-anal excision should also undergo trans-
rectal ultrasound or high resolution MRI.
It is advisable to image the whole colon if colonoscopy, CT colonography or barium enema
can be tolerated. Further staging investigations might be necessary in light of discussion by
the MDT.
4.2 Policy for Referrals for Patients outside the Agreed Primary Care -
Referral Process.
When an endoscopist identifies an abnormality at sigmoidoscopy or colonoscopy as a cancer
with a high degree of confidence from a source other than those above, the endoscopist
should take responsibility for ensuring the rapid entry of the patient into the local
management pathway. This will require the identification of biopsy specimens as urgent for
rapid processing within the pathology department, informing the referring clinician of the
suspected diagnosis on the day of investigation and informing the MDT co-ordinator of the
patient’s details.
When colorectal cancer is diagnosed with a high degree of confidence on an imaging
investigation initiated by a non-MDT clinician or clinical service (including a GP) the report
will be transmitted to the referring clinical team on the day of diagnosis through the locally
established communication mechanism for transmitting urgent reports. The MDT Co-
ordinator should also be informed at the same time.
When a diagnosis of colorectal cancer is established in a biopsy which was not regarded as
malignant by the endoscopist, the pathologist should inform the responsible clinician on the
day of diagnosis in a similar fashion to above.
4.3 Clinical responsibility
Colorectal cancer by its very nature may present in many guises and to many differing
clinical groups. Each Trust should have a local policy for clinicians who are not members of
the Colorectal MDT to refer all new and recurrent cases to a core surgical member of the
MDT by the end of the first working day following the discovery of the diagnosis.
21Each MDT should have a clear point and method of contact. The responsibility for informing
the patient of the diagnosis remains with the clinician in charge of the patient at the time the
diagnosis is made. Non-clinical groups that are most likely to encounter colorectal cancer are
upper GI surgeons, gynaecologists, gastroenterologists, and consultant physicians with an
interest in medicine for the elderly, these groups need to be kept abreast of changes in
patient pathways.
Stage of clinical care Responsible clinician(s)
Prior to first referral to secondary care GP
Diagnostic Consultant of first appointment
Initial treatment (MDT) Surgeon
Primary surgery Surgeon
Primary non-surgical oncology Clinical or Medical Oncologist
Post-surgery Surgeon or Clinical/Medical Oncologist
Treatment for metastatic disease Clinician in the most relevant specialty
Follow-up Surgeon/CNS with Remote Surveillance
where available
Palliative care Specialist Palliative Care Team and/or
GP
General principles
Urgent suspected cancer referrals to the named diagnostic service remain the
responsibility of the GP until the patients attends an appointment with the diagnostic
service
Responsibility for requesting further diagnostic tests, staging investigations or onward
referral to a core MDT member then belongs to the consultant under whose care the
original diagnostic service appointment occurred.
Subsequent responsibility is determined by the treatment planning decision of the
MDT
Throughout the pathway there should be ongoing access to the Clinical Nurse
Specialists and the MDT
Timely and detailed communication with primary care colleagues is essential at all
times
Teenage and young Adult Pathways (TYA)
TYA MDTs are responsible for overseeing the care of young adults with cancer.
The TYA MDT may provide care jointly with local colorectal MDTs for patients aged
13 to 24 years of age, based on locally-agreed guidelines.
The treatment plan of all cases jointly agreed by the respective Colorectal MDT and TYA
MDT according to the relevant clinical guidelines.
22Young patients diagnosed with colorectal or anal cancer below the age of 25 are referred to
the Teenage and Young Adult (TYA) MDT in Leeds. This should be done immediately on
diagnosis of a cancer and details should be emailed to jill.doherty@nhs.net with a formal
letter to follow.. The local TYA cancer pathway and referral form is available from the TYA
MDT team. Patients wanting egg or sperm preservation are referred to the Leeds Centre for
Reproductive Medicine, based at Seacroft Hospital.
The Teenage and Young Adult with Cancer Pathways 16-18 and also the Teenage and
Young Adult with Cancer Pathway 19-24 are both available from Leeds Teaching Hospitals
NHS Trust.
4.4 Communication
The diagnosis should be communicated to the patient by the clinician in charge of the patient
(as identified in the table above) in a comfortable, private environment preferably when
accompanied by a relative or friend. Whenever possible a specialist nurse, who has skills in
counselling, should be present at the interview. The patient should be given both verbal and
written information and should be given time and support to reflect on the information. Any
questions regarding the implications of the diagnosis and possible treatment pathways
should be answered. Advice regarding access to the service for subsequent support and
information should be provided. A personal diary (if routinely used) could provide a useful
record and guide for the intended further interventions.
The GP must be informed within 24 hours of the patient receiving the diagnosis.
Support and guidance are provided by the specialist nurses throughout the staging process
and subsequently when the further management options are discussed. Prior discussion at
the MDT meeting should be used to advise the most appropriate further treatment whether it
be adjuvant treatment, surgery or palliative treatment. The patient must again be provided
with all the necessary information and support to make a decision. Where appropriate, the
specialist nurse should provide advice and counselling regarding stoma care, up to and
including the hospital admission. The patient can expect to start treatment within the ensuing
4 weeks.
GPs will be notified of new patients diagnosed with cancer the next working day after the
patient has been informed. This might be by fax, telephone, email or transmitted
electronically.
The GP should also be informed of the MDT decision, following discussion with the patient in
the presence of a CNS and core member of the MDT. This will require an establishment of
colorectal CNSs to cover a 52 week service.
235 Imaging guidelines
5.1 Diagnosis
The preferred method of establishing a definitive diagnosis of colorectal cancer is with
endoscopy (either sigmoidoscopy or colonoscopy) and biopsy. All units recognised for
colorectal cancer diagnosis should be JAG accredited.
In a significant number of patients the initial diagnosis is made using imaging (i.e.
conventional CT or CT colonography). Whatever the means of initial diagnosis full staging
will be required as detailed below.
The choice of investigation within the diagnostic pathway is based on the patient’s symptoms
as detailed in Chapter 3. The pathway and mechanism for ensuring timely discussion of
patients referred by an MDT member is determined by each MDT, with patients with high risk
symptoms passing down the local “straight to test” pathway. The responsibility for the onward
progression of patients with positive or indeterminate investigations is detailed within the
MDTs pathway.
If a previously undiagnosed colorectal cancer is made with a high degree of confidence on
the basis of an imaging technique from a non-member of the colorectal MDT, the reporting
radiologist should ensure that the report is transmitted to the referring clinician by the end of
the working day. In addition a copy of the report should be passed to the local MDT co-
ordinator to enable the patient to be discussed at the next MDT meeting.
Histological confirmation of a tumour should be sought preoperatively in all tumours if at all
feasible. However if histology cannot be obtained, the findings of radiological investigations
should be discussed at the MDT and a management plan determined on the merits of each
individual case.
If colonoscopy is incomplete due to obstructing tumour then preferably CT colonography
should be used to complete the examination of the large bowel.
In the emergency setting investigation will depend on available expertise. Where feasible CT
of the abdomen and pelvis should be performed after resuscitation to establish a diagnosis
and stage the tumour. A single contrast enema may be of value in some patients. Depending
on the quality of CT performed, or available, a single contrast enema may be used to
supplement or as an alternative means of establishing a diagnosis. A contrast enema has the
limitation of being unable to stage any obstructing tumour.
Ideally full staging CT should be performed at the first attendance (outpatient or acute). If
staging is not performed pre-operatively then a formal staging CT should be performed once
the patient has recovered from the surgery and prior to any proposed adjuvant therapy.
5.2 Staging
5.2.1 Colon and rectal cancer
Contract-enhanced CT of Chest, abdomen and pelvis. The liver acquisition should be
performed in the portal venous phase.
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