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Work-up and Referral

These excepts are taken from the draft standards for the Diagnosis and Referral of Patients who are Clinically Suspicious for Colorectal Cancer. See the full version of this document for more information.

TARGET POPULATION

Adult patients presenting in primary care settings.

This standard does not provide recommendations for patients who present with alarming emergency symptoms and signs of hemodynamic instability, acute gastrointestinal hemorrhaging, acute intestinal obstructions, or unremitting abdominal pain. These patients should be immediately referred to emergency for assessment and treatment.

This standard does not address colorectal cancer (CRC) screening for asymptomatic patients. Please refer to the Cancer Care Nova Scotia Colon Cancer Prevention Program Colon Cancer Screening Guidelines.

Primary Care Providers (PCPs) and endoscopists should not use the guidelines for screening of asymptomatic patients to triage symptomatic patients. 

 

INTENDED USERS

This document is intended for Family Physicians (FP), general practitioners, emergency room physicians, nurse practitioners, registered nurses, surgeons and gastroenterologists.  A companion document will be provided for the public.

This document is also intended for policymakers to help ensure that resources are in place so that target wait times can be achieved.

For the purposes of this document, we have referred to:

·         FPs, general practitioners, emergency room physicians, and other PCPs as ‘PCPs’

·        Surgeons, gastroenterologists and other specialists competent in endoscopy as “endoscopists”

 

Purpose

The purpose of this standard is to facilitate the timely diagnosis and appropriate referral of patients who are clinically suspicious for colorectal cancer.

Principles

Good communication and coordination between PCPs and specialists is essential to a timely diagnosis.

The patient must be kept informed at every step.

 

 

STANDARD RECOMMENDATIONS

Work-Up

Clinical Presentation (See flowchart)

A thorough history and physical by the primary care provider is key to a timely diagnosis.

A focused history and physical examination should be performed if patients present with ONE OR MORE of the following signs or symptoms:

·         Palpable rectal mass

·         Palpable abdominal mass

·         Anemia (especially iron-deficiency anemia)

·         Rectal bleeding

·         Change in bowel habits

·         Weight loss

·         Abdominal discomfort

·         Perianal symptoms

 

The focused history should determine the following details:

·         Age and gender

·         Rectal bleeding, and if yes,

-      Colour (dark versus bright red)

-      Location of blood relative to stool (mixed in with stool versus separate from stool, on the toilet paper)

·         Change in bowel habit over recent months/years, and if yes,

-        Increased loose or watery stools or diarrhea

-        Increased constipation or difficulty passing stools

-        Feeling of incomplete emptying

-        Increased urgency

-        Incontinence of stools or soiling

·         Weight loss

·         Nature and characterization of abdominal discomfort (e.g. pain, tenderness, bloating)

·         Perianal symptoms such as prolapsed lump, pruritus, pain, hemorrhoids (the presence of perianal disease does not rule out rectal cancer)

·         Symptoms of anemia [e.g., fatigue, weakness - see Figure 1 Anemia diagnostic algorithm

·         If unexplained iron-deficiency anemia present, explore possible causes of blood loss or blood dyscrasia.

·         Personal history of colorectal polyps or inflammatory bowel disease (IBD)

·         A first-degree family history of CRC and the age of onset

 

To supplement the history, a focused physical examination or investigations should include the following:

·         Digital rectal examination (DRE)

·        Abdominal examination. If palpable mass detected, order abdominal/pelvic imaging as clinically indicated.

·         Look for signs of anemia –  see Figure 1 Anemia diagnostic algorithm

·         Weight (and comparison to previous weights if possible)

·         Complete blood count (CBC), and ferritin

 

Considerations of increased risk for colorectal cancer:

High risk

  • Personal history of colorectal neoplasm
  • Family history of CRC (first degree relative)
  • History of Inflammatory Bowel Disease

 

Moderate Risk

  • African descent
  • Male
  • Alcohol consumption greater than 45 gm/day
  • Overweight
  • Smoking
  • Increased red meat intake (>5 servings a week)
  • Low physical activity
  • Low fruit/vegetable consumption

 

Upon receiving reports suspicious for CRC, the PCP will review the results as soon as possible with the patient and inform him/her that a cancer diagnosis is a possible outcome, and initiate the referral process promptly. 

It is the position of the College of Physicians and Surgeons of Nova Scotia (CPSNS) that the follow-up of test results and treatment is the responsibility of the ordering or treating physician, unless other physicians involved in the patient’s care have been informed and have explicitly agreed to assume this responsibility.The College of Registered Nurses of Nova Scotia (CRNNS) Nurse Practitioner Standards of Practice specify that nurse practitioners are responsible to “establish a systematic and timely process to receive, document, track and communicate test results [and] communicate diagnoses, potential implications, treatment plans, expected outcomes and overall prognosis in a sensitive, honest, and respectful manner”.

 

Fecal Occult Blood Testing

There is no role for fecal occult blood testing in the work-up of a patient who is symptomatic of or clinically suspicious for colorectal cancer.

 

Referral

Principles of Referral

Referral and wait time recommendations for the following indications are based on evidence of the relative predictability for CRC of single or combined signs, symptoms, or diagnostic investigations. The referral wait times were reached by consensus, considering the recommendations developed by the Canadian Association of Gastroenterology, the Cancer Care Ontario recommendations and the Nova Scotia practice environment.

Good communication between the PCP and the specialist is essential to a timely and appropriate referral process.

To facilitate triage, timely consultations and appropriate use of resources, referrals will be made using the standardized referral form (Appendix A). Endoscopists will respond to referrals using the standardized response at the bottom of the referral form (See Appendix A).

The CPSNS Guidelines for Physicians Regarding Referral and Consultation and the CRNNS Nurse Practitioner Standards of Practice Standard 4 (Assessing, Diagnosing and Monitoring) and Standard 7 (Collaboration, Consultation and Referral) set out expectations for physicians and nurse practitioners regarding the responsibilities of referring and receiving physicians. This standard (Diagnosis and Referral of Patients Clinically Suspicious for Colorectal Cancer) is predicated on these documents.

In keeping with CPSNS Guidelines for Physicians Regarding Referral and Consultation:

  • The endoscopist will acknowledge receipt of the referral and provide the anticipated wait time or appointment date within 14 days to the referring PCP. Because urgent patients need to be seen quickly, endoscopists are encouraged to inform the referring PCP if they will be unable to see the patient in a timely fashion.

 

  • The PCP should inform the endoscopist (preferably by personal contact) if the estimated wait time is inappropriately long for the patient's condition, or if the patient's condition changes during the wait period. The PCP should also consider referring the patient to another consultant if the clinical condition of the patient requires an earlier appointment than the consultant can accommodate.

 

We recommend that endoscopists should inform referring PCPs of expected timelines for endoscopy at the time of referral.  PCP and specialists should work together regarding responsibility for further testing when there are excessive wait times for endoscopy.

 

Triage Standards and Timelines

URGENT REFERRALS

The patient has at least one of the following:

·         Palpable rectal mass suspicious for CRC

·         Abnormal abdominal imaging result suspicious for CRC

 

PCP

Will send a referral to an endoscopist promptly (i.e. within 1-2 working days) using the standardized referral form (Appendix A). Due to the urgent nature and expedited timeline, PCPs should contact the endoscopist by telephone to discuss the referral.

Endoscopist

Patient to be seen for consultation with a definitive diagnostic workup completed within 4 weeks of referral.

 

SEMI-URGENT REFERRAL

If a patient has at least one of the following:

·        Unexplained rectal bleeding in patients with at least one of the following characteristics or combinations of symptoms:

-        Rectal bleeding mixed with stool

-        Rectal bleeding in the absence of perianal symptoms

-        Rectal bleeding associated with mucous or epithelial tissue discharge

-        Rectal bleeding and change in bowel habits

-        Rectal bleeding and weight loss

-        Dark rectal bleeding

 

·         Unexplained iron-deficiency anemia

PCP

Will send a referral to an endoscopist promptly (i.e. within 1-2 working days) using the standardized referral form (Appendix A).
PCPs are encouraged to contact the endoscopist by telephone to discuss the referral.

Endoscopist

Definitive diagnostic work up to be completed within 8 weeks of referral. This is in keeping with the 8 week standard for patients with a positive FIT through the Colon Cancer Prevention Program.

 

Unexplained Iron Deficiency Anemia

PCPs should investigate unexplained anemia, especially iron-deficiency anemia.

 See Figure 1 Anemia diagnostic algorithm 

Consider the possibility of a CRC diagnosis in pre-menopausal women.  If treatment for menstruation problems does not address the anemia, reassess the patient and follow closely. 

 

 

OTHER UNEXPLAINED SIGNS OR SYMPTOMS

If the unexplained signs or symptoms of patients do not meet the criteria for referral but, based on clinical judgment, there remains a:

High level of suspicion of CRC

PCP

Send a referral to an endoscopist using the standardized referral form (Appendix A). PCPs are encouraged to contact the endoscopist by telephone to discuss the referral.

Endoscopist

PCP and endoscopist will reach agreement on degree of urgency and timelines for consultation and a definitive diagnostic work up.

Low level of suspicion of CRC

PCP

1. Treat the sign and/or symptom if applicable.

2. Review within 4 to 6 weeks. A return appointment should be booked.

3. If signs and/or symptoms are not resolving in 4 to 6 weeks, then consider referral to an endoscopist.