Identifying and managing patients at low risk of bowel cancer in general practice

All NHS patients who are suspected to have bowel cancer by their general practitioner should now be seen by a specialist within two weeks. The government introduced this policy in July 2000 in response to concerns that some patients had to wait too long for an outpatient appointment. However, this new policy could distort referral patterns either by increasing the referral of patients with transient symptoms or by increasing the delay for cancer patients presenting with non-typical symptoms. Unless general practitioners act as efficient gatekeepers, specialist services could become overloaded. We explain the basis for the government's guidelines for referral and discuss how to manage patients at low risk of cancer. The Department of Health has developed guidelines to help general practitioners decide which patients require fast track referral and which can safely be treated and monitored in general practice (table).1 2 View this table: Department of Health criteria for high and low risk of bowel cancer The guidelines were based on data from relevant studies, which were assigned levels of evidence by established methods.3 The grading system for the higher risk symptoms was similar to that used to grade recommendations for hypertension, thrombosis, and diabetes.4–6 The high prevalence of rectal bleeding,7 8 changes in bowel habit,9 and abdominal pain10 in the community relative to the incidence of bowel cancer means that most patients with these symptoms are at very low risk of cancer. Many of these symptoms are transient or cause no alarm, and over 80% of patients do not seek medical advice.7–11 Of those who do, only 40-50% are referred to hospital.7 8 The risk of cancer in patients with rectal bleeding, for example, varies from 1:700 in the community8 to 1:30 in primary care,12 and 1:16 …