The two week referral for colorectal cancer: a retrospective analysis

The two-week referral (TWR) system was introduced in July 2000 to address the delays in referral, diagnosis and treatment of colorectal cancer (CRC) and lessen the associated psychological morbidity of prolonged waiting. General practitioners complete a proforma outlining 'high-risk' criteria for CRC to ensure an urgent referral within 14 days. The aim of the study was to analyse the TWR process and the proforma criteria.

One hundred and forty-nine two-week referral proforma were retrospectively reviewed between January and August 2001. The waiting times and proforma data, together with investigations performed and diagnoses made were gathered for 144 patients. Three did not attend clinic and two sets of notes were missing.

Ninety-six percent of patients (n = 144) were two week compliant and 14 CRC (10%) were diagnosed. The most common referral symptom was a recent change in bowel habit (36.6%) but specificity for all criteria was low. The highest diagnostic yield was a palpable abdominal or rectal mass where 16.7% had CRC and iron deficiency anaemia had high sensitivity (90%) for surgical pathology. Per rectum examination and haemoglobin analysis by general practitioners was infrequently performed.

Our study has shown that CRC is difficult to diagnose by history and examination alone with a 10% detection rate. CRC incidence in TWR may be improved by primary care through routine rectal examinations, increased detection of iron deficiency anaemia and public education to reduce presentation via other referral routes. Further studies are needed to address these issues.