West Yorkshire & Harrogate Cancer Alliance (plus York) Guidelines for the Management of Colorectal Cancers - Version 4.0

 
West Yorkshire & Harrogate Cancer
       Alliance (plus York)

 Guidelines for the Management
     of Colorectal Cancers

            Version 4.0

                 1
Contributors 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

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i 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
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                                 Valid at date of publication
Contributors 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

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ii 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

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iii 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
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8.3     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

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19          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

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iv 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.

                                                9
1 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

                                                11
2 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

                                                       13
Bradford 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.

                                                 14
Urgent 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.

                                                  15
These 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)

                                                     16
Consider 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

                                                19
4        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

                                                20
We 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.

                                               21
Each 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.

                                              22
Young 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.

                                              23
5        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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