The two-week rule colorectal cancer pathway: an update on recent practice, the unsustainable burden on diagnostics and the role of faecal immunochemical testing

Ann R Coll Surg Engl. 2020 Apr;102(4):308-311. doi: 10.1308/rcsann.2020.0019. Epub 2020 Feb 21.


Introduction: Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services.

Methods: A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports.

Findings: There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.

Keywords: Colorectal neoplasms; Early detection; Occult blood.

MeSH terms

  • Colonoscopy / statistics & numerical data
  • Colorectal Neoplasms / diagnosis*
  • Colorectal Neoplasms / epidemiology
  • Critical Pathways / standards*
  • Critical Pathways / statistics & numerical data
  • Databases, Factual / statistics & numerical data
  • Early Detection of Cancer / methods
  • Early Detection of Cancer / standards*
  • Humans
  • Medical Overuse / prevention & control
  • Medical Overuse / statistics & numerical data
  • Occult Blood*
  • Practice Guidelines as Topic
  • Predictive Value of Tests
  • Prevalence
  • Referral and Consultation / standards
  • Referral and Consultation / statistics & numerical data
  • Time Factors
  • Triage / standards*
  • United Kingdom / epidemiology