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New risk tool to help UK GPs decide if patients under 50 have a serious bowel condition

The University of Exeter, in partnership with Bowel Cancer UK Never Too Young campaign, Durham University and North Tees and Hartlepool NHS Foundation Trust, publishes in the British Journal of...

The University of Exeter, in partnership with Bowel Cancer UK Never Too Young campaign, Durham University and North Tees and Hartlepool NHS Foundation Trust, publishes in the British Journal of General Practice a new research and risk assessment tool. Funded by the Department of Health, this tool aims to support GPs to identify the symptoms of a serious bowel condition for patients aged under-50. This research comes ahead of Bowel Cancer Awareness Month in April.

The assessment tool will calculate the risk of a serious bowel condition allowing the GP to decide whether a patient needs further tests. This is the first of its kind for younger people and aims to speed up the diagnosis of patients under 50 who often experience significant delays.

Lower gastrointestinal (GI) symptoms are common and in younger people are often attributed to non-serious conditions, like Irritable bowel syndrome (IBS). But we know there are more than 2,500 new diagnoses of bowel cancer every year in under 50s in the UK and approximately 13,000 people are diagnosed with inflammatory bowel disease, many of these also under the age of 50.

Symptoms of these conditions account for one in 12 GP appointments, but given that most of these symptoms won't be caused by bowel cancer, it can be difficult for GPs to distinguish between those patients with non-serious conditions, such as IBS, and serious conditions, like bowel cancer and inflammatory bowel disease.

Using data from the well-established Clinical Practice Research Datalink (CPRD), a high quality national database representative of the UK as a whole, the researchers assessed the frequency of symptoms in people with a serious bowel condition, and used this to calculate the positive predictive value (PPV) of bowel cancer or inflammatory bowel disease.

Using symptoms, a physical examination and blood test results, the tool calculates the PPV of a serious disease with a percentage, as well as suggesting next steps:

  • Risk level
  • Risk level 1-3%: The GP should recommend the patient for a faecal calprotectin test to help rule out a non-serious condition like Irritable bowel syndrome (IBS).
  • Risk level >3%: The GP should refer the patient for an urgent colonoscopy or refer the patient to a specialist for further assessment.

The tool recommends that patients with a risk threshold of 3% or more should have further urgent investigation, an action which is in line with NICE referral guidelines for suspected cancer and the NICE Quality Standard for inflammatory bowel disease.

Willie Hamilton, Professor of Primary Care Diagnostics at the University of Exeter Medical School, who led the research says: "The risk assessment tool should be used as a reminder to GPs to consider the likelihood of an individual patient having a serious bowel condition given the symptom or combination of symptoms they present with. The tool does not replace clinical judgement but provides more information to base a referral decision."

Deborah Alsina MBE, Chief Executive, Bowel Cancer UK, says: "As the numbers of under-50s affected by bowel cancer and bowel disease continues to rise, research is fundamental in finding better ways to diagnose people early when treatment is likely to be more successful.

"We launched our flagship Never Too Young campaign in 2013 to highlight the experiences of young people for the first time and to improve their diagnosis, treatment and care so that more lives are saved. Delayed diagnosis is all too common for young patients with both bowel cancer and inflammatory bowel disease therefore finding quicker, more effective ways to identify and diagnose these patients earlier is crucial. Our research shows that one in five young patients have to visit their GP five times or more before they get their diagnosis and this is simply not acceptable.

"This important research has the potential to help GPs to decide which of their young patients need a referral for further tests and which have less serious bowel conditions. However this is just the start, the next step is to ensure that all GPs across the UK have access to this potentially life-saving tool as part of their day to day practice"

Greg Rubin, Professor of General Practice and Primary Care at the School of Medicine, Pharmacy and Health at Durham University, says: "Bowel symptoms are common in younger people and it is crucial to develop tools that help GPs identify those who need to be referred for further investigations. Our findings will support them to do this more effectively."

Matt Rutter, Professor of Gastroenterology at North Tees and Hartlepool NHS Foundation Trust, says: "We hope that this risk assessment tool will make the journey from GP to referral for younger patients with potentially serious bowel conditions much quicker. At the moment, we know that younger people often have to visit their GP many times before a referral for further tests. This delay is costly to their health, wellbeing and the NHS."

Rodger Jones, Emeritus Professor of General Practice, King's College, London & Editor at the British Journal of General Practice & BJGP Open, says: "Many cancer diagnosis guidelines regard patients under the age of 50 as at low risk, but, sadly, most GPs will have had a patient who was much too young to have colorectal cancer (CRC), but died from it.

"Many other patients with lower bowel symptoms may have the diagnosis of Inflammatory Bowel Disease (IBD) delayed unnecessarily, with adverse health outcomes. Sally Stapley and colleagues have reviewed the clinical data on over 11,000 patients under the age of 50 with colon cancer or IBD, and determined which symptoms put them at highest risk of CRC/IBD, emphasising the importance of an initial physical examination which includes a rectal examination, full blood count and inflammatory markers. 10 features were independently associated with a high probability of CRC/IBD, but the highest positive predictive values were for rectal bleeding accompanied by a change in bowel habit with abnormal haematological or inflammatory indices. Diarrhoea accompanied by thrombocytosis was also more predictive of a serious diagnosis.

"These data are important in helping GPs to choose patients likely to benefit most from referral for colonoscopy."

Nearly 98% of people will survive bowel cancer for five years or more if detected at stage 1 compared with less than one in ten people diagnosed at stage 4. In addition, Bowel Cancer UK research shows that nationally, 3 out of 5 people diagnosed under the age of 50 will be at stages 3 or 4, with a third (34%) being diagnosed in an emergency situation, like A&E. This means that many younger people have a lower chance of survival than they should.

Article: Clinical features of bowel disease in primary care: a large case-control study, Sally A Stapley, Greg P Rubin, Deborah Alsina, Elizabeth A Shephard, Matthew D Rutter and William T Hamilton, British Journal of General Practice, doi: 10.3399/bjgp17X690425, published 27 March 2017.

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