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PTH-96 COLORECTAL CANCER DIAGNOSED AT
SIGMOIDOSCOPY, IS COLONOSCOPY NECESSARY TO
ASSESS FOR SYNCHRONOUS CANCER?
Vikram Mohanan, Ajay Verma*. Kettering General Hospital Nhs Foundation Trust, Kettering,
UK
10.1136/gutjnl-2021-BSG.299
Introduction The Association of Coloproctology of Great Brit-
ain & Ireland (ACGBI) 2017 colorectal cancer (CRC) guide-
lines reaffirmed the longstanding practice of assessing for
synchronous cancer in patients diagnosed with CRC at sigmoi-
doscopy (f-sig). Ideally by colonoscopy in addition to CT stag-
ing of chest, abdomen & pelvis (CT CAP), or alternatively
CT colonography (CTC) and CT thorax if complete colono-
scopy not possible.
In the literature, approximately 3.5% of patients had syn-
chronous CRC. Scheduling colonoscopy may delay treatment
and be onerous for patients. Access to prompt colonoscopy
can be challenging due to capacity issues, especially in the
COVID-19 pandemic era.
Methods Data were retrospectively analysed from electronic
endoscopy, radiology and pathology records from patients
diagnosed with CRC at f-sig and colonoscopy over 11 years
(2010-2020 inclusive).
Results Analysis 1: 680 patients who had CRC diagnosed at f-
sig: 230 underwent pre-treatment colonoscopy (33.8%).
Interval between f-sig and colonoscopy; mean 17.5 days/
median 15.0 days.
Two synchronous cancers identified at colonoscopy; 0.9%
1. 57 years old man with primary rectal cancer and syn-
chronous transverse colon cancer –both lesions reported on
staging imaging scans.
•69 years old woman with a primary rectal cancer and
synchronous sigmoid colon cancer (not seen at f-sig due to
poor preparation) –both lesions reported on staging imaging
scans.
Analysis 2: 796 patients who had CRC diagnosed at
colonoscopy:
48/796 have a significant 2nd finding (6.0%)
•24 had synchronous CRC (3.0%)/24 had a significant
polyp >20 mm (3.0%)
In these 48 cases, if F-sig was performed instead of colon,
what would have been the outcome?
•Only in one case would a significant lesion be missed.
72 years old man with a primary rectal cancer and a 30 mm
ascending colon polyp (not seen on staging CT scan).
•In the other 47 cases; staging CT scans pick up lesions
or metastases, or lesions are all left sided and would be seen
at F-sig, or lesions are all right sided and would not be seen
at f-sig, or missed lesion was a benign polyp.
Conclusions This is a large analysis of 1476 patients diagnosed
with CRC. Of the 796 diagnosed at colonoscopy, 6.0% had a
synchronous lesion (48 patients), 3.0% had a synchronous
CRC, only 1 patient would have had a missed lesion if they’d
had a f-sig alone. Of the 680 patients diagnosed with CRC at
f-sig, 230 had a colonoscopy (33.5%), the rest were precluded
due to advanced disease/obstruction or weren’t fit due to
advanced age/co-morbidity. Colonoscopy was undertaken at a
median of 15.0 days. The yield of identifying a synchronous
cancer at colonoscopy in this cohort is < 1%, in both cases
these lesions were reported on staging imaging scans.
British Society of Gastroenterology and ACPGBI guidelines
from 2019 suggest that in patients who are fit/suitable they
should undergo a surveillance colonoscopy at 12 months post
CRC diagnosis. Given the capacity issues affecting colonoscopy
services in the pandemic era, a proposed pathway for patients
diagnosed with CRC at sigmoidoscopy; if staging imaging
scans shows resectable CRC without synchronous lesion, is to
consider undergoing surgery and to utilise 12-month colono-
scopy to clear any adenomas. Alternatively CTC and CT
thorax could be utilised though capacity issues may limit this
approach. This data supports the consideration of alternative
approaches as the likelihood of a synchronous cancer not seen
at sigmoidoscopy and staging imaging scan appears to be very
low.
PTH-97 FIT IN THE POST-COVID-19 COLORECTAL PATHWAY –
ARE WE DOING IT RIGHT?
1
Hing Chi Kristie Leung*,
1
Preena Patel,
2
Edward Seward.
1
UCL Medical School, Faculty of
Medical Sciences, University College London, London, UK;
2
Endoscopy Department,
University College London Hospital, London, UK
10.1136/gutjnl-2021-BSG.300
Introduction During COVID-19 pandemic, national guidance
updated NG12 colorectal cancer (CRC) referral criteria to
incorporate Faecal Immunochemical Testing (FIT), previously
reserved only for patients on the low risk DG30 pathway.
Positive FIT results (10mg/g of faeces) in patients with color-
ectal symptoms would trigger a two week wait (2ww) referral
for urgent investigations. Otherwise, patients with ‘negative
FIT’were expected to be safety-netted but not investigated.
Patients with high-risk symptoms (i.e. NG12 compliant) could
be referred in the absence of FIT result. We wished to explore
how this change has affected referral patterns and whether
the new guidance was adhered to.
Methods We extracted 2ww colorectal referrals to University
College London Hospital from August to October 2020. Dem-
ographics, reason for referral, symptoms, investigations and
outcome were recorded. These values were compared between
patients who had FIT (FIT group) to those who did not (no
FIT group). Two-tailed t-test and Chi-squared test were used
to assess for significant difference between the two groups.
Results 522 referrals were received in the period examined,
92 were excluded as they were either repeat referrals or con-
tained insufficient clinical information. Of the remaining 420,
315 underwent FIT, although 37% of results were negative.
Of those with a positive FIT, 73% were NG12 compliant and
27% had neither NG12 nor DG30 symptoms. In the FIT neg-
ative group, 77% were NG12 compliant. 105 patients were
referred without FIT, of these 90% were NG12 compliant.
There was no significant difference in mean age (FIT 62 v no
Abstract PTH-96 Table 1
Colonoscopy after
f-sig
Number
(n)
Female
(n)
Male (n) Mean age
(years)
Median age
(years)
No 450 193 257
(57.1%)
73.2 75.5
Yes 230 77 153
(66.5%)
66.8 67.8
Colonoscopy only 796 320 476
(59.8%)
69.1 69.1
Abstracts
Gut 2021;70(Suppl 4):A1–A220 A161
on November 14, 2021 by guest. Protected by copyright.http://gut.bmj.com/Gut: first published as 10.1136/gutjnl-2021-BSG.300 on 7 November 2021. Downloaded from
FIT 62 years, p = 0.10) and gender (p = 0.41). Although
the differences did not reach significance, advanced pathology
in the FIT group was much higher, both in polyps 10mm
diameter (FIT 86% v no FIT 14%, p = 0.30) and CRC inci-
dence (FIT 4.5% v no FIT 1.0%, p = 0.19).
Conclusions Despite the challenges of managing clinical serv-
ices during a pandemic, our data demonstrates an increased
use of FIT in the colorectal pathway in line with updated
guidance. This is particularly encouraging as there was insuffi-
cient time for an adequate communication strategy. However,
a substantial proportion of patients were referred based on
FIT results with neither NG12 nor DG30 compliant symp-
toms; perhaps showing that FIT can potentially increase refer-
rals if used incorrectly. Some patients were referred with a
negative FIT and a preponderance of NG12 symptoms, possi-
bly indicating that clinical concern over traditional cancer
symptoms may prompt referral despite an objectively very low
cancer risk.
PTH-98 FAECAL IMMUNOCHEMICAL TEST, FAST SCORE OR
NG12 CRITERIA FOR DETECTION OF CANCER
1
Rigers Cama*,
1
Neel Kapoor,
1
Lefkothea Zacharopoulou,
1
Leila Mebarek,
1
Haroon Bhatti,
2
Philip Sawyer,
3
Bharat Patel,
1
Jonathan Landy.
1
Gastroenterology Dept, West Hertfordshire
Hospitals NHS Trust, Watford, WD18 0HB;
2
Parkbury House Surgery, Herts Valleys CCG, St
Albans, AL1 3HD;
3
Chemical Pathology Dept, West Hertfordshire Hospitals NHS Trust,
Watford, WD18 0HB
10.1136/gutjnl-2021-BSG.301
Introduction Studies have evaluated FIT in patients meeting
NG12 criteria suggesting greater accuracy for colorectal cancer
(CRC) detection. The FAST score (faecal-Hb, age and sex test
score) was proposed to improve the utility of fHb in the diag-
nosis of CRC. In 2019, Herts Valleys CCG instituted the use
of FIT for patients in primary care presenting with symptoms
meeting DG30 and some lower risk NG12 criteria (PPV
<3%), excluding those with higher risk symptoms of iron
deficiency anaemia (IDA), mass or rectal bleeding. We aimed
to evaluate the utility of FIT with NG12 referral criteria and
FAST score for the detection of CRC in our population.
Methods The medical records of all patients undertaking a
FIT sample with a minimum of 6 months follow up between
June 2019 and July 2020 were reviewed and cross referenced
with the trust cancer database. Other outcomes recorded
included inflammatory bowel disease and high-risk adenomas
(defined as polyps of 1cm, 5 polyps or high-grade dyspla-
sia). FIT analysis was performed using a single OC-Sensor ana-
lyser (Eiken Chemical Co., Tokyo, Japan). FAST scores (>
2.12 versus < 2.12) were calculated as previously described
by Digby et al. (2019). Sensitivity, specificity, predictive values
and numbers needed to investigate, were calculated using
MedCalc
®
statistical software.
Results 3460 patients returned a FIT sample. The median age
of population was 66 (IQR 56-76), with 57% being female.
1046 patients underwent any investigation with 701 patients
having full colonic evaluation. 22% had FIT >10 mg/g, 75%
had FAST score >2.12 and 59% met NG12 criteria. Sensitiv-
ity for CRC, in FIT, FAST group (> 2.12) and NG12 groups
was 94% (95% CI 84-99%), 100% (95% CI 93-100%) and
82% (95% CI 67-91%) respectively. Specificity for CRC was
83% (95% CI 82-84%), 25% (95% CI 24-27%) and 42%
(95% CI 40-43%) respectively. The number needed to investi-
gate to detect a patient with cancer was 16, 52 and 50 for
FIT >10 mg/g, FAST score >2.12 and NG12 criteria
respectively.
Conclusions FAST score >2.12 has the best sensitivity for
detection of cancer. However, the specificity is low and signif-
icantly more patients would require investigation. FIT >10
mg/g performed better than NG12 criteria.
PTH-99 FAECAL IMMUNOCHEMICAL TESTSFOR YOUNGER
PATIENTS PRESENTING WITH BOWEL SYMPTOMS
1
Lefkothea Zacharopoulou*,
1
Rigers Cama,
1
Neel Kapoor,
1
Leila Mebarek,
1
Haroon Bhatti,
2
Philip Sawyer,
3
Bharat Patel,
1
Jonathan Landy.
1
Gastroenterology Dept, West Hertfordshire
Hospitals NHS Trust, Watford, WD18 0HB;
2
Parkbury House Surgery, Herts Valleys CCG, St
Albans, AL1 3HD;
3
Chemical Pathology Dept, West Hertfordshire Hospitals NHS Trust,
Watford, WD18 0HB
10.1136/gutjnl-2021-BSG.302
Introduction Quantitative faecal immunochemical tests (FIT)
are recommended by NICE (DG30) guidelines for use in
patients with suspected colorectal cancer in primary care.
However, the utility of FIT in patients under the age of 50
versus the use of faecal calprotectin is unclear. In 2019, Herts
Valleys CCG instituted the use of FIT for patients over the
age of 40 years, presenting with symptoms meeting DG30
and some lower risk NG12 criteria, excluding those with
higher risk symptoms of iron deficiency anaemia (IDA), mass
or rectal bleeding. We aim to evaluate the accuracy of FIT
for significant bowel disease (SBD) in patients under 50 years
with those 50-59 and over 60 years in our population.
Methods The medical records of all patients undertaking a
FIT sample with a minimum of 6 months follow up between
June 2019 and July 2020 were reviewed. The outcome of
SBD (a composite of either colorectal cancer, inflammatory
bowel disease or high-risk adenomas (defined as polyps of
1cm, 5 polyps or high-grade dysplasia) was recorded. FIT
analysis was performed using a single OC-Sensor io analyser
(Eiken Chemical Co., Tokyo, Japan). The sensitivity, specificity,
predictive values and accuracy of FIT for SBD were assessed
for each age group. Fisher’s exact test was used to assess the
differences in sensitivity and specificity of FIT between
patients <50 and older age groups. MedCalc
®
statistical soft-
ware was used for all calculations.
Results 3460 patients with bowel symptoms undertook a FIT
sample. 132 patients had SBD. 13% of patients were <50
with a FIT result 10mg/g in 12%. 22% were 50-59 with a
FIT result 10mg/g in 16%. 65% were 60 with a FIT result
10mg/g in 26%. The sensitivity, specificity, PPV, NPV and
accuracy of a FIT result 10mg/g for patients 50-59 were
85% (CI 66 to 95.8%), 87% (CI 84 to 89%), 19% (CI
15.8% to 23%), 99.4% (CI 98.5% to 99.8%) and 87% (CI
84% to 89%) and for patients 60 years were 86% (CI 77
to 92%), 77% (CI 75 to 78.5%), 14% (CI 13 to 16%),
99.2% (CI 98.7% to 99.5%) and 77% (CI 75% to 79%).
The sensitivity, specificity, PPV, NPV and accuracy of a FIT
result 10mg/g for patients <50 years were 87.5% (CI 47 to
99.7%) p=1.0, 89% (CI 85.7 to 91.9%) p=0.35 and <0.01,
13% (CI 9 to 17.8%), 99.7% (CI 98.4 to 99.96%) and 89%
(CI 86 to 92%) respectively.
Conclusion FIT performed well for the detection of SBD in
all age groups with equivalent sensitivity between age groups
and improved specificity in younger age groups compared
with patients 60 years.
Abstracts
A162 Gut 2021;70(Suppl 4):A1–A220
on November 14, 2021 by guest. Protected by copyright.http://gut.bmj.com/Gut: first published as 10.1136/gutjnl-2021-BSG.300 on 7 November 2021. Downloaded from