Are “Straight to Test” Pathways Always Best for Patients? A Prospective Observational Study of Two-Week-Wait Colorectal Referrals

Abstract

Aim: Many centres have adopted a straight to test approach to deliver a fast-track service for suspected lower GI cancer. We undertook a prospective comparison between patients having a straight to test (STT) flexible sigmoidoscopy and those attending an outpatient appointment (OPA). The study aimed to determine whether STT reduced diagnostic time without additional investigations. Methods: An observational study of 200 consecutive fast-track colorectal referrals was undertaken. Data collected included: patient demographics, whether STT or OPA, investigations undertaken (including dates) and final diagnosis. Outcomes were compared by adjusted linear regression and logistic regression, for numerical and binary outcomes respectively. Potential confounding factors included were: age, gender and whether NICE referral criteria were achieved. Results: 186 out of 200 referrals attended their appointment, 62% (116/186) went STT and 38% (70/186) had an OPA. No significant difference was seen in the number of days to final investigation, adjusted coefficient - 3.71, 95% C.I. -8.92 to 1.50. The STT group had 0.4 more tests per patient, adjusted 95% C.I. 0.07 to 0.73, than the OPA group. Significantly more patients in the STT group had a flexible sigmoidoscopy in addition to whole colonic imaging (all modalities), compared to the OPA group, adjusted OR of 93.47 (95% C.I. 29.26 to 298.54). Conclusion: This study highlights the potential disadvantages of STT flexible sigmoidoscopy for patients referred under the two-week-rule with suspected lower GI cancer. Despite the previously published work highlighting the potential cost and time benefits, it may come at the sacrifice of exposing patients to additional investigations.