Welcome to the North Bristol electronic straight to test 2 week wait colorectal pathway.  This pathway means GPs can book tests directly and we will track the patients internally as a 2 week wait.  This pathway has improved cancer performance and was shortlisted for a BMJ award. We have provided packs containing guidance. One contains information on why we have done this, how it has improved cancer performance and time to diagnosis.  This also contains more detailed information about the individual tests.  There is also a document just containing guidance as to what test is most appropriate for each patient based on symptoms and fitness. The third is a very quick  ‘how to’ guide showing what test to book for which symptom complex.  There is also a link to a patient information leaflet that we would be grateful of you downloaded and gave to your patient. This contains NBT contact numbers should they have any problems.  All tests whether endoscopy or radiology can be booked on ICE at http://ocs/icedesktop/

Download:

• Colorectal 2WW - Why and how.pptx457.4 KB
• Colorectal 2WW - Recommended tests for new NICE guidance.docx24.29 KB
• Colorectal 2WW - Quick reference how to guide.pptx58.5 KB

Patient Information

• The referenced media source is missing and needs to be re-embedded.

If you prefer not to book to a test or the patient has an abdominal or rectal mass then please book a clinic appointment via NHS eRferral.

Guidance on appropriate test

The below will help you to understand which is the appropriate test to book. More detail about each of the different tests are contained within the packs.

What Happens Next

The below table demonstrates what will happen following the GP making the query cancer referral. Essentially, if the test result shows cancer or significant non cancer abnormality then North Bristol NHS Trust will pick up the care of the patient and will proceed with possible treatment options. If the results are normal or show no significant abnormality then the care will remain with the GP, although appropriate advice and guidance will be provided.

What if your patient doesn't fulfil the criteria?

The ICE referral system is set up for patients who fulfil one of the NICE criteria. If your patient does not fulfill the criteria you will not be able to book them direct to test. However, these patients can be referred under the 2 week wait if you suspect that they may have cancer. Please refer these patients to a 2 week wait clinic via NHS eReferral.

If you have any questions or concerns about the pathway then please contact any member of the colorectal or endoscopy team.

Colorectal Cancer Nurse Specialists: 0117 4140557
Colorectal secretaries: 0117 4140828, 0117 4140838, 0117 4140835
Endoscopy: 0117 4145070

Advance Care Planning (ACP) is a process of often several voluntary discussions between an individual and any health care professional who knows them. Aspects of ACP may include:

• Discussing the individual’s understanding about their illness or prognosis
• Exploring the options available to them
• Identifying their wishes, preferences, priorities and concerns
• Refusing specific treatment , if they wish to
• Asking someone to speak for them if they are not able to do so
• Appointing someone to make healthcare decisions for them, using a Lasting Power of Attorney
• Letting people know their wishes for their future care

If the individual wishes, their family and friends may be included in the discussions. With the individual's agreement, this discussion should be recorded, regularly reviewed and communicated to key persons involved in their care.
Not everyone wishes to have conversations about these issues and there should be no obligation to do so.

Advance Statement (also known as Preferred Priorities for Care (PPC))
An advance statement is a written statement that allows a persons preferences, wishes, beliefs and values regarding their future care to be formally documented. The aim is to provide a guide to anyone who might have to make decisions in the persons best interest if they have lost the capacity to make decisions or to communicate them. An advance statement is not legally binding, but anyone who is making decisions about an individuals care should take it into account.

An Advance Decision to Refuse Treatment (ADRT)
An Advance Decision to Refuse Treatment (previously called a Living Will or Advance Directive) is different from a Statement of Wishes and Care Preferences as it is a formal, legally binding document or verbal statement which allows the refusal of certain medical treatments by an individual who is over 18 and has capacity to make the decision. It cannot be used to demand medical treatments which are not thought to be of benefit to the individual, request to have life ended or the refusal of basic essential care.  An Advance Decision to Refuse Treatment which includes reference to life sustaining treatment must be in writing. A compliant advance decision is as valid as a contemporaneous decision, that is, one made at that time. An Advance Decision to Refuse Treatment must exist, be valid and be applicable to the current circumstances.

Lasting Power of Attorney
A Lasting Power of Attorney is a legal document. It allows the individual (known as the donor) who has capacity, to appoint someone they trust as an ‘attorney’ to make decisions on their behalf. The circumstances under which attorneys can make decisions depends on the type of LPA.

There are two types of Lasting Power of Attorney.

1. Health and Welfare/ Personal Welfare Lasting Power of Attorney
This type of LPA may give the individual’s attorney(s) the right to make decisions on behalf of the individual e.g.

• medical care
• choosing place of care: moving into a care home etc.
• life-sustaining treatment
• daily care routine

This type of LPA only comes into force if the individual loses the ability to make decisions and is only valid once it has been registered with the Office of the Public Guardian.

2. Property and Affairs Lasting Power of Attorney
This type of LPA may give the individual’s attorney(s) the ability to make financial decisions for them e.g.

• pay their bills
• collect their benefits
• manage their bank accounts
• sell their property

The individuals attorney has the authority to take over the management of their financial affairs as soon as the LPA is registered with the Office of the Public Guardian, unless the LPA states that this can only happen if they lose mental capacity to manage their own affairs.

There are special rules about appointing a LPA. Please visit the website Office of the Public Guardian at www.gov.uk/office-of-public-guardian telephone 0845 330 2900.

Further information about Advance Care Planning
Planning Your Future Care - A Guide - This booklet provides an explanation about advance care planning and the different options available, visit www.nhs.uk/Planners/end-of-life-care/Pages/planning-ahead/advance-statement

Advance Statement (also known as Preferred Priorities for Care) - For further information and examples of documents to help write down preferences and wishes for the future, visit www.nhs.uk/Planners/end-of-life-care/Pages/advance-statement and www.westonhospicecaregroup.org.uk

Office of the Public Guardian - To help with protection of people who lack capacity, visit www.publicguardian.gov.uk

Making Decisions- A Guide - Information booklets about the Mental Capacity Act, visit www.dca.gov.uk/legal-policy/mental-capacity/mibooklets/booklet01.pdf

Advance Decision to Refuse Treatment - For further information visit www.nhs.uk/Planners/end-of-life-care/Pages/advance-decision-to-refuse-treatment and www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Advancedcancer/AdvanceDecision

Gold Standards Framework - Is an approach to optimising the care for patients nearing the end of life delivered by community health care teams. It is concerned with helping people to live well until the end of life and includes care in the final years of life for people with any end stage illness in any setting. visit www.goldstandardsframework.org.uk/patients-amp-carers

You may be able to get help to access these through your Community Nurse, GP or Hospital Specialist Nurse.

Reviewed on 20/10/21

Where can I find an information leaflet in English or in other languages?

Where can I find further information?

What if my baby is in NICU or a specialist hospital unit?

What happens to my baby's bloodspot card?

North Bristol NHS Trust Standing Orders, including Standing Financial Instructions and Scheme of Delegated Authorities.

NHS Trusts are required by law to make Standing Orders (SOs), which regulate the way in which the proceedings and business of the Trust will be conducted.

High standards of corporate and personal conduct are essential in the NHS. These “extended” Standing Orders, incorporating the Standing Financial Instructions (SFIs) and Scheme of Delegated Authorities (SoDA) identify who in the Trust is authorised to do what.

• The consolidated document provides a single source of the key rules under which the Trust is managed and governed.
• The regulations which determine the way that the Trust Board operates and the Trust is governed are spelt out in the Standing Orders.
• Financial responsibilities and authorities are described in the SFIs and SoDA
• All employees of the Trust need to be aware of their responsibilities and authorities described in this document.

Download:

Links to guideline and information resources

American Society of Hematology

British Society of Blood and Marrow Transplantation

British Society of Haematology

European Hematology Association

National Institute for Health and Clinical Excellence

National Cancer Research Institute

Royal College of Pathologists

World Health Organisation

Sources of information for patients

Lymphoma Association

Macmillan Cancer

Myeloma UK

This statement outlines the purpose and functions of the Haemato-Oncology Diagnostic Service at North Bristol NHS Trust.

• The service is a collaboration by components of the department of haematology, immunology, cellular pathology and genetics. The collaboration is necessary to provide an integrated diagnostic and reporting service for leukaemia, lymphoma and other haematological neoplasms. The service will meet or exceed the criteria outlined in the NICE Improving Outcomes Guidance for Haematological Cancers, 2004. The service will accept samples for initial diagnosis, assessment of prognostic factors, assessment of relapse and assessment of minimal residual disease.
• The service will develop to provide the following components a) Single specimen reception b) Single request form c) Integrated report d) Specialized IT system to link diagnostic sections and integrate reports e) SOP for systematic testing defining order and choice of tests f) SOP for standardised reporting terminology g) Website/user handbook to provide information about the service h) Tissue banking
• A steering group to manage and direct the development of the service
• A scientific group to provide support to diagnostic review meeting and clinical MDTs. This group provides advice on developing new investigations and investigative pathways and investigative modalities.
• The service will support education of scientific and medical staff.
• The service will support laboratory and clinical research projects.
• The service will receive samples from local and distant clinical services for complete or partial diagnostic investigation.

Internal quality assurance

Standard operating procedures are used for diagnostic investigation and consistent reporting. BHODS uses the following approaches to maintain quality of sample processing and results reporting.

A SOP dealing with for registration of patient details, clinical information and recording of samples received.

A SOP by tissue type for initial and subsequent investigation panels.

A SOP for reporting and authorisation.

A SOP based on the WHO 2017 classification gives the diagnostic standards for haematological malignancies. It identifies the disease to be diagnosed, ICD / SNOMED code, relevant prognostic factors and any differences from the WHO criteria in making the diagnosis if appropriate.

Interim reports may be issued when the diagnosis is made but additional information such as that required for prognosis is pending Interim reports will be finalised with a “Final report” and any corrections to a final report will be amended with an “addendum” report.

A typical, unusual or rare cases will be independently checked before authorisation and report issue.

SOP's are reviewed annually and are in line with those of other similar diagnostic services.

Trusts sending samples to BHODS are offered regular input for clinical MDT meetings Laboratory IT systems are used to check reporting accuracy, reporting concordance and reporting times.

The process of multidisciplinary investigation of Haematological Malignancy will result in a small number of cases where either diagnostic modalities or reporting clinicians are unable to define a single unifying diagnosis. These cases are subject to multi-disciplinary review within NBT SIHMDS Diagnostic Review Meeting.

The service has target turnaround times for investigative processes. The majority of cases will be dealt within the target times but in some situations it may prove impossible to meet these by reason of technical or complicated diagnostic pathways.

Bristol Haemato-Oncology Diagnostic Service Reporting Times

1. Includes haematological morphology, immunophenotyping and trephine histopathology

2. Includes lymph node morphology and immunohistochemistry

3. Where supplementary tests are required the target reporting times are as detailed below

Haematological morphology

Immunophenotyping

Histopathology

Cytogenetics

Molecular Pathology

Investigative techniques: Morphology/Cytology
Consideration of the clinical information, blood count results and conventional light microscope morphology of marrow or blood helps to determine the most appropriate panel of investigations form a number of techniques.

Investigative techniques: Flow Cytometry
Provides a method of rapidly enumerating and characterising the antigen expression of cells in suspension using a panel of antibodies labelled with florochromes.

In the haematopathlogy field the technology can be used to distinguish chronic lymphoproliferative disorders and separate these from reactive states; define acute leukamias, identify prognostic markers and monitor minimal resisdual disease; count specific cells types and identify condition associated with aberrant antigen expression.

Investigative techniques: Histopathology
The assessment of fixed tissue prepared as tissue sections is used for the examination of lymph nodes, marrow trephines as well as potential tumours from any body site. Histopathology of lymph nodes is the best method to diagnose and classify lymphoma. Fresh node sent to the laboratory allows the use of flow cytometry to facilitate the diagnosis. Frozen, fixed or paraffin embedded can be assessed by morphology and immunohistochemistry. If appropriate clonality of lymphoid populations can be assessed by IgH and TCR gene rearrangement or FISH on paraffin embedded tissue can identify characteristic chromosome translocations.

Investigative techniques: Cytogenetics
Conventional cytogenetics requires the culture of cells to provide metaphases. For this reason it takes longer to produce results than some other technologies but is a well-established technique able to provide results that are critical in the classification and prognostication of haematological disorders.

Investigative techniques: Fluorescence in-situ hybridisation (FISH)
FISH provides a method to identify changes that help define or provide prognostic information for lymphoid and myeloid disorders. The ability to use metaphase or interphase preparations is powerful and results are confirmed by subsequent conventional assessment whenever possible.

Investigative techniques: Molecular Genetics
The use of sensitive molecular techniques to assess DNA and RNA provide important and evolving tools. A range of techniques may be used for identifying mutations or molecular markers for diagnosis, prognosis and monitoring response to therapy and remission status. Examples of technologies used are qualitative and quantitative polymerase chain reaction assays, fragment analysis, methylation assays, and direct sequencing. Increasingly molecular ghenetic tests are moving across to next generation sequencing (NGS) technologies which allow the parallel investigation of multiple genes at increased sensitivity and resolution.

Investigative techniques: Whole Genome Analysis (WGA)
Following on from the 100K Genomes Project patients with acute leukaemia or any childhood patient with an Haematological cancer will be able to access WGA.  WGA is an incredibly powerful technique which uses NGS to enable the simultaneous investigation of molecular genetic, FISH and cytogenetic diagnostic targets in a single, high resolution, assay.  WGA requires simultaneous assessment of tumour (somatic) and normal (germline) material and therefore provides the additional benefit of identifying germline changes which may be contributing to the patient’s clinical presentation or have implications for treatment and management.