International Journal of Colorectal Disease

, Volume 28, Issue 11, pp 1531–1534 | Cite as

The Two-Week Referral System for colorectal cancer—not fit for purpose

  • Robert T. PadwickEmail author
  • Adeel A. Bajwa
  • Annabel Shaw
  • Edmund Leung
  • James Francombe
  • Michael L. Stellakis
Original Article



The UK government target expects all suspected colorectal cancer (CRC) patients to be seen within the Two-Week Referral (TWR) system made by general practitioners. These guidelines originally derived from only level 5 evidence. However, this has significant impact on the workload for colorectal surgeons. The aim of the study is to investigate the effectiveness of this colorectal service and whether the referral criteria are predictive of CRC.


A retrospective study of all patients referred under the TWR guidance in 2010 was assessed. The first 573 TWRs were piloted for analysis. Clinical information from each patient was collected regarding TWR criteria and additional colorectal symptoms or risk factors. Multiple regression analysis was performed to determine which symptoms independently correlated with CRC.


One hundred twenty-six CRCs were diagnosed via all methods of referral in 2010. There were 940 patients referred under the TWR guidelines in that year, when 50 CRC patients were identified. Amongst the 573 patients, 32 CRCs were diagnosed. Multiple regression analysis revealed tenesmus to be independently associated with CRC (p = 0.003, Pearson’s r = 0.09185). None of the individual TWR criteria confidently predicted CRC.


Our preliminary results suggest that the current TWR guidelines cannot effectively predict CRC. There is an urgent need for an evidence-based approach to referral criteria for suspected CRC.


Two-week referral Fast-track referral Colorectal cancer Referral criteria Presentation 


  1. 1.
    Department of Health (2000). Referral guidelines for suspected cancer. Accessed 8 June 2012
  2. 2.
    Chohan DP, Goodwin K, Wilkinson S, Miller R, Hall NR (2005) How has the ‘two-week wait’ rule affected the presentation of colorectal cancer? Colorectal Dis 7:450–453PubMedCrossRefGoogle Scholar
  3. 3.
    Greenlee RT, Murray T, Bolden S, Wingo PA (2000) Cancer statistics, 2000. CA Cancer J Clin 50:7–33PubMedCrossRefGoogle Scholar
  4. 4.
    National Institute of Clinical Excellence (2005). NICE Guideline 27—referral guidelines for suspected cancer. Accessed 6 June 2012
  5. 5.
    Flashman K, O’Leary DP, Senapati A, Thompson MR (2005) The Department of Health’s “two week standard” for bowel cancer: is it working? Gut 53:387–391CrossRefGoogle Scholar
  6. 6.
    Leung E, Grinager J, Bandla N, Wong L (2010) The effectiveness of the “2-week wait” referral service for colorectal cancer. Int J Clin Pract 64:1671–1674PubMedCrossRefGoogle Scholar
  7. 7.
    Thorne K, Hutchings HA, Elwyn G (2006) The effects of the Two-Week rule on NHS colorectal cancer diagnostic services: a systematic literature review. BMC Health Serv Res 6:43PubMedCrossRefGoogle Scholar
  8. 8.
    Eccersley AJ, Wilson EM, Makris A, Novell JR (2003) Referral guidelines for colorectal cancer—do they work? Ann R Coll Surg Engl 85:107–110PubMedCrossRefGoogle Scholar
  9. 9.
    Jones R, Rubin G, Hungin P (2001) Is the two week rule for cancer referrals working? BMJ 322:1555–1556PubMedCrossRefGoogle Scholar
  10. 10.
    Smith RA, Oshin O, McCallum J, Randles J, Kennedy S, Delamere S, Rooney PS, Carter PS (2007) Outcomes in 2748 patients referred to a colorectal two-week rule clinic. Colorectal Dis 9:340–343PubMedCrossRefGoogle Scholar
  11. 11.
    Selvachandran SN, Hodder RJ, Ballal MS, Jones P, Cade D (2002) Prediction of colorectal cancer by a patient consultation questionnaire and scoring system: a prospective study. Lancet 360:278–283PubMedCrossRefGoogle Scholar
  12. 12.
    Debnath D, Dielehner N, Gunning KA (2002) Guidelines, compliance, and effectiveness: a 12 months’ audit in an acute district general healthcare trust on the two week rule for suspected colorectal cancer. Postgrad Med J 78:748–751PubMedCrossRefGoogle Scholar
  13. 13.
    Barwick TW, Scott SB, Ambrose NS (2004) The two week referral for colorectal cancer: a retrospective analysis. Colorectal Dis 6:85–91PubMedCrossRefGoogle Scholar
  14. 14.
    Shaw AG, Simpson J, Tierney G, Goddard AF, Reynolds JR, Lund JN (2008) Referral of patients with iron deficiency anaemia under the lower gastrointestinal two-week wait rule. Colorectal Dis 10:294–297PubMedCrossRefGoogle Scholar
  15. 15.
    Rai S, Kelly MJ (2007) Prioritization of colorectal referrals: a review of the 2-week wait referral system. Colorectal Dis 9:195–202PubMedCrossRefGoogle Scholar
  16. 16.
    NHS Improvement (2009) Going further on cancer waits: the symptomatic Breast Two Week Wait Standard. Accessed 9 Aug 2012

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Robert T. Padwick
    • 1
    Email author
  • Adeel A. Bajwa
    • 1
  • Annabel Shaw
    • 2
  • Edmund Leung
    • 3
  • James Francombe
    • 1
  • Michael L. Stellakis
    • 1
  1. 1.Department of Colorectal SurgerySouth Warwickshire Hospitals NHS Foundation TrustWarwickUK
  2. 2.Department of General SurgeryWorcestershire Acute Hospitals NHS TrustWorcesterUK
  3. 3.Department of Colorectal SurgeryUniversity Hospitals Coventry and Warwickshire NHS TrustCoventryUK

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