Shaping better health
REMEDY : BNSSG referral pathways & Joint Formulary

Lower GI - 2WW

Checked: 06-01-2023 by vicky.ryan Next Review: 05-01-2024


**Please note: Go live on ICE is planned for UHBW on Monday the 9th and for NBT on Monday the 16th January 2023**


The same Fast track suspected lower GI cancer pathway is now in use at NBT, BRI and WGH.

The majority of patients should be referred using the ICE suspected cancer straight to test (STT) pathway, where they will be booked for either colonoscopy, CT colonography or a CT abdomen/pelvis with or without contrast depending on their co-morbidities and age.

Please ensure that a full clinical assessment and appropriate initial tests are done in primary care before referral.

See also the FIT test page for further information on the qFit test.

The qFIT test requested for patients with symptoms has a much lower threshold for a positive result from the qFit test done as part of the routine NHS Bowel screening program (10 μgHb/g vs 120 μgHb/g for a positive result) and as such a negative bowel screening test does not remove the need to repeat a qFit test for a symptomatic patient.

Who to Refer

Following the release of BSG guidance in May 2022 the pathways for patients with suspected colorectal cancer have been changed, with the extension of the use of qFIT to risk stratify patients with symptoms that could be attributable to colorectal cancer.

This guidance has been partially adopted in BNSSG as follows;

Patients who do not require a FIT test

Patients with an unexplained rectal or anal mass or unexplained anal ulceration should be referred on the Suspected Lower GI Cancer referral form via eRS

Patients with an unexplained abdominal mass should be referred straight to CT using the colorectal 2ww referral pathway on ICE

Patients over 60 with an unexplained Iron-deficiency anaemia should be referred straight to test on ICE (actual test to depend on patient fitness)

Patients who require a FIT test

  • Aged 40 and over with unexplained weight loss and abdominal pain
  • Aged 60 and over with changes in bowel habit
  • Aged 50 and over with unexplained rectal bleeding
  • Aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, iron-deficiency anaemia

Please see the FIT test page for full details and referral action based on results

Patients where a FIT test is not possible, or a GP has significant concerns about malignancy, but cannot refer via ICE

2WW referral can be submitted via e-RS using the Suspected Lower Gastro-Intestinal Cancer Referral Form. Please free text concerns on the 2WW form making it clear why ICE referral is not possible or not appropriate.

If advised to refer into MDT, then please submit a 2WW referral to the relevant secondary care team who will ensure that all the required information is available to enable an effective MDT discussion. 

Ongoing symptoms after colorectal investigation

If a qFit is positive and the secondary care investigative test is negative indicating no colorectal cancer then secondary care advice is not to repeat the qFit or re-refer on a colorectal 2ww pathway (assuming investigative test performed has been of adequate quality as noted by the endoscopist/radiologist).

As per those patients who are qFit negative consider other potential causes of the patient’s symptoms and if there is ongoing concern, then the patient can be referred on routine or urgent pathway for further assessment. Please see the FIT Test page for information on suggested next steps.


At time of referral please issue the BNSSG Understanding Your Urgent Fast Track Referral patient information leaflet.

Referrals on ICE

Patients with symptoms meeting the 2WW criteria should be referred direct to test on ICE unless exclusions apply.

2WW direct to test is available for colonoscopy, CT colonoscopy and CT Abdomen and Pelvis. The ICE form will direct you towards the most appropriate test for you patient. 

Referral Tip - Use search term '2WW' to find the available options and select appropriate test.

Before starting the ICE referral it is useful to gather the following information to avoid the frustration of having to come out of ICE in order to find it

  • contraindications for colonoscopy
  • capacity to consent to the procedure
  • patient fitness – can the patient turn unaided 
  • co-morbidities - If diabetic or hypertensive a recent eGFR will be required
  • infection – the presence of current infection is a contraindication 
  • current medication - iron tablets should be stopped.
  • anticoagulation 
  • patient contact phone number
  • patient availability in the next two weeks.

If patients are not suitable for direct to test they can be referred using ERS to the suspected colorectal cancer clinic using the Suspected Lower Gastro-Intestinal Cancer Referral Form Referrals to NBT - Please note: This service is moving to a RAS at NBT (2WW Suspected Colorectal Malignancies) from 23/01/23. Therefore, you need to select 'send for triage' in eRS rather than selecting a date and time for dummy appointment.

Please free text concerns on the 2WW form making it clear why ICE referral is not possible or not appropriate for example frailty, unable to tolerate bowel prep, learning difficulties.

Colonoscopy: the clinician will also be asked to agree to be the prescriber of the bowel preparation which will be dispensed by the Hospital. As sedation and analgesia will be used it is essential that the patient has someone at home the evening of the procedure. Primary Care Guidance on Bowel Prep

CT Colonoscopy (CTC) is less invasive and the bowel prep less aggressive so this is a more appropriate investigation for frail or elderly patients. However, note that this investigation is not sensitive to picking up lesions at the ano-rectal junction and so please ensure that a rectal PR examination has been carried out. If polyps are identified another referral will be needed to arrange their removal.

The NBT lower GI team ask that when making a referral please be sure to give the patient the  NBT suspected bowel cancer patient information leaflet regards the referral process.


(1) Faecal Immunochemical Testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC) - The British Society of Gastroenterology

NICE lower GI tract cancer guidelines(2015) 

CKS Summary (2017).

SWAG Cancer Alliance Primary and Secondary Care Guidance Lower GI 2WW Pathway during COVID-19 (March 2021)

Advice to local systems on triaging patients with lower gastrointestinal symptoms (NHSE / NHSI)