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Lower GI - USC (2WW)

Checked: 13-02-2024 by 3 Vicky Ryan Next Review: 12-02-2025


From early 2023, the same Fast track suspected lower GI cancer pathway has been 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 page for further information on the qFit.

Who to Refer

Following the release of BSG guidance in May 2022 (1), qFIT is now used to stratify patients with symptoms that could be attributable to colorectal cancer.

This guidance has been adopted in BNSSG as follows;

Patients who do not require a FIT

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

  • 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
  • (see FAQ section for further information on why qFIT is required in patient with rectal bleeding)

Please see the FIT page for further information on FIT, including when to request a FIT for the “low risk but not no risk” cohort of patients.

Patients with a positive (>10) FIT with symptoms that could be attributable to CRC

These patients should be referred on a 2WW pathway for further investigation.

Patients where a FIT 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 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. Please make sure you select 2WW urgency for referrals on UHBW ICE

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

  • patient contact phone number
  • qFit result
  • whether the patient weighs over 120kg
  • capacity to consent to the procedure and fitness (can the patient turn unaided)
  • co-morbidities
  • infection – the presence of current infection is a contraindication 
  • current medication - iron tablets should be stopped if referring for colonoscopy
  • anticoagulation 
  • patient availability in the next two weeks.
  • (See FAQ section for information on the bowel prep question)

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 (see details in Resources section below). 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.


Why does the 2WW ICE form ask me to prescribe bowel prep? 

Bowel prep for 2WW lower GI referrals is dispensed by the hospital with information on how to take/low residue diet etc. The hospital also contact the patient before the procedure to discuss this with them as well as co-morbidities/medications. The primary care clinician is the prescriber of bowel prep and so should not refer the patient for a colonoscopy if they do not think this will be tolerated but the administration and counselling for this will be provided by the endoscopy department. Please see the following document for more information:

Lower GI Endoscopy; Guidance for Primary Care 

Why is a qFIT required in patients with rectal bleeding?

It feels counter intuitive but qFit is helpful for patients with rectal bleeding to guide whether a 2ww referral is required.

The patient information leaflet in the pack emphasises that the sample should be taken from an area of the stool where there is not visible surface blood. The test is looking for blood within the stool rather than picked up on the surface.

This was agreed in the BSG guidance that NHSE has mandated to be implemented (1).

If a patient has visible rectal bleeding, normal examination and qFit negative then their probability of having Cancer is significantly lower than 3% and so they should not be referred on a colorectal 2ww pathway unless you have other significant concerns. This isn’t to say that they don’t need an endoscopy, but that they don’t need a 2ww investigation. This is because qFit is a much better indicator of cancer risk than any symptoms.

If a patient has rectal bleeding and their qFit is positive then they should remain on a 2ww pathway to have a colonoscopy. There is no fast track flexible sigmoidoscopy option, as patients with a positive qFit require imaging of their whole colon. If a patient has a negative qFit and ongoing unexplained rectal bleeding, they can be referred for a routine/urgent flexible sigmoidoscopy.

Is a qFIT needed if a patient has recently had a test as part of the NHS Bowel screening program?

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

How can I make a direct to test referral if I don't have ICE access?

All referring clinicians should ensure they have ICE access in order to request diagnostic tests. If you are a locum, new to a practice or don't have access to ICE, then please contact your system administrator who should be able to set this up for you. If you still cannot access ICE then please use the 2WW referral form and send via eRS but state clearly on the referral that you are using this form due to lack of access to ICE.

Will waiting for FIT results cause a delay in patients getting appropraite investigations for cancer?

David Messenger writes: 'The lead time to do a qFIT will not significantly alter the course of the disease due to the speed at which colorectal cancer (CRC) progresses.

Negative predictive value for qFIT in rectal bleeding is 99.8% at 10ug cut off, i.e. only 0.2% of those with FIT<10 and rectal bleeding will have CRC. Hence, it is a good rule out test. (Hicks et al. Colorectal Disease 2021 - sub-group analysis of NICE FIT RCT).

In terms of proportion of those with rectal bleeding >50 years with CRC, you are essentially looking at the positive predictive value (PPV). This was defined in a study by Hamilton et al. (Br J Cancer 2005) who were part of the academic primary care group in Bristol. Their study was based on adults >40 years. PPV was 2.4% at first presentation and 6.8% at two or more presentations (hence the risk associated with 'persistent rectal bleeding'). These findings subsequently informed NICE guidance.

Rectal bleeding as a presenting feature of CRC accounts for 32% of all cases. In younger patients <50 years, this is closer to 50% and reflects the more distal nature of their disease.


(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)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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