Changes

August 2025 — reviewed. This topic is a direct implementation of the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral. 

Update

Goals

To support primary healthcare professionals to:

• Recognize symptoms suggestive of lower gastrointestinal cancers.
• Refer people with suspected lower gastrointestinal cancers within the appropriate timescales.
• Offer appropriate patient information and support for people with suspected cancer.

Outcome measures

No outcome measures were identified for this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

NICE quality standards

Suspected Cancer

• GPs have direct access to diagnostic endoscopy, ultrasound, MRI, X-ray and CT for people with suspected cancer.
• People presenting in primary care with symptoms that suggest oesophageal or stomach cancer have an urgent direct access upper gastrointestinal endoscopy.
• Adults presenting in primary care with symptoms that suggest colorectal cancer, who do not meet the referral pathway criteria, have a test for blood in their faeces.
• People with suspected cancer who are referred to a cancer service are given written information encouraging them to attend.

[NICE, 2021]

Presentation

• Colorectal cancer:
  • Several symptoms have been reported, the most common being diarrhoea, constipation (sometimes referred to as ‘change of bowel habit’), rectal bleeding, loss of weight, and abdominal pain.
  • Colorectal cancer may present with anaemia, particularly iron-deficiency anaemia.
  • These features of colorectal cancer can also be present in other cancers, especially intra-abdominal ones.
  • The symptoms of colorectal cancer may also be misdiagnosed as non-malignant conditions, such as irritable bowel disease. A number of methods of diagnosing colorectal cancer are available.
  • Colonoscopy is considered to be the gold standard diagnostic test, though some clinicians offer flexible sigmoidoscopy to selected patients with rectal bleeding. Both these methods allow biopsy.
  • CT colonography is increasingly used for those unfit for colonoscopy, but does not include biopsy.
  • These diagnostic tests can be performed with the GP retaining clinical responsibility.
• Anal cancer:
  • Anal cancer is generally considered separately from colorectal cancer. The histology is different, with almost all being squamous cell cancers.
  • Several symptoms have been reported, including anal pain, tenesmus, and rectal bleeding.
  • Diagnosis is generally made by direct visualization (proctoscopy/sigmoidoscopy) and biopsy.
  • Some GPs perform proctoscopy, but biopsies are performed in secondary care.

[NICE, 2025]

How common is it?

• Colorectal cancer:
  • Around 40,000 new colorectal cancers are diagnosed each year in the UK, up to a quarter of these following screening.
  • A full-time GP is likely to diagnose approximately one person with colorectal cancer every year.
• Anal cancer:
  • Just over 1000 new anal cancers are diagnosed each year in the UK, meaning that a full-time GP is likely to diagnose approximately 1–2 people with anal cancer during their career.
  • Anal cancer occurs in both sexes, though nearly two-thirds occur in women.

[NICE, 2025]

What is the prognosis?

• Colorectal cancer:
  • The 5-year survival is approximately 60%, though this figure includes cancers detected by screening as well as those identified after symptoms have occurred.
• Anal cancer:
  • The 5-year survival is around 60%.

[NICE, 2025]

What symptoms are suggestive of gastrointestinal tract (lower) cancers?

Table 1. Symptoms suggestive of gastrointestinal tract (lower) cancers.

When should I offer faecal immunochemical testing (FIT)?

• Offer quantitative faecal immunochemical testing (FIT) using HM-JACKarc or OC-Sensor to guide referral for suspected colorectal cancer in adults:
  • With an abdominal mass, or 
  • With a change in bowel habit, or
  • With iron-deficiency anaemia, or 
  • Aged 40 years and over with unexplained weight loss and abdominal pain, or 
  • Aged under 50 years with rectal bleeding and either of the following unexplained symptoms:
    • Abdominal pain.
    • Weight loss, or
  • Aged 50 years and over with any of the following unexplained symptoms:
    • Rectal bleeding.
    • Abdominal pain.
    • Weight loss, or
  • Aged 60 years and over with anaemia even in the absence of iron deficiency.
• Consider if people need additional help, information or support to return their sample. 
• Offer FIT even if the person has previously had a negative FIT result through the NHS bowel screening programme.
  • People with a rectal mass, an unexplained anal mass or unexplained anal ulceration do not need to be offered FIT before referral is considered.
• Refer adults using a suspected cancer pathway referral for colorectal cancer if they have a FIT result of at least 10 micrograms of haemoglobin per gram of faeces. 
• For people who have not returned a faecal sample or who have a FIT result below 10 micrograms of haemoglobin per gram of faeces:
  • Ensure safety netting processes are in place.
  • Do not delay referral to an appropriate secondary care pathway if there is a strong clinical concern of cancer because of ongoing unexplained symptoms (for example, abdominal mass).

Scenario: Referral for suspected gastrointestinal tract (lower) cancer

From birth onwards.

Search strategy

Scope of search

A full literature search was not conducted as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral.

Search dates

August 2020 - August 2025

Key search terms

A full literature search was not conducted as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.