STEP 2: Presentation, initial investigations and referral
The following signs, symptoms and results should be investigated:
- positive iFOBT
- passage of blood with or without mucus in the faeces
- unexplained iron deficiency anaemia
- change in bowel habit (loose stools or constipation), especially a recent one that does not have another explanation such as an infection or opioids
- undiagnosed abdominal pain or tenderness
- unexplained rectal or abdominal mass
- unexplained weight loss (Cancer Council Australia Colorectal Guidelines Working Party 2019)
- lethargy.
The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of colorectal cancer.
Presenting symptoms should be promptly and clinically triaged with a health professional.
General practitioner examinations and investigations should include:
- physical examination
- digital rectal examination
- full blood examination and iron studies (Cancer Council Australia Colorectal Guidelines Working Party 2019).
Note: a negative result from an iFOBT does not exclude cancer.
A detailed family history should be obtained from patients presenting with possible symptoms of colorectal cancer.
Test results should be provided to the patient within one week of testing.
All patients referred for colonoscopy should be seen by a specialist accredited in colonoscopy by the Conjoint Committee of the Royal Australasian College of Surgeons, Royal Australasian College of Physicians and Gastroenterological Society of Australia) to make the diagnosis.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral for suspected or diagnosed colorectal cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
If a pathological (or endoscopic) diagnosis has been made, the patient should be referred to a general or colorectal surgeon affiliated with (or with access to) a multidisciplinary team. Some early cancers can be managed by endoscopy alone without surgical consultation but should also be considered by a multidisciplinary team.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
If symptoms suggest colorectal cancer, patients should be referred and a colonoscopy completed within four weeks of the general practitioner referral.
Patients should be seen by the surgeon within two weeks of the general practitioner referral following a positive diagnosis of colorectal cancer via colonoscopy. Patients should bring a copy of the colonoscopy report and other relevant medical and psychosocial history.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties
- management of physical symptoms including pain, fatigue and altered bowel function
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).
For more information refer to the NICE 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
- supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
