Family Practice 2012; 29:182–188 Ó The Author 2011. Published by Oxford University Press. All rights reserved.

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Advance Access published on 5 October 2011

Assessment of a rapid referral pathway for

suspected colorectal cancer in Madrid
Beatriz Valentı́n-Lópeza,*, Juan Ferrándiz-Santosb, Juan-Antonio
Blasco-Amaroa, Juan-Diego Morillas-Sáinzc and Pedro Ruiz-Lópezd
a
Health Technology Assessment Unit (UETS), Agencia Laı́n Entralgo, Madrid, bDepartment of Quality Assurance, Regional
Health Care Services, Madrid, cDepartment of Gastroenterology, Hospital Clı́nico San Carlos, Madrid and dQuality Assessment
Unit, Hospital Universitario 12 de Octubre, Madrid, Spain.
*Correspondence to Beatriz Valentı́n-López, Health Technology Assessment Unit, Agencia Lain Entralgo, Gran Vı́a 27, 7a planta,
28013 Madrid, Spain; E-mail: beatriz.valentin@salud.madrid.org
Received 8 July 2011; Revised 16 August 2011; Accepted 30 August 2011.

Objective. To assess the results achieved with a rapid referral pathway for suspected colorectal

Downloaded from http://fampra.oxfordjournals.org/ by guest on October 11, 2013

cancer (CRC), comparing with the standard referral pathway.
Methods. Three-year audit of patients suspected of having CRC routed via a rapid referral path-
way, and patients with CRC routed via the standard referral pathway of a health care district serv-
ing a population of 498 000 in Madrid (Spain). Outcomes included referral criteria met, waiting
times, cancer diagnosed and stage of disease.
Results. Two hundred and seventy-two patients (mean age 68.8 years, SD 14.0; 51% male) were
routed via the rapid referral pathway for colonoscopy. Seventy-nine per cent of referrals fulfilled
the criteria for high risk of CRC. Fifty-two cancers were diagnosed: 26% Stage A (Astler–Coller),
36% Stage B, 24% Stage C and 14% Stage D. Average waiting time to colonoscopy for the rapid
referral patients was 18.5 days (SD 19.1) and average waiting time to surgery was 28.6 days (SD
23.9). Colonoscopy was performed within 15 days in 65% of CRC rapid referral patients com-
pared to 43% of standard pathway patients (P = 0.004). Overall waiting time for patients with
CRC in the rapid referral pathway was 52.7 days (SD 32.9); while for those in the standard path-
way, it was 71.5 days (SD 57.4) (P = 0.002). Twenty-six per cent Stage A CRC was diagnosed in the
rapid referral pathway compared to 12% in the standard pathway (P < 0.001).
Conclusion. The rapid referral pathway reduced waiting time to colonoscopy and overall waiting
time to final treatment and appears to be an effective strategy for diagnosing CRC in its early
stages.
Keywords. Colorectal cancer, early detection of cancer, rapid referral, waiting times.

Introduction a diagnosis rapidly for patients in whom CRC is sus-

Colorrectal cancer (CRC) is the second most common
form of cancer in the majority of developed countries;
only lung cancer causes more cancer-related deaths.
In Europe, 413 000 estimated cases of CRC were
diagnosed in 2006—some 12.9% of all cancers newly
diagnosed—and 207 400 people died of this disease.1,2
In Spain, CRC is also the second most important neo-
plasm with 22 000 new cases being diagnosed every
year. In 2007, it caused 13 495 deaths. Although the in-
cidence of CRC in Spain and its associated mortality
are lower than the average figures for Europe, mortal-
ity is higher than in France, Italy and the UK, and inci-
dence appears to be increasing over time (mean annual
increase 2.6% for men and 0.8% for women).3,4
Disease stage at the time of diagnosis is the most im-
portant factor determining patient survival.5–7 Reaching
pected, and reducing diagnosis-to-treatment times is
a priority of all health systems. However, controversy
exists regarding the effectiveness of pathways designed
to shorten the waiting time to treatment.8
In August 2004, a rapid referral pathway between
primary and specialized care in a Madrid (Spain)
health care district was introduced for patients sus-
pected of having CRC.9 In line with similar ven-
tures,5,10–15 the goal of this pathway was that such
patients should undergo colonoscopy within 15 days.
The aim of the present work was to assess the re-
sults achieved with this rapid referral pathway over
the first 3 years of its functioning. The waiting times
to diagnosis and treatment, and the stage of disease
at diagnosis in patients finally diagnosed with CRC,
are compared with figures for the standard referral
pathway.

182
 Rapid referral pathway for CRC
Methods
This study included all patients who entered a rapid
referral pathway for suspected CRC in a Madrid
health care district (serving 498 000 people in the
southeast Madrid area) between August 2004 and
October 2007.
The rapid referral pathway between primary and spe-
cialized care in a Madrid health care district included
patients suspected of having CRC seeking advice from
a GP. All patients meeting some high-risk criterion for
CRC (Table 1) were routed via the rapid referral path-
way ideally in order to undergo colonoscopy within
15 days. The sequential implementation of the rapid re-
ferral pathway was done in two phases: 97 GPs from 10
primary health care centres were in first phase, and 315
GPs from 28 primary health care centres were finally
included in the second one. The rapid referral pathway
allows direct referral of patients for colonoscopy with-
out the need of a specialist consultation and reducing
the delay of CRC diagnosis. In both phases, there were
six specialists performing the referred colonoscopies at
the district’s tertiary hospital.
The rapid referral pathway was developed and coor-
dinated by a committee consisting of hospital and pri-
mary care managers and specialists involved in the
health care process. To improve the compliance with
the rapid referral pathway, the high-risk criteria for
CRC were actively disseminated through educational
meetings and brief reminders for GPs participating in
the process. In each primary health care centres, a co-
ordinator of the referral pathway, in continuous com-
munication with the specialist involved at the hospital,
was appointed. Standardized documentation and data
registry were also implemented to ensure the referral
criteria compliance.
In the study, the sociodemographic data of all pa-
tients were recorded prospectively in a database, as
well as their symptoms and signs of disease, the refer-
ral criteria, the results of colonoscopy, the waiting
TABLE 1 CRC high-risk symptoms and signs
All ages Palpable mass in the right hemiabdomen
Rectal tumour detected during manual
exploration
Rectal bleeding associated with changes in bowel
habits (increased number of defecations
and/or reduced stool consistency) lasting >4
weeks
Unexplained ferropenic anaemia (Hb < 11 g/dl in
men and Hb < 10 g/dl in postmenopausal
women)
CRC strongly suspected given prior imaging
results
Patients >50 Recent changes in bowel habits (increased
years of age number of defecations and/or reduced stool
consistency) lasting >6 weeks
Persistent rectal bleeding with associated anal
symptoms lasting over 3 weeks
183
times between stages of assistance and the stage of dis-
ease and surgery performed in patients finally diag-
nosed with CRC. The results for these patients were
compared to those of patients also diagnosed via colo-
noscopy but who were referred through the district’s
standard referral pathway. The data for the latter
pathway were recorded retrospectively via the exami-
nation of the patients’ clinical records.
A descriptive analysis was made of the results ob-
tained with the rapid referral pathway: referral criteria
met, waiting times, number of cancers diagnosed, en-
doscopic polypectomies performed, surgery for CRC
and the stage of disease at surgery. The waiting times
recorded (in days) were those between the request for
colonoscopy made by the GP and its performance by
a specialist (waiting time to colonoscopy), that be-
tween firm diagnosis and surgery (waiting time to sur-
gery) and the overall delay to surgery (waiting time
between the request for colonoscopy by GP until sur-
gery including any time required for anatomopatho-
logical diagnosis). The target waiting times for the
rapid referral pathway were: <15 days waiting time to
colonoscopy, <30 days waiting time to surgery and
<90 days overall waiting to surgery. These target wait-
ing times were established from those recorded as de-
sirable in the literature.5,6,16,17
The waiting times and disease stage at diagnosis for
the two pathways were compared by analysis of vari-
ance and the chi-square test as required. Significance
was set at P < 0.05.
Results
A total of 272 patients were referred via the rapid re-
ferral pathway during the study period; 51% (138)
were male; the average age of patients was 68.8 years
(SD 14.0 years). The study involved the participation
of 28 primary care centres and 315 GPs belonging to
the selected health care district, together with six colo-
rectal specialists at the district’s tertiary hospital.
A total of 252 (92.6%) rapid referral pathway pa-
tients finally underwent colonoscopy. Twenty patients
were excluded from the colonoscopy study: 13 failed
to attend their colonoscopy appointment, 5 had signifi-
cant co-morbidity precluding colonoscopy and 2 pa-
tients rejected the procedure.
The most common symptom for which patients were
routed via the rapid referral pathway was a change in
bowel habits (49.8%), followed by rectal bleeding
(23.9%), rectal bleeding plus a change in bowel habits
(7.7%) and iron deficiency anaemia (10.1%).
Overall, 200 of the 252 above patients (79.4%) ful-
filled at least one high-risk criterion for rapid referral.
The remaining 52 (20.6%) patients did not meet any
rapid referral criterion. Of these latter 52, 31 (12.3%)
symptomatic patients met none of the symptomatic
184 Family Practice—The International Journal for Research in Primary Care

criteria defined or had symptoms/signs of too long
a history; 10 (4.0%) had a family history of CRC—a
criterion not considered in the present rapid referral
pathway, and 11 (4.4%) were routed for rapid refer-
ral but without any pertinent information being re-
corded.
Fifty-two (20.6%) of the rapid referral patients
were finally diagnosed with CRC. In 62.7% (32 pa-
tients), the cancer was located in the colon and
37.3% (19) in the rectum or at the recto-sigmoid
junction. Some 87.8% of the detected cancers
were colonic adenocarcinomas; three patients had
carcinoma-in-situ. Twenty-six per cent (13 patients)
of those diagnosed with CRC had Astler–Coller
Stage A disease, 36% (18) had Stage B disease, 24%
(12) Stage C and 14% (7) Stage D. Forty-nine pa-
tients (94.2% of those diagnosed with CRC) under-
went surgery; curative surgery was performed in 39
(79.6%). The three patients who did not undergo sur-
gery had Stage D disease; these received palliative
oncological treatment.
Colonoscopy also detected 73 patients (29% of the
252 who underwent the procedure) with high-risk le-
sions: 64 (25.4%) had adenomatous polyps, 8 (3.2%)
had inflammatory bowel disease (IBD) and 1 patient
(0.4%) was diagnosed with both polyps and IBD.
Twenty-one patients (32.3%) received polypectomy
during colonoscopy; biopsies were taken in 7 of these
patients.
The mean waiting time to colonoscopy for the pa-
tients in the rapid referral pathway was 18.5 days (SD:
19.1 days); the median waiting time was 15 days (range
0–138 days), and the P75 was 20 days. The waiting time
to colonoscopy for patients with CRC decreased to
13.8 days (SD: 8.8 days) compared to 19.7 days (SD:
20.8 days) for patients without cancer (P = 0.051).
The waiting time to surgery in patients with CRC was
28.6 days (SD: 23.9 days). The overall mean waiting
time was 52.7 days (SD: 32.9 days).
Over the same time period, 311 patients in the stan-
dard referral pathway were diagnosed with CRC.
Table 2 shows the characteristics of the patients
routed via the standard and rapid referral pathways.
Significant differences can be seen in the number and
type of symptomatic criteria for referral between the
two groups. However, these results should be inter-
preted with caution given the large number of missing
data for the standard referral pathway patients.
The waiting time to colonoscopy was significantly
shorter for patients in the rapid referral pathway
(Fig. 1) [13.8 days (SD 8.8) compared to 33.8 days
(SD 38.7) in the standard pathway; P < 0.001]. Some
64.7% of patients underwent colonoscopy in <15 days
compared to 43.0% of patients in the standard referral
pathway (P = 0.004). No significant differences were
seen in the waiting time to surgery for the two referral
routes [28.6 days (SD 23.9) in the rapid referral path-
way and 31.0 days (SD 34.4) in the standard pathway:
P = 0.559]. Sixty-four per cent of patients in the stan-
dard referral pathway underwent surgery within 30 days
of diagnosis compared to 61.2% patients in the rapid
referral pathway; nevertheless, it should be noted that
the number of patients who underwent surgery in-
creased from 48% in the first year to 73% in the third.
The overall waiting time was also significantly shorter
for the patients in the rapid referral pathway [52.7 days
(SD 32.9) compared to 71.5 days (SD 57.4) in the stan-
dard pathway]. Some 91.7% of patients in the rapid
pathway had an overall waiting time of <3 months
compared to 74.4% patients in the standard pathway
(P = 0.008).
No differences were found between the patients of
the two referral pathways in terms of the location of
cancers, the proportion of patients who underwent

TABLE 2 Comparison of Patient characteristics routed via the standard and rapid referral pathways

Patient characteristics Rapid pathway Standard pathway P

52 CRC 311 CRC

Sex
Male 53.8% (28) 62.1% (193) 0.284
Female 46.2% (24) 37.9% (118)
Average age, SD (years) 73.3 (11.6) 71.2 (11.2) 0.200
<50 years 5.8% (3) 5.5% (17) 0.929
>50 years 94.2% (49) 94.5% (294)
Co-morbidity
No 46.2% (24) 51.8% (161) 0.662
<3 co-morbidities 38.5% (20) 32.2% (100)
>3 co-morbidities 15.4% (8) 16.1% (50)
Symptomatic criteria for colonoscopy referral
One symptom 80.4% (41) 64.8% (59) 0.051
Two symptoms 19.6% (10) 35.2% (32)
Change in bowel habits 56.9% (29) 26.7% (24) 0.002
Rectal bleeding 21.6% (11) 28.9% (26)
Rectal bleeding and change in bowel habits 11.8% (6) 13.3% (12)
Anaemia and constitutional syndrome 9.8% (5) 31.1% (28)
 Rapid referral pathway for CRC 185

FIGURE 1 Waiting times for patients with CRC attended to via the rapid and standard referral pathways. *statistically significant

TABLE 3 Cancer characteristics according to referral route

Discussion
The rapid referral pathway reduced the waiting time
CRC patients Rapid Standard P to colonoscopy, thus shortening the overall waiting
pathway pathway
52 311 time in patients diagnosed with CRC. The present
CRC CRC rapid pathway for identifying and referring patients
with symptoms suggestive of CRC is similar to others
Cancer location 0.995 that have been implanted in other countries, e.g. in
Colon 62.7% (32) 60.5% (185) the UK (two-week standard rule).5 However, while
Recto–sigmoid junction 9.8% (5) 10.8% (33)
these programs aim for rapid referral from primary to
Rectum 27.5% (14) 28.8% (88)
Surgery 94.2% (49) 89.7% (279) 0.307 specialist care, the aim of the present pathway was to
Curative 90.7% (39) 84.1% (207) 0.265 allow direct referral for colonoscopy from primary
Palliative 9.3% (4) 15.9% (39) care within 15 days without the need to first consult
Astler–Coller stage
A 26.0% (13) 11.6% (28) 0.063
with a specialist.
B 36.0% (18) 41.1% (99) The direct referral of patients for colonoscopy is
C 24.0% (12) 32.4% (78) a practical and effective means of reducing the num-
D 14.0% (7) 14.9% (36) ber of specialist consultations and reduces the delay
to diagnosis for the patient.18 In order for GPs to
make the request for colonoscopy, a number of highly
surgery nor the aim of surgery (curative/palliative) predictive criteria were established that allowed rapid
(Table 3). However, the stage of disease at diagnosis attention to be sought for high-risk patients while
was influenced by the referral route. With the rapid avoiding unjustifiable colonoscopies (and therefore
referral pathway, 26.0% of cancers were diagnosed avoiding the risks the procedure entails).5,9 These cri-
at Stage A, while the standard referral pathway only teria also try to avoid the rapid referral pathway satu-
diagnosed 11.6% at this stage (P = 0.007). The differ- rating the resources of the health district’s digestive
ence was maintained after stratifying by cancer site; medicine departments and thus increasing the waiting
25.8% of colon cancers were diagnosed at Stage A in times of patients referred via the standard pathway—a
the rapid pathway patients compared to 11.0% in problem referred to in other studies.8
standard route patients (P = 0.030) and 22.2% of rec- Overall compliance with the referral criteria was
tum cancers at Stage A in the rapid pathway patients 80%; this reaches 100% if only those patients even-
compared to 12.5% in the standard pathway patients tually diagnosed with CRC are taken into account. Pa-
(P = 0.276). tients who met none of the criteria for rapid referral
186 Family Practice—The International Journal for Research in Primary Care
made up 4% of all inappropriate referrals, while
those who did not explicitly meet the established crite-
ria even though they had symptoms and a family back-
ground of CRC made up 16% of inappropriate
referrals. The compliance rates reported in other stud-
ies for other rapid referral pathways are lower at 50%
and 73%10–14 for patients suspected of having CRC,
and 85–92% for those finally diagnosed with can-
cer.11–14 In contrast, Maruthachalam et al.15 report
a compliance rate of 99%; however, in this latter
study, very different referral criteria were followed.
The most common symptoms shown by the patients
routed via the rapid referral pathway were changes in
bowel habits and rectal bleeding; these findings agree
with those reported by other authors.11,12,19,20 The pa-
tients routed via the standard pathway more often
showed more than one symptom, and more often had
asthenia/anaemia. This might indicate that these pa-
tients had more advanced disease. However, such an
interpretation should be understood with caution
given the lack of data for many of the standard path-
way patients.
For patients with CRC, the rapid referral pathway re-
duced the waiting time to colonoscopy to 14 days com-
pared to the 34 days for the standard pathway. Other
authors report similar reductions in waiting time: 9–14
days compared to 24–29 days via the standard path-
way.10–12,21 However, it should be remembered that
these studies report the waiting time until seeing a spe-
cialist able to request colonoscopy not the waiting time
to direct access colonoscopy via a GP. Maruthachalam
et al.15 who compared the waiting time to colonoscopy
via a specialist visit with direct access colonoscopy via
a GP also showed a reduction in waiting time to colo-
noscopy (9 days compared to 52 days).
The overall waiting time to colonoscopy (for all pa-
tients irrespective of the final diagnosis) in the rapid
referral pathway was 18.5 days (median 15 days).
Fifty-six per cent of patients underwent colonoscopy
in under 15 days—less than the 85–100% reported in
other studies.10,11,13–15,19,21 Although the present rapid
referral pathway needs adjusting to bring it closer into
line with the 15 day standard, it should be noted that
75% of patients received a colonoscopy within 20 days
and that those who were eventually diagnosed with
CRC had a smaller waiting time than those without
cancer (13.8 compared to 19.7 days). It may be that
those patients strongly suspected of having CRC re-
ceived a colonoscopy more quickly. Reducing the
waiting time to colonoscopy to 15 days depends on
the availability of resources and their adequate use.
Since the selected health district has no dedicated co-
lonoscopy unit to which patients can be referred, the
proper organization/distribution of patients suspected
of having CRC is essential if the 15 day standard is to
be met and the waiting times of standard pathway pa-
tients not increased.
No significant differences were seen between the two
referral pathways with respect to the waiting time to
surgery, which was 30 days. This is less than the
36-day wait reported for both types of referral pathway
by Chohan et al.12 Both referral pathways in the present
work met the waiting time targets set, showing the ex-
cellent organization between the district’s gastroenter-
ology and surgery departments.
The overall delay for patients diagnosed with CRC
was reduced by the rapid referral pathway from 72 to
53 days; much of this via the reduction in the waiting
time to colonoscopy. Other studies report reductions
in this respect from 65–75 to 49–55 days.12,15,22 Thus,
some 92% of patients with CRC in the present rapid
referral pathway were diagnosed and received treat-
ment in under 3 months—meeting the standard set.
Chohan et al.12 established a standard of 62 days for
treatment to be received; 69% of patients were trea-
ted within this time, similar to the 71% of patients
who were treated in under 2 months in the present
work.
The rapid referral pathway allowed a greater number
of cancers to be detected at Stage A of disease (26%)
compared to the standard pathway (12%). Other stud-
ies have failed to demonstrate that the stage of detec-
tion is influenced by the referral pathway,10,11 in fact
one even suggests that rapid pathways might refer pa-
tients with more advanced stages of disease.12 Once
CRC presents clinically, the stage of disease is the most
important factor influencing survival.5–7 At Stage A, the
cancer is localized and survival is 75–90%,23–25 reflect-
ing the need to treat early. Survival studies are required
to confirm the suspected impact of the present rapid re-
ferral pathway’s detection of tumours at earlier stages
of development. Such an undertaking was beyond the
scope of the present work.
The aim of rapid referral pathways is to reduce
waiting times in order for an early diagnosis to be
made and hopefully improve survival. Only Iversen
et al.26 have shown that a diagnostic/therapeutic delay
of over 60 days is associated with reduced survival in
patients with rectal cancer; no other studies have been
able to show this.6,16,17,27 However, independent of its
potential effect on patient prognosis, a delay in arriv-
ing at a diagnosis generates great anxiety for patients.
The length of this delay is also a marker of the quality
of assistance patients receive.
The percentage of patients eventually diagnosed with
CRC routed via the rapid referral pathway was 21%
over its first 3 years of functioning. In the final year of
the study period, this percentage was 17%, higher than
the 8–14% reported in other studies.10–12,14,15 Some
14% of all cancers detected in the final year were at
Stage A, a figure similar to that reported for other
rapid referral pathways (9–19%).11,12,14
During the study period, 447 new cases of CRC
were diagnosed in the selected health care district, 52
 Rapid referral pathway for CRC
(12%) via the rapid referral pathway, 311 (69%) via
the standard pathway and 84 (19%) in the emergency
room. In the final year of this period, during which
148 cases were detected, 18% were detected via the
rapid pathway, 59% via the standard pathway and
22% in the emergency room. These results for
the rapid pathway are similar to those reported by
Eccersley et al.10 but lower than the 22% and 41% re-
ported by other authors.11–15 As the present rapid re-
ferral pathway becomes more extended in the primary
health care setting, the number of cancers detected
through its use should increase.
The present study suffers from a number of limita-
tions. The monitoring of the patients routed via the
rapid pathway was prospective in nature, while the re-
sults for the standard pathway patients were collected
retrospectively. This could introduce bias into patient
selection and data gathering. The organization of the
rapid referral pathway, the characteristics of the
health care area and the resources destined to it
means it is difficult to extrapolate the present results
to other settings, although the results published in the
literature are similar.
The use of the present rapid referral pathway led to
substantial improvements in waiting times to colono-
scopy over the standard pathway. Cancers were diag-
nosed at earlier stages; this is the first time such
results have been reported. Although the results ap-
pear promising, further monitoring is required for
them to be confirmed. Long-term studies should also
examine the survival and quality of life of patients to
determine the impact of this rapid referral pathway in
clinical practice and on health related outcomes.
Acknowledgements
The authors wish to thank Isabel López-Villar for her
help in the data collection process.
Declaration
Funding: Partially financed by Quality Plan from
Spanish Health System.
Ethical approval: none.
Conflict of interest: none.
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