Based on referral criteria from National Institute for Health and Care Excellence (NICE), translated into:

👉 who you should urgently refer on the cancer pathway
👉 not guideline jargon

This is one of the most important systems to understand when working in the NHS.

Because missing a 2WW referral:

delays cancer diagnosis
causes harm
creates medico-legal risk

✅ What is the Two-Week Wait pathway?

Also called:

👉 Urgent suspected cancer referral

It means:

patient seen by specialist within 2 weeks
fast-tracked endoscopy/imaging

Used when:

cancer risk is significant enough that we shouldn’t wait routine months

Not every symptom needs this.

But red flags must not be missed.

✅ First principle

Always ask:

Is there a red flag symptom?

If yes → 2WW referral
If no → routine pathway

Simple.

🔴 Upper GI (oesophagus/stomach) – When to refer urgently

Think:
👉 dysphagia + weight loss + anaemia

🚨 Refer 2WW if:

Dysphagia (most important)

Any new or progressive dysphagia

solids or liquids

Cancer until proven otherwise

Always urgent.

Never routine.

Weight loss + upper abdominal symptoms

Examples:

persistent dyspepsia
reflux
pain

Especially in older patients

Iron deficiency anaemia

Unexplained IDA (particularly:

men
postmenopausal women)

Needs urgent OGD ± colonoscopy

Persistent vomiting

Concern for obstruction/malignancy

Upper abdominal mass

Always urgent

Practical rule for upper GI

If you see:
👉 dysphagia or weight loss or anaemia

Think:
👉 urgent OGD

🔴 Lower GI (colorectal) – When to refer urgently

This is extremely common in real life.

🚨 Refer 2WW if:

Change in bowel habit

Persistent (>6 weeks), especially:

looser stools
increased frequency
older patients

Rectal bleeding + red flags

Bleeding PLUS:

weight loss
anaemia
change in bowel habit

Iron deficiency anaemia

Very important trigger

Even without bowel symptoms

Positive FIT test

Automatically fast-tracked

Palpable rectal/abdominal mass

Always urgent

Practical rule for lower GI

If you see:
👉 bleeding, anaemia, or change in bowel habit

Think:
👉 urgent colonoscopy

🟡 When NOT to use 2WW (very common overuse)

These are usually routine, not urgent:

simple IBS symptoms
young patient with haemorrhoids only
short-term dyspepsia
constipation alone
bloating alone
chronic stable symptoms with no red flags

Don’t overload the pathway unnecessarily.

It delays care for higher-risk patients.

✅ Step-by-step ward/GP-style thinking

When you see GI symptoms:

Step 1

Check for:

weight loss
dysphagia
anaemia
bleeding
persistent change in bowel habit

Step 2

If YES → 2WW
If NO → routine referral or conservative management

That’s basically the algorithm.

✅ Practical real-life scenarios

Scenario 1

65-year-old, new dysphagia
→ urgent OGD → 2WW

Scenario 2

Iron deficiency anaemia, no symptoms
→ urgent GI workup → 2WW

Scenario 3

Young patient, bloating, normal bloods
→ likely IBS → no 2WW

Scenario 4

Rectal bleeding + weight loss
→ urgent colonoscopy → 2WW

Scenario 5

Chronic reflux controlled with PPI
→ routine, not urgent

✅ What to include in your referral (important for acceptance)

Good referrals get processed faster.

Include:

exact symptoms + duration
Hb/ferritin
FIT result if done
weight loss
examination findings
comorbidities

Instead of:
❌ “?cancer – please review”

Write:
✔ “3 months change in bowel habit + IDA + weight loss”

Much clearer.

❌ Common junior mistakes

Missing dysphagia red flag
Treating IDA with iron only
Overusing 2WW for IBS
Not documenting weight loss
Sending tumour markers instead of scopes
Delaying referral “to wait for more tests”

If suspicious → refer early.

✅ Simple memory hack

Think:

Upper GI → Dysphagia
Lower GI → Bleeding/anaemia/change

If present → urgent

✅ Take-home concept

Red flags trigger urgent referral, not routine clinic.
Don’t delay dysphagia or iron deficiency anaemia.

If unsure — it’s safer to refer.