The Faecal Immunochemical Test (FIT) is an important test in helping to improve the diagnosis of colorectal cancer.
The test looks for microscopic amounts of blood in a stool sample collected at home by the patient using a special FIT collection kit. This kit can be given out by the GP or medical practice administration staff following a consultation.
Traces of blood in the stool can be caused by other medical conditions and doesn’t necessarily mean the patient has cancer. But if it is cancer, finding it at an early stage means there are more treatment options available.
In July 2022 the British Society of Gastroenterology (BSG) and the Association of Coloproctology of Great Britain & Ireland (ACPGBI) published a NICE accredited joint guideline on use of FIT in patients with signs or symptoms of colorectal cancer.
The recommendations from these guidelines included:
- the use of FIT in primary care for patients presenting with all NG12 suspected colorectal cancer symptoms (excluding anal/rectal mass or anal ulceration), and
- those patients with a FIT of fHb <10 10μg Hb/g, a normal full blood count and no ongoing clinical concerns are not referred on a lower GI urgent cancer pathway, and are instead managed in primary care or referred on an alternative pathway.
In October 2022 NHSE letters to health system leads on the use of FIT in the LGI pathway asked for the recommendations in the BSG/ACPGBI guidance to be implemented in full.
In August 2023 NICE Diagnostic Guidance on FIT and updated NG12 Suspected Cancer Referral Guidelines were published.
- FIT should be used to guide referral on a colorectal suspected cancer pathway and symptomatic patients should be referred if they have a FIT result of at least 10 µg Hb/g. However referral should not be excluded on the basis of FIT alone IF there is strong clinical concern of cancer.
- Patients with a rectal or anal mass or anal ulceration do not need to be offered FIT before referral.
What has changed?
The LGI Suspected Cancer referral form has been updated in line with the NICE guidance and should be available in your usual fast track referral folder in Ardens (HIOW) and C the Signs (Dorset). For reference and to check you are using the correct version please see a copy here.
The Wessex FIT<10 Secondary Care Safety Netting Pathway has now closed. This was an interim pathway designed to support the transition to using FIT to guide referrals in primary care.
- As per national guidance, patients with a FIT result <10 should be safety netted in primary care with clinical review and repeat testing as appropriate. See the LGI Decision Support Flowchart for details.
- The majority of patients with a FIT<10 result can be safety netted, and other causes for their symptoms investigated. The risk of colorectal cancer in those with a FIT<10 result, normal exam and full blood count is <0.1%, lower than the general population risk (Monahan et al, 2022).
- It is not necessary to ask all patients with a FIT <10 result to repeat their test, only those for whom you have ongoing clinical concern of cancer. Recent research has shown that patients with two FIT<10 results have a colorectal cancer risk of <0.04% (Hunt et al, 2021).
- Patients with a FIT<10 result may be referred on a LGI suspected cancer pathway if there is very high clinical suspicion of colorectal cancer but this is the exception and the reasons for concern must be stated clearly on the referral form.
- If concerning symptoms persist consider alternative fast track pathways, Iron Deficiency Anaemia or Rapid Investigation Service referral for non-specific symptoms.
Information for your patients on how to complete a FIT test can be found on the Cancer Matters Wessex website
Testing for blood in your poo using the FIT test – Cancer Matters Wessex
There is also information available for patients who are being referred on the FIT <10 pathway
Colorectal Follow Up Pathway (FIT less than 10) – Cancer Matters Wessex
Primary care teams will need to have systems in place to make sure patients can rapidly have blood tests and FIT testing, and to safety net receipt of the results.
- Coding the provision of FIT, running regular reports and use of scheduled tasks and text message reminders (e.g. AccuRx) can all help.
- Ensure wider team members including reception staff are familiar with the test and process, and encourage patients to return their sample as quickly as possible.
We have produced some safety netting guidance to help you consider when safety netting will be needed in the new pathway and tips for how to do this. Please also see examples below of safety netting protocols and templates from other Wessex practices, that you can adapt to suit your needs:
- FIT Protocol for Lower GI Referrals – Southampton North PCN
- FIT Protocol – Mid Dorset PCN
- FIT Flow Chart – Mid Dorset PCN
- FIT Information Slip – Mid Dorset PCN – to be stapled to the outside of the FIT kit envelope before handing to patients
The Cancer Research UK Safety Netting Hub also has a range of resources to support primary care with safety netting.
FIT Data, Coding and Safety Netting
You can use the following codes to record the provision of FIT:
- Provision of FIT kit – Y36a6 (READ code) / 149421000000109 (SNOMED
- FIT kit declined – Y35d6 (READ Code) 149441000000102 (SNOMED)
The FIT result should auto-generate the following code in the patient record. This is the code that achievement of the IIF indicator CAN-01 will be based on.
- FIT result received – Xaf0H (READ Code) / 1049361000000101 (SNOMED)
We are aware that in some parts of Wessex the result was not coding last year but we believe this has now been resolved. If you have any concerns about this please get in touch via wessexcanceralliance@wca.uhs.nhs.uk