One of the legacies of the pandemic has been the increased use of FIT (Faecal Immunochemical Test) in patients with abdominal and non-specific symptoms suggestive of lower GI cancer.

It has now become clear that FIT >10 in the absence of an unexplained abdominal, rectal or anal mass / ulcer, is the best indicator that we currently have in primary care to suggest a symptomatic patient may have a lower GI cancer whatever their symptoms (including rectal bleeding). The risk of lower GI cancer in a symptomatic patient with a FIT < 10 with normal examination (including rectal examination) and a normal FBC is < 0.1%[1].

New evidence based and NICE accredited guidelines on the use of FIT by the British Society of Gastroenterology (BSG) and the Association of Coloproctology of Great Britain & Ireland (ACPGBI) have been published. The recommendations include:

• 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.

NHS England have now called for these recommendations to be implemented in full. Two NHSE letters on FIT have been sent to primary and secondary care detailing how the guidelines should be applied.

Wessex Cancer Alliance have been working closely with secondary care leads across Dorset and Hampshire & Isle of Wight to develop an approach for Wessex that aligns with the national guidance but will provide further safety netting support for primary care, via a proposed non-2WW pathway for symptomatic patients with FIT <10. This is a model that has been successfully introduced in other parts of the country.

The Alliance has also been working with the LMC and secondary care to develop a revised 2WW Lower GI referral form which reflects the new guidance but retains the ability for primary care to refer using ‘gut feeling’ or if a patient is unable or unwilling to do a FIT test, or results are delayed.

Details of a Wessex model are being finalised and will be communicated as soon as possible. In the meantime please continue to request FIT on all your patients with concerning colorectal symptoms, including rectal bleeding.

Increased utilisation of FIT in the lower GI pathway is an exciting improvement meaning that patients at the greatest cancer risk can be investigated promptly and that patients with a very low risk will be spared unnecessary investigations.  We understand that this also represents a significant change to practice which will take time to embed. Wessex Cancer Alliance are working with the LMC to facilitate this transition and ensure both primary and secondary care feel confident and supported to implement this new approach.

If you have any questions please contact Wessex Cancer Alliance at wessexcanceralliance@wca.uhs.nhs.uk.

 

[1] Juul JS , Hornung N , Andersen B , et al . The value of using the faecal immunochemical test in general practice on patients presenting with non-alarm symptoms of colorectal cancer. Br J Cancer 2018;119:471–9.doi:10.1038/s41416-018-0178-7