CAN-02 refers to the percentage of lower gastrointestinal (LGI) two-week wait (2WW, fast track) cancer referrals accompanied by a faecal immunochemical test (FIT) result, with the result recorded in the twenty-one days leading up to the referral.

• DES points: 22
• Lower threshold: 65% (likely to change next year).

All GPs are expected to implement the recommendations set out in the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) guidance, which is NICE accredited and evidence-based.

The guidance recommends the use of FIT in primary care for patients presenting with all NG12 suspected colorectal cancer symptoms, except those with an anal/rectal mass or anal ulceration. The guidance also recommends that those with a FIT of fHb < 10μg Hb/g, a normal full blood count, and no ongoing clinical concerns are not referred on a LGI urgent cancer pathway, but are instead managed in primary care or referred on an alternative pathway.

Where patients are not referred, appropriate safety netting must be in place. For safety netting, clinical teams should consider the recommendations set out in NHS England’s publication on FIT implementation. This includes the use of advice and guidance via e-Referrals (e-RS), providing patients with clear information of who to contact if they develop new symptoms, a referral to non-specific-symptoms pathways if appropriate, and much more.

Cancer alliance budgets include service development funding to support FIT implementation. In the short term, this funding can also be used to purchase FIT kits where there are local commissioning issues. Primary care networks (PCNs) can email england.edcancer@nhs.net if they would like an introduction to their cancer alliance FIT lead.

There are a number of steps a PCN may take to ensure that FIT is implemented across all practices. These include:

• Encouraging patient uptake of FIT: Make sure the patient is aware of the importance of completing a FIT test and returning it as quickly as possible. This could include sending instant text message reminders to patients. Cancer Research UK has materials to support patient uptake available on its website.
• Working closely with secondary care: Use e-RS prereferral specialist advice (advice and guidance) where it is unclear if a patient requires an urgent referral based on their FIT result and symptoms. 
• LGI urgent cancer forms: Include FIT results on the LGI 2WW referral form so that they can be used by LGI triage teams to determine the appropriate onward pathway for the patient.

Numerator: Of the denominator, the number of referrals accompanied by a FIT, with the result recorded in the 21 days leading up to the referral.

Denominator: Number of LGI 2WW referrals for suspected cancer.

Exclusions: Provision of FIT test kit declined / Patients with anal ulcerations or with anal or rectal masses.

To support faster diagnosis, Wood Green CDC is piloting a direct access straight to CT pathway, which is open to all NCL patients. This pathway is designed to detect primary lung cancer when a patient undergoes a chest X-ray. If any abnormalities are seen, the patient will receive a CT scan during the same appointment. Community Diagnostic Centre (CDC) Radiologists are required to report CT scans within 48 hours and notify the referring physician through standard channels, such as report notifications or emails to the referring GP. Patients with abnormal chest x-rays at other sites should be referred on the urgent suspected lung cancer pathway.  

There is a different process to other diagnostic requests. The referral form and more information is available on the CDC imaging webpage. This is a walk-in service and patients must bring the referral form with them.  

A revised Suspected Cancer Urgent Diagnostics Referral form and electronic GP Imaging OrderComms system (ICE) will be going live later in 2024. These will improve the referral process for diagnostics. NCL ICB will keep practices updated about when these go live. 

The DES highlights that primary care should promote the use of non-specific symptoms (NSS) pathways. This year, the NCLCA are delivering webinars for primary care to continue to promote these pathways to ensure GPs are aware of the referral criteria. 

There is more information on non-specific symptoms pathways and making use of these on the Cancer Alliance website. 

Ensuring that urgent suspected cancer referrals for lower GI cancers are accompanied by a Faecal Immunochemical Test (FIT) result is our key focus for improving bowel referral practice. A patient’s FIT score correlates to their risk of having bowel cancer. Making use of FIT completion plays an important role in following NG12 referral guidance and improving system capacity by reducing unnecessary colonoscopies. In addition, patient experience is improved by reducing unnecessary invasive investigations. More information can be found on the NCL Cancer Alliance website. 

The North Central London Cancer Alliance (NCLCA) have identified upper GI as tumour sites for referral improvement work following our analysis of local staging data and other performance data. The NCLCA are currently scoping primary care interventions.  

Please get in touch at uclh.ncl.primarycarecancer@nhs.net if you wish to share examples of referral improvement work to inform the NCL-wide approach.