FIT for suspected colorectal cancer

From 1 April 2019, the FIT test for suspected colorectal cancer has been available to NCL GP practices. FIT tests should be offered before referring to assess for colorectal cancer in adults in both low-risk (DG30) and high-risk (NG12) cases with lower gastrointestinal (GI) symptoms who meet the eligibility criteria. Patients who have rectal or anal mass, or anal ulceration should be referred straight onto the Lower GI (LGI) Two-Week Wait (2WW) for Suspected Colorectal Cancer (CRC) pathway. See Downloads for NCL LGI pathway FAQs.

Patients should take the sample as per the instructions on the patients leaflet (see Downloads). It is essential that the sample is taken as soon as the faeces is produced as it deteriorates quickly. The sample must also be sent with correctly completed tQuest/SunQuest ICE form to avoid delays in getting back results.

FIT for symptomatic patients is the same test as the FIT used in the National Bowel Cancer Programme. However, the cut off level for positivity is much higher in the screening programme (120µg/g faeces vs. 10µg/g faeces). It is therefore important to request a FIT for a symptomatic patient even if they recently returned a bowel cancer screening FIT.

Practices are reminded that faecal immunochemical test (qFIT/FIT) samples for symptomatic patients should be clearly labelled and sent to local laboratories. Any symptomatic samples sent to the Bowel Screening Hub will not be processed. See Downloads for the differences between FIT for symptomatic patients and FIT for screening.

SMS reminders now available for practices ordering FIT kits for patients

NHS England has implemented SMS reminders in all GP practices to remind patients to return their FIT kits to the practice for analysis. NCL has a relatively low FIT uptake compared to the rest of the capital (only around 65% of 2WW suspected cancer referrals have an accompanying FIT result), so SMS reminders should be helpful.

FIT is an important tool in stratifying a patient's risk of having bowel cancer, but the overall usefulness of FIT relies on the test being completed and returned before the 2WW suspected cancer referral is made to secondary care.

The SMS reminder function now sits within EMIS. Accrux, the company which manages the SMS reminder software, has prepared the following to help with using the SMS reminders:

• step-by-step instructions with a brief introduction to what the messages say, and how to use them are available
• a three-minute video to guide you through setting up the pathway.

For most practices, there will be no additional charge associated with using the reminders, as it is likely that Accrux is already in use for SMS appointment reminders and/or video consultations.

If you would like to implement SMS FIT reminders but are not currently using Accrux, please get in touch with the NCL Cancer Alliance to explore other options for doing this. Investigations are also currently underway to see how these messages could be automated when a FIT kit is ordered for a patient. More information will follow on this in due course. 

A patient information leaflet for the FIT < 10 pathway can also be sent using Accurx. See the Cancer Care Resources section for more related information.

FIT<10 NG12 follow-up pathway

From 30 April 2021, a separate, non-2WW, referral pathway to the existing LGI urgent cancer pathway was introduced in NCL as part of a service evaluation programme. Instead of safety netting this cohort of patients in primary care, GPs should refer patients with the following referral criteria to secondary care via e-RS on the FIT<10 safety netting pathway:

• symptoms meeting NG12 criteria for suspected CRC
• FIT concentration <10 µg/g
• absence of any of the following: iron deficiency anaemia, rectal mass, anal ulceration.

The NCL protocol for this pathway is as follows: 

• referral received via e-RS on 'FIT<10 NG12 follow-up pathway'
• referral checked for completeness and missing information sought from GP
• patient will be booked by the hospital for repeat bloods (FBC), FIT, and a virtual follow-up clinic in eight to ten weeks
• face-to-face clinic with consultant or senior SpR (or equivalent) to determine management plan
• options are D/C to GP, consultant upgrade onto urgent cancer pathway, further investigations on referral to treatment (RTT) pathway.

This cohort of patients will be tracked based on referral source on a specific tracking list in order to differentiate them from the 2WW and RTT patient tracking list (PTL). This differentiation means that the safety netted patients will not distort 2WW performance reporting and will be easy to identify.

Following national guidance and in collaboration with NCL providers, NCL Cancer Alliance has developed pathways within the colorectal services to move patients who have appropriate symptoms from the 2WW pathway to the NCL FIT<10 secondary care pathway. 

If a patient is referred on the colorectal 2WW pathway and they have a FIT<10 but do not have a rectal/anal mass or iron deficiency anaemia, following a clinical consultation with the patient with no alarming symptoms, they may be moved to the FIT<10 pathway for follow up.

See Downloads for the pathway.

Eligibility Criteria

Inclusions

For FIT<10 NG12 follow-up pathway

Low-risk (DG30) symptomatic criteria in adults without rectal bleeding:

• ≥ 50 years with unexplained abdominal pain or weight loss
• < 60 years with changes in bowel habit
• < 60 years with iron-deficiency anaemia
• ≥ 60 years with anaemia but without iron deficiency.

 
NICE high-risk (NG12) urgent referral criteria:

• ≥ 40 years with unexplained abdominal pain and weight loss 
• > 50 with unexplained rectal bleeding 
• > 60 with iron deficiency anaemia or change in bowel habit 
• < 50 with rectal bleeding and any one of the following: abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia.

Exclusions

• patients must not have an iron deficiency anaemia, a rectal or anal mass, or anal ulceration.

How to Refer