Guidance for referring patients for suspected lower gastro-intestinal cancer

In summary:

• GPs should continue to refer patients with suspected lower gastro-intestinal (GI) cancer on the current urgent suspected cancer (USC) form.
• GPs should undertake faecal immunochemical (FIT) testing in symptomatic patients in line with NICE guidelines. Exceptions are anal mass, rectal mass or anal ulceration; these patients should be referred directly (without a FIT test) onto the suspected lower GI cancer pathway.
• Patients who have had a negative or normal bowel screening result and present to their GP practice with possible suspected lower GI cancer symptoms should have a FIT test in primary care.

FIT for suspected colorectal cancer

FIT tests should be offered to patients with bowel symptoms in line with guidance and the result should be used to guide referrals for suspected LGI cancer. Patients who have a rectal or anal mass, or anal ulceration should be referred straight onto the suspected LGI cancer pathway, without the need for a FIT test.

FIT for symptomatic patients is the same test as used in the National Bowel Cancer Programme. However, the cut off level for positivity is much higher in the screening programme. In the bowel cancer screening programme, a result of >80µg/g faeces is positive, requiring further investigation. In testing symptomatic patients, a result of >10µg/g faeces is positive. It is therefore important to request a FIT for a symptomatic patient even if they recently returned a bowel cancer screening FIT.

Patients should complete the sample as per the instructions on the patient information leaflet (see Downloads). It is essential that the sample is take completed  as soon as the faeces is produced. The sample must also be sent with a correctly completed tQuest/SunQuest ICE form to avoid delays in results being returned.

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 the Cancer Research UK website for key things to know about FIT.

FIT <10

The majority of patients with a FIT<10 can be reassured that their symptoms do not represent colorectal cancer and can be managed appropriately, as the data suggests a FIT<10 is 99.8% predictive for the absence of colorectal cancer. 

However, if there is ongoing clinical concern that there is a possibility something more serious could be going on, they can be safety netted with the following pathway.

• Arrange further clinical review in primary care, re-evaluate symptoms. 
• Consider other potential diagnosis such as haematology, upper GI etc. (myeloma or pancreatic cancer can have vague presentations). 
• Consider an RDC/NSS referral for those patients who have worrying symptoms suspicious of cancer but do not align with a tumour specific pathway, for example with vague abdominal pain, weight loss, anaemia.
• Assess whether the patient requires a non-urgent lower GI referral. 
• Consider repeating the QFIT and a full blood count in 6 to 8 weeks if you remain worried about the risk of colorectal cancer as an effective safety-netting measure. 

This remains a safe and effective approach for managing patients with low-risk colorectal symptoms. 

Accurx SMS message reminders for patients to complete their FIT test

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 result used to guide referral.

Accurx has worked in conjunction with NHS England to create a series of FIT sample reminder SMS messages. The reminder SMS message is sent immediately after the FIT is requested and the second SMS is scheduled to send in a few days afterwards. This is found under the title 'FIT sample reminder (in partnership with NHSE)' on the Accurx text message search function. It is very useful in reminding patients to return their FIT kits to the practice for analysis. 

Accrux has prepared the following to help clinicians using the text reminders:

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

Eligibility Criteria

Inclusions

• positive FIT with symptoms suggestive of cancer, where FIT ≥10 ug/g
• abnormal lower GI investigations (colonoscopy/flexible sigmoidoscopy/CT scan) suggestive of cancer
• unexplained rectal mass
• unexplained anal mass or anal ulceration

How to Refer