GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

Bailey, James A.; Khawaja, A. R.; Andrews, H.; Weller, Jill; Chapman, Caroline; Morling, Joanne R; Oliver, Simon; Castle, Steven; Simpson, Jayne; Humes, David J.; Banerjea, Ayan

doi:10.1016/j.surge.2020.03.002

Cited by 23 publications

(39 citation statements)

References 14 publications

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“…This is a large English data set on primary care access to FIT in symptomatic patients for all symptoms and all age groups. In previous studies, a colorectal cancer diagnosis rate of 0.2 per cent in patients undergoing 2WW investigation with fHb below 4 µg Hb/g faeces was documented 9 , 11 , 22 . Data from Scotland suggest a similar ‘miss rate’ with longer follow-up in patients with unquantifiable fHb levels on a different manufacturer’s platform 10 .…”

Section: Discussionmentioning

confidence: 84%

“…This local pathway was designed to incorporate FIT as a triage tool for all referral criteria in adult patients of any age, except those with rectal bleeding and rectal mass, as described elsewhere 11 , 22 , presenting to local GP practices within the authors’ catchment area. GPs were able to request FIT (and blood tests) independently and to act on the result, or, if clinical suspicion was high, they could submit an RCCD referral form contemporaneously.…”

Section: Methodsmentioning

confidence: 99%

“…An electronic guidance system F12 (SystmOne; The Phoenix Partnership, Leeds, UK) was also used to guide GPs on the use of FIT and the new pathway in practices that used this system, with direct links to the relevant referral form where appropriate. FIT dispatch and return were entirely postal, and kits were analysed according to the manufacturer’s protocols as described elsewhere by an accredited BCSP hub laboratory ( Appendix S2 ) 9 , 11 , 22 . The OC-Sensor™ platform (Eiken Chemical, Tokyo, Japan) was used as described previously 9 .…”

Section: Methodsmentioning

confidence: 99%

“…In November 2017, a rapid colorectal cancer diagnosis (RCCD) pathway incorporating direct general practitioner (GP) access to FIT and the use of FIT, FBC and ferritin results for ‘rule in’, ‘rule out’ and ‘first test’ selection in secondary care was introduced 11 . This study aimed to evaluate the colorectal cancer diagnoses from the first 2 years of this pathway, stratified by FIT level 22 .…”

Section: Introductionmentioning

confidence: 99%

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Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation

et al. 2021

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Background A novel pathway incorporating faecal immunochemical testing (FIT) for rapid colorectal cancer diagnosis (RCCD) was introduced in 2017. This paper reports on the service evaluation after 2 years of pathway implementation. Methods The RCCD protocol was based on FIT, blood results and symptoms to stratify adult patients in primary care. Two-week-wait (2WW) investigation was indicated for patients with rectal bleeding, rectal mass and faecal haemoglobin (fHb) level of 10 µg Hb/g faeces or above or 4 µg Hb/g faeces or more in the presence of anaemia, low ferritin or thrombocytosis, in all other symptom groups. Patients with 100 µg Hb/g faeces or above had expedited investigation . A retrospective audit of colorectal cancer detected between 2017 and 2019 was conducted, fHb thresholds were reviewed and critically assessed for cancer diagnoses. Results In 2 years, 14788 FIT tests were dispatched with 13361 (90.4 per cent) completed returns. Overall, fHb was less than 4 µg Hb/g faeces in 9208 results (68.9 per cent), 4–9.9 µg Hb/g in 1583 (11.8 per cent), 10–99.9 µg Hb/g in 1850 (13.8 per cent) and 100 µg Hb/g faeces or above in 720 (5.4 per cent). During follow-up (median 10.4 months), 227 colorectal cancers were diagnosed. The cancer detection rate was 0.1 per cent in patients with fHb below 4 µg Hb/g faeces, 0.6 per cent in those with fHb 4–9.9 µg Hb/g faeces, 3.3 per cent for fHb 10–99.9 µg Hb/g faeces and 20.7 per cent for fHb 100 µg Hb/g faeces or above. The detection rate in the cohort with 10–19.9 µg Hb/g faeces was 1.4 per cent, below the National Institute for Health and Care Excellence threshold for urgent referral. The colorectal cancer rate in patients with fHb below 20 µg Hb/g faeces was less than 0.3 per cent. Conclusion Use of FIT to "rule out" urgent referral from primary care misses a small number of cases. The threshold for referral may be adjusted with blood results to improve stratification .

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Section: Discussionmentioning

confidence: 84%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation

et al. 2021

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“…In contrast, few have studied higher f-Hb thresholds but, because of the imperative to prioritize patients for further investigation in the current COVID-19 pandemic, a f-Hb threshold of 100 mg/g has been suggested for England despite the clinical characteristics being unknown at present. 17 Others have proposed 150 mg/g for use as a threshold in assessment of patients with symptoms, 31,32 the rationale being that this threshold gives positivity approximating to that found in the past in the NHS Bowel Cancer Screening Programme with guaiac faecal occult blood tests. 33 However, the dataset provided here can be used to guide a rational choice of numerical f-Hb thresholds for use in primary care to guide the investigation of symptomatic patients.…”

Section: Discussionmentioning

confidence: 99%

Faecal haemoglobin concentration thresholds for reassurance and urgent investigation for colorectal cancer based on a faecal immunochemical test in symptomatic patients in primary care

et al. 2021

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Background Faecal haemoglobin concentration (f-Hb), estimated using a faecal immunochemical test, can be safely implemented in primary care to assess risk of colorectal cancer (CRC). Clinical outcomes of patients presenting with symptoms of lower gastrointestinal disease were examined using an extensive range of f-Hb thresholds to decide on reassurance or referral for further investigation. Methods All patients who attended primary care and submitted a single faecal specimen faecal immunochemical test in the first year of the routine service had f-Hb estimated using HM-JACKarc: f-Hb thresholds from <2 to ≥ 400 µg Hb/g faeces (µg/g) were examined. Results Low f-Hb thresholds of <2, <7, <10 and <20 µg/g gave respective CRC risks of 0.1, 0.3, 0.3 and 0.4%, numbers needed to scope for one CRC of 871, 335, 300 and 249, and ‘false negative’ rates of 2.9, 11.4, 13.3 and 17.1%. With thresholds of <2, <7, <10 and <20 µg/g, 48.6, 74.6, 78.1 and 83.2% respectively of symptomatic patients could be managed without further investigation. With reassurance thresholds of <2 µg/g, <7 µg/g and <10 µg/g, the thresholds for referral for urgent investigation would be >400 µg/g, ≥200 µg/g and ≥100 µg/g. However, patients with a f-Hb concentration of <10 or <20 µg/g with iron deficiency anaemia, or with severe or persistent symptoms, should not be denied further investigation. Conclusions In primary care, f-Hb, in conjunction with clinical assessment, can safely and objectively determine individual risk of CRC and decide on simple reassurance or urgent, or routine referral.

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Quantitative FIT stratification is superior to NICE referral criteria NG12 in a high-risk colorectal cancer population

et al. 2021

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Background Guidelines for urgent investigation of colorectal cancer (CRC) are based on age and symptom-based criteria. This study aims to compare the diagnostic value of clinical features and faecal immunochemical test (FIT) results to identify those at a higher risk of CRC, thereby facilitating effective triage of patients. Methods We undertook a review of all patients referred for investigation of CRC at our centre between September 2016 and June 2018. Patients were identified using a prospectively recorded local database. We performed a logistic regression analysis of factors associated with a diagnosis of CRC. Results One-thousand-and-seven-hundred-eighty-four patients with FIT results were included in the study. Change in bowel habit (CIBH) was the most common referring clinical feature (38.3%). Patients diagnosed with CRC were significantly older than those without malignancy (74.0 years vs 68.9 years, p = 0.0007). Male patients were more likely to be diagnosed with CRC than females (6.5% vs 2.5%, Chi-squared 16.93, p < 0.0001). CRC was diagnosed in 3.5% (24/684) with CIBH compared to 8.1% (6/74) with both CIBH and iron deficiency anaemia. No individual or combination of referring clinical features was associated with an increased diagnosis of CRC (Chi-squared, 8.03, p = 0.155). Three patients with negative FIT results (< 4 µg Hb/g faeces) were diagnosed with CRC (3/1027, 0.3%). The highest proportion of cancers detected was in the ≥ 100 µg Hb/g faeces group (55/181, 30.4%). Conclusion In a multivariate model, FIT outperforms age, sex and all symptoms prompting referral. FIT has greater stratification value than any referral symptoms. FIT does have value in patients with iron deficiency anaemia.

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GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

Abstract: Service evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for "rule out", "rule in" and "first test selection".

Cited by 23 publications

References 14 publications

Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation

Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation

Faecal haemoglobin concentration thresholds for reassurance and urgent investigation for colorectal cancer based on a faecal immunochemical test in symptomatic patients in primary care

Quantitative FIT stratification is superior to NICE referral criteria NG12 in a high-risk colorectal cancer population

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