Use of FIT (Faecal Immunochemical Testing) in the Lower GI Suspected Cancer Pathway

Changes to colorectal cancer pathways across Wessex have come into effect from January 2023. 

The new guidance is summarised below, and full details can be found in the following documents:

• WCA letter to primary care teams outlining the new pathway
• Webinar held on 11^th January to introduce the changes to the pathway
• Wessex LGI Pathway Flowchart

Some areas have adapted the pathway to reflect local variation, see below:

• Portsmouth & SE Hants LGI Pathway Flow Chart
• Dorset LGI Pathway Flowchart

The guidance is based on national recommendations and evidence provided by a NICE accredited guideline on the use of FIT published last year, and follows recent NHSE communication to primary and secondary care system leads.

What has changed?

1. New LGI two week wait referral form

• The form has been updated in line with the national guidance making a FIT result ≥ 10μg Hb/g the main referral criterion unless the patient has an unexplained abdominal, rectal or anal mass/ulceration.

• The updated form is now available in GP systems across most of Wessex, and in all areas by 30^th January.

Please note that the new form retains the ability for referral where there is concern about colorectal cancer even if FIT < 10 or patient is unable or unwilling to do a FIT test, or the result is delayed.

2. Provision of a secondary care FIT < 10 safety netting pathway

• This is a pathway that primary care can refer into for patients with NG12 symptoms but who have FIT <10 and normal examination, where the GP is not happy to safety net in primary care.

• Patients will receive a repeat FIT test within 8-10 weeks followed by a telephone consultation to review their symptoms and triage. 

• The FIT <10 referral form will be available in your usual folders alongside the two week wait forms. 

It is important that a physical examination (including rectal exam) and full blood count are done before referral on this pathway. This pathway is not suitable for patients with an abdominal/rectal/anal mass or ulcer who should be referred via two week wait regardless of their FIT test result.

Why are these changes to the lower GI suspected cancer pathway needed?

Bowel cancer is the fourth most common cancer in the UK with 42,900 new cases annually, and the second most common cause of cancer death.

Survival is closely linked to stage at diagnosis. Bowel cancer is treatable and curable especially if diagnosed early, with over 92% people surviving for 5 years or more if diagnosed at Stage 1 compared to only 10% when diagnosed at Stage 4.

Currently around 20% of bowel cancer is diagnosed at Stage 4 meaning that anything that can help to diagnose bowel cancer at an earlier stage could make an enormous difference to survival.

Benefits of FIT

There is a growing body of evidence to show that FIT is a valid and reliable triage tool for colorectal cancer.

• FIT is a better predictor of colorectal cancer risk than any symptom including in cases of rectal bleeding
• The risk of colorectal cancer in those with a FIT <10, a normal examination and full blood count is 0.1%, which is lower than the general asymptomatic population risk
• Recent evidence suggests that patients with two FIT <10 results have a 0.04% risk of colorectal cancer.

Only around 50% of LGI 2WW referrals in Wessex have a FIT result available in time to support effective triage. Alongside this, referrals onto the LGI suspected cancer pathway have increased significantly since the pandemic and waits have lengthened more than for any other tumour group.

Comprehensive use of FIT in NG12 patients is therefore critical to improving bowel cancer survival, ensuring that the highest priority patients can be investigated more quickly.

Colorectal Cancer Safety Netting in Primary Care

Primary care teams will need to have systems in place to make sure patients can rapidly have blood tests and FIT testing, and to safety net receipt of the results.

Coding the provision of FIT, running regular reports and use of scheduled tasks and AccuRx text message reminders can all help. 

Ensure wider team members including reception staff are familiar with the test and process, and encourage patients to return their sample as quickly as possible.

We have produced some safety netting guidance to help you consider when safety netting will be needed in the new pathway and tips for how to do this. Please also see examples below of safety netting protocols and templates from other Wessex practices, that you can adapt to suit your needs:

• FIT Protocol for Lower GI Referrals - Southampton North PCN
• FIT Protocol - Mid Dorset PCN
• FIT Flow Chart - Mid Dorset PCN
• FIT Information Slip - Mid Dorset PCN - to be stapled to the outside of the FIT kit envelope before handing to patient.

Cancer Care Coordinators are well placed to take on some of the key tasks around tracking patients and their FIT results. If you are considering recruiting to this role the Cancer Alliance can support you, please see our dedicated Cancer Care Coordinators project page and ARRS toolkit.

Consent to re-route patients

There is a new section on the LGI two week wait referral form that asks you to tick a box to indicate that you are happy for the patient to be re-routed to a different pathway, following triage by a secondary care clinician.

What happens to the patient if I tick Yes?

Once the referral is received in secondary care it will be triaged by a clinician. This may result in a decision to re-route a patient to an alternative pathway if deemed clinically appropriate. Currently it is only the original referrer who can alter the pathway. This mechanism is intended to allow the clinician to review the patient and place them on the pathway they feel is most suitable based on their clinical judgement. The clinical responsibility lies with secondary care who are responsible for tracking and informing the patient. 

Secondary care will provide a point of contact for the patient should their symptoms worsen or they develop any new symptoms, so they have direct access to the specialist team. This will ensure that the decision can be reviewed if any new information becomes available.

Patient information

Information for your patients on FIT can be found on the Cancer Matters Wessex website including a film explaining how to complete the test, and links to step by step instructions.

Patient information on the FIT<10 pathway and what to expect is also available on Cancer Matters Wessex. This can be printed off to give to your patient during their consultation. It can also be translated into different languages.

Bowel Cancer UK’s Symptom Diary is a useful resource to help patients keep track of their symptoms ahead of, or between appointments. Consider printing out a copy for your patient or sending them a link.

How do you feel about the changes to the colorectal cancer pathway?

Referring clinicians - please take a couple of minutes to tell us your thoughts on the new colorectal pathway guidance, and the emphasis on using the FIT result to triage patients. What would help to embed these changes in your practice? 

Let us know here by completing this short survey.

FREE Cancer Study Days for Primary Care

Wessex Cancer Alliance have teamed up with GatewayC to run two FREE virtual study days, with each session tailored to support different clinicians within primary care. The study days will be split into short, accessible sessions, each covering several cancer-related topics.

Ask questions to your local cancer specialists and gain over 4 CPD credits.

More information about the days, and links to register, can be found here.