This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through the new diagnostic guidance on Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care, which was published in August 2023 by the National Institute for Health and Care Excellence (NICE).

I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel:  

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the PDF summary can be downloaded here: 

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEQYDkYwIy2vUALl?e=RcrJuC 

The Full NICE guidance can be found at:

·      https://www.nice.org.uk/guidance/dg56

Joint guidelines from ACPGBI and BSG can be found at: 

·      https://www.acpgbi.org.uk/resources/1075/fit_in_patients_with_signs_or_symptoms_of_suspected_crc_a_joint_guideline_from_acpgbi_and_bs 

Other references:

·      https://gpnotebook.com/en-gb/simplepage.cfm?ID=x20230616201913313209&linkID=82871 

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• Music provided by Audio Library Plus  
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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the new NICE guidance on faecal immunochemical tests, commonly known as FIT tests, to guide colorectal cancer referrals and which represents a change in the criteria for cancer referrals

So let’s jump into it.

John Smith is 77 and has recurrent rectal bleeding. He has no other symptoms and his abdominal and rectal examination is normal. What should we do next?

·      Should we refer?

·      Or should we do a FIT test?

And NICE now says that we need to do a FIT test.

And you may ask yourself, why? If the test is positive, it is not going to tell us anything that we did not already know and, if it is negative, are we not going to refer him for further investigations? So, what’s the point?

Well, let’s have a look at the new guidance and try to understand it. But first let’s remind ourselves that FIT tests detect blood in stools using antibodies specific to human haemoglobin. Human haemoglobin, degrades as it travels through the gastrointestinal tract, so FIT tests are less accurate in upper gastrointestinal bleeding. They were developed as an alternative to the old technique of faecal occult blood tests, which could react with chemicals in food and medicines resulting in false positive results.

Before considering the rationale of the NICE recommendations, let’s look at them first. And it is probably easier if we start by looking at when we will NOT need to request a FIT test, which is when there is:

·      a rectal or anal mass, or an unexplained anal ulceration. They are what NICE refers to as “red flags” or “bypass symptoms”, meaning that they will trigger an automatic urgent cancer referral

And what about an abdominal mass? Is that a bypass symptom? Well, yes and no, depending on how you look at it. It is not a bypass symptom given that you should still request a FIT test because, if it is positive, it will point towards a colorectal cause and will help us refer the patient to the appropriate service. But, and this is a big BUT, we are going to refer the patient regardless of the result. So, if the result is positive, we will refer to a colorectal service, and if it is negative, provided that we have a clinical suspicion of cancer, we will refer them urgently to another secondary care service. Which one will depend on our clinical judgement. However, if we have concerns that the patient may delay or not engage with the FIT test because of any reason, we should consider making the urgent cancer referral without the FIT test.

And now let’s look at when we will organise the FIT test. And please note that some of these clinical situations would have triggered an urgent cancer referral according to the old guidelines. Also, we need to remember that a FIT test should still be offered even if the patient has had a negative result through the screening programme because the thresholds are different.

So, a FIT test should be requested for:

1.   Adults of any age:

·      with an abdominal mass,

·      with a change in bowel habit,

·      with iron-deficiency anaemia,

2.   If they are 40 or over with:

·      unexplained weight loss AND abdominal pain

3.   If they are under 50 with rectal bleeding AND either:

·      abdominal pain or

·      weight loss,

4.   If they are 50 or over with either:

·      rectal bleeding

·      abdominal pain or

·      weight loss,

5.   And lastly, if they are 60 or over with anaemia even in the absence of iron deficiency.

And we will organise an urgent cancer referral if the FIT test result is 10 or more.

And now let’s try to understand why NICE has made these recommendations.

And it is basically because FIT tests are an excellent way of assessing a patient’s risk of having colorectal cancer. A patient with a FIT test <10 has a less than 1% of risk of having colorectal cancer and we should consider alternative diagnoses and investigatory. This means that colonoscopy resources can be prioritised for people who most need them.

In the old cancer referral guidelines, patients with 'high risk' symptoms were referred urgently without a FIT test.

However, many of these referred patients did not have cancer following colonoscopy, even in situations such as iron deficiency anaemia and rectal bleeding. So, NICE concluded that using FIT tests could reduce the number or the urgency of patients referred for colonoscopy and therefore also reduce the waiting times.

It is all good so far but, are there any drawbacks?

Well, there are concerns about patients that may not return the FIT test, which may be related to sociodemographic factors or disability and this group of patients may need more support.

There is also the concern of those patients with symptoms and a FIT test <10.

We said earlier that a patient with a FIT test <10 has a less than 1% risk of having colorectal cancer. However, this low risk partly reflects the rarity of colorectal cancer in the general population and we need to be aware that between 10 and15% of patients with colorectal cancer may have a FIT test result which is <10. Therefore, if we have any concerns or any reasons for suspecting cancer, it is reasonable to refer the patient to rule it out. 

The joint guideline from the Association of Coloproctology of Great Britain & Ireland and the British Society of Gastroenterology also recommend referral of patients with persistent or recurrent anorectal bleeding for flexible sigmoidoscopy even if the FIT test result is <10.

So, the summary is that for patients who have not returned a faecal sample or who have a FIT test result < 10 we should either:

·      Refer them if we are concerned because of cancer or unexplained symptoms or

·      Provide safety netting. Now, what safety netting actually means is going to vary according to our clinical judgement and it may include things like:

o  management in Primary Care following a “watch and wait” approach or

o  offering further tests, including another FIT test or tests for other possible conditions.  

So, let’s quickly go back to John, our 77-year-old patient with rectal bleeding. We are going to do a FIT test and if it is 10 or more, we will organise an urgent colorectal cancer referral. And if it is <10 we will refer him for further investigations, possibly a flexible sigmoidoscopy. The urgency of this referral will depend on our clinical judgement and on how concerned we may be.

The take home message is that FIT testing is, despite imperfections, the best method that we have to assess the urgency of a referral to exclude colorectal cancer, but we can still refer if we think it is needed.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.