The potential of FIT in patients presenting with bowel cancer symptoms
Written by Baljit Singh, Colorectal Surgeon, University Hospital Leicester
Tuesday 21 August 2018
The new faecal immunochemical test (FIT) is due to be introduced into the bowel cancer screening programme (BCSP) in England later this year to replace the current test. FIT works in a similar way to the current test by detecting hidden traces of blood in poo that could indicate bowel cancer or pre-cancerous growths known as polyps. An abnormal FIT result suggests that there may be bleeding within the bowel and further investigation is required via colonoscopy or a CT colon.
As part of the bowel cancer screening programme, FIT is used in people with no symptoms and who are otherwise healthy individuals. However as FIT can detect hidden traces of blood in poo that could indicate bowel cancer, it can also be used to help detect bowel cancer in patients who do have symptoms (known as symptomatic patients).
FIT in symptomatic patients
As bowel cancer symptoms can be common and non-specific (for example, unexplained weight loss and abdominal pain), they can be easily attributed to less serious conditions. There is therefore an urgent need to better detect the disease in patients. This is in the hope of getting an earlier diagnosis of bowel cancer, when it is more treatable and even curable, and also to avoid patients being put though unnecessary invasive investigations.
So as well as using FIT as part of the screening programme, last year the National Institute for Health and Care Excellence (NICE) recommended that FIT is used in England to guide GP referral for patients who don’t have rectal bleeding but have unexplained low risk symptoms. These patients with ‘low risk’ symptoms do not usually meet the criteria for urgent referral for suspected bowel cancer, also known as the urgent two week wait (2WW) referral pathway, to receive further investigation. Often they face a delayed diagnosis or have to see their GP a number of times before being referred down the 2WW referral pathway.
FIT can therefore help GPs to better identify and refer the right patients from this patient group quickly for investigation, which could help detect bowel cancer at an earlier stage. An estimated 9 in 10 people will survive bowel cancer if diagnosed at the earliest stage, so early diagnosis is crucial if we are to save more lives.
However, we are also currently investigating how FIT may be used for symptomatic patients that do meet the 2WW referral pathway. Currently in England, the urgent 2WW referral pathway for suspected bowel cancer only picks up cancer in 5-7% of patients that are referred, so there is a need to streamline the referral pathway and reduce the number of unnecessary investigations. This is particularly important because there is a serious lack of workforce capacity within endoscopy and radiology units to meet the demand on services, which has been increasing year on year. The introduction of FIT for symptomatic patients in this patient group may therefore be used as a triaging test by clinicians before referral to further urgent investigations whilst making sure those with non-specific symptoms are still investigated. It will also help to earlier identify patients with a high risk of having colorectal cancer.
Piloting FIT in symptomatic patients in the East Midlands
Over the last six months we have introduced FIT testing as part of the urgent 2WW referral pathway in Leicester and Nottingham. Whilst the pathways are slightly different between the two hospital trusts, both are using FIT in primary care, with the samples being analysed at the Eastern Bowel Cancer Screening Hub. Patients who have a positive test are then being investigated as per the urgent 2WW referral pathway by the respective hospitals.
Although this is in the initial stages, we have been able to successfully triage patients presenting with potential bowel cancer symptoms using FIT, with approximately 60% of the people tested not requiring further urgent investigation. This has reduced pressure on services and stress for the individual. Crucially it can reduce delays to diagnosis, which can result in a higher chance of a late stage diagnosis. For younger bowel cancer patients, who often have difficulty being diagnosed, using FIT to guide referrals could help to speed up their diagnosis.
FIT in symptomatic therefore has the potential to improve early diagnosis, particularly for patients under 60, whilst also ensuring added pressure to endoscopy and radiology services are avoided.
What’s next for the initiative?
Our initiative in the East Midlands is currently being evaluated as part of the East Midlands Cancer Alliance FIT programme and our results will be used to help guide NHS England about the wider rollout of FIT in symptomatic patients.
The introduction of FIT was only possible by engagement between primary and secondary care. I would like to acknowledge the following: Mr Dan Barnes, UHL Cancer Centre Clinical Lead; Dr Paul Danaher, GP and clinical lead for cancer at Leicester City CCG; Mr Ayan Banerjea, Consultant Colorectal Surgeon; Nottingham Colorectal Service; Dr Caroline Chapman, Programme Hub Manager, Eastern Bowel Cancer Screening Hub.
FIT can therefore help GPs to better identify and refer the right patients from this patient group quickly for investigation