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NICE Recommends FIT Testing Strategy for Colorectal Cancers

The National Institute for Health and Care Excellence (NICE) has issued advice to GPs that all patients with signs or symptoms suspicious of colorectal cancer be offered a faecal immunochemical test (FIT).

There are 42,000 new cases of colorectal cancer each year according to Cancer Research UK. It is the fourth most common cancer in the UK.

Current NICE guidance dating from 2017 is that FIT be used to guide primary care referral for suspected colorectal cancer in people without rectal bleeding who have unexplained symptoms but do not meet the criteria for a suspected cancer pathway referral. This meant that FIT had been offered to some people presenting to primary care with symptoms suggestive of colorectal cancer, while others were immediately referred on the suspected cancer pathway, which includes a colonoscopy.

Under its new draft guidance, NICE said that all such patients should receive a home FIT kit. It said that the rationale for extending FIT testing was "to reduce the waiting times for a colonoscopy". There were sometimes "long wait times" because "colonoscopy capacity is limited", NICE explained. 

FIT First Could Halve Urgent Colonoscopy Referrals 

"Many people on the suspected colorectal cancer referral pathway do not have any unusual findings at colonoscopy," NICE said. Using FIT first "could mean that people who are unlikely to have colorectal cancer may avoid colonoscopy, and those that are likely to have colorectal cancer can be prioritised more effectively".

The strategy could reduce the number of people referred for colonoscopy unnecessarily, thus freeing up appointments for more non-urgent referrals and reducing the waiting times to allow people on non-urgent referral pathways to be seen more quickly. NICE estimated that this could lead to 50% fewer referrals for urgent colonoscopies being made by GPs in primary care settings each year.

For people where there was "ongoing clinical concern", the guidance remained to refer immediately to secondary care. The committee agreed that it was important that GPs could still refer patients for colonoscopy without a positive FIT result if they thought it was necessary and symptoms were persisting.

NICE's diagnostic advisory committee recommended either the HM-JACKarc or OC-Sensor quantitative FIT, both of which require patients to send their sample by post to a laboratory for analysis, with results taking up to a week. The tests cost between £4 and £5 per sample and can correctly identify about 90% of those with colorectal cancer. Colonoscopies are about 97%, although some research say it is closer to 94%.

People with 10 or more micrograms of haemoglobin in their faeces should be referred for further investigation with colonoscopy, or CT colonography, NICE said. Further research was recommended to evaluate other tests, higher haemoglobin thresholds, and methods for improving uptake and return of FIT. 

Faster Diagnosis

Mark Chapman, interim director of medical technology and digital evaluation at NICE, said: "Ensuring people receive a fast diagnosis must be a priority to allow treatment to get started as soon as possible.

"We know the demand for colonoscopies is high, so recommending the use of FIT in primary care could identify people who are most likely to have a condition that would be detected by colonoscopy," he said. "Introducing FIT to people as an initial test will also mean that those who are unlikely to have colorectal cancer may avoid having a colonoscopy, and those who are more likely to have it can be prioritised. We hope this will reduce waiting times because fewer people will be receiving a colonoscopy they don't need.

"These recommendations ensure we are balancing the best care with value for money, while at the same time delivering both for individuals and society as a whole."

Asked to comment by Medscape News UK, Dr Lisa Wilde, director of research and external affairs at Bowel Cancer UK, said: "Those with low risk symptoms, especially younger people, often face a delayed diagnosis or have to see their GP a number of times before being referred for further tests. 

"This guidance will help GPs better to identify and refer the right patients for further testing quickly, and could help detect bowel cancer at an earlier stage when it is more treatable and curable," she said.

FIT Test Should Not Become the Only Criteria for Referral: RCGP

In a statement to Medscape News UK, Professor Kamila Hawthorne, chair of the Royal College of GPs, said: "FIT tests can be useful tools, and given the long waiting lists for colonoscopies, they have an important role to play in identifying when referrals on to secondary care are most necessary. However, it's important that this does not become the only, or primary, criteria for referral. FIT tests are not 100% accurate and GPs, as highly qualified medical professionals, still need to be able to refer urgently based on their clinical suspicions.

"Our priority is patient care. We want to ensure a cancer diagnosis is made in as timely a way as possible, and so we need to ensure that patients who do not complete their FIT test are not excluded from secondary care support and still have access to appropriate investigation," she said.

The draft guidance has been released for consultation until Wednesday 19 July, with a second diagnostics advisory committee meeting scheduled for 27 July, after which the recommendations may change.