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This guidance covers the referral of a patient who presents with symptoms suggestive of colorectal or anal cancer to a team specialising in the management of lower gastrointestinal cancer, depending on local arrangements.
The letter from NHS England dated 6.10.2022 states:
All GPs should now implement the recommendations in this NICE accredited, evidence-based guidance, in full. In particular, the guidance recommends the use of FIT in primary care for patients presenting with all NG12 suspected colorectal cancer symptoms except those with an anal/rectal mass or anal ulceration.
The key change in the process is that all patients being considered for referral to a suspected lower GI cancer pathway, except for those with an anal mass or anal ulceration, should have had a Faecal Immunochemical Test (FIT) completed prior to a final decision to refer.
FIT test requests will be carried out by the laboratory irrespective of the criterion marked on the form.
Please note that the national screening programme also uses FIT, but at a much higher threshold for asymptomatic patients. This is not considered adequate to exclude serious disease in the symptomatic patient. A recent normal national screening FIT should not affect your decision making in assessing the symptomatic patient and repeating a FIT test as appropriate.
All patients with an abnormal FIT test should be referred for investigation for possible colorectal cancer.
Patients with a normal FIT test are unlikely to have colorectal cancer.
History should include key features such as:
Examination should include:
All patients with suspected colorectal cancer (including those with rectal bleeding – see guidance below on sample collection) should have a Faecal Immunochemical Test (FIT) completed prior to referral via the ‘Suspected Lower GI Cancer’ pathway.
1. Unexplained anal mass or unexplained anal ulceration – to be referred without need for FIT test.
Please note that the national screening programme also uses fit, but at a threshold of abnormality in the asymptomatic patient of 120mcg/g. This is not considered adequate to exclude serious disease in the symptomatic patient. A recent normal screening FIT should therefore not affect your decision making in assessing the symptomatic patient.
Who should get a FIT test?
How do I order a FIT test?
How should the FIT sample be collected?
Can I refer without a FIT test?
In exceptional circumstances a patient may be either unable or unwilling to complete a FIT test. If this is the case, and the GP has significant concern about the possibility of a colorectal cancer, a referral can be sent explaining why a FIT test has not been possible.
Could waiting for the FIT test result cause the patient harm?
In exceptional circumstances the GP may encounter a patient with symptoms of such severity that they are concerned a delay associated with FIT testing will adversely affect outcome. If this is the case, we recommend the clinician consider whether inpatient rather than outpatient assessment is the correct route. The delays incurred by FIT testing, a few days at most, do not represent a concerning delay to cancer treatment.
How should I interpret a FIT test result?
1. All patients with a positive FIT test should be referred to investigate possible cancer via the Lower GI Suspected Cancer Pathway, quoting the FIT result in the referral.
2. All patients with iron deficiency anaemia (IDA) should be referred to the lower GI pathway irrespective of FIT result, but should still be accompanied by the FIT test. This is because anaemia is known to reduce FIT test accuracy and patients with IDA still need investigating as usual. The British Gastroenterology Society recommends that IDA should be investigated with both upper and lower GI endoscopy.
3. In patients meeting the criteria for referral for suspected cancer, but who have a negative FIT result, the likelihood of colorectal cancer is extremely low.
a. Consider whether there are factors such as anaemia present that could give an inaccurate FIT result. If this is the case, refer the patient to the Lower GI Suspected Cancer Pathway.
b. Where the patients’ symptoms raise a high clinical concern of serious disease, for example (but not restricted to) the presence of abdominal pain in combination with weight loss, consider referral to a suspected cancer pathway for a non-colorectal site such as upper GI, Urology or Gynaecology if the criteria for these pathways are met.
c. Where patients’ symptoms are associated with a lower risk of cancer, for example less pronounced changes in bowel habit as an isolated symptom, consider reassessment of the patient with appropriate safety netting. Under these circumstances you might also consider performing a second FIT test. You could also consider seeking advice on symptom management via a routine referral.
d. If despite a negative FIT test, you continue to have strong suspicion of a colorectal cancer, you can continue to refer to the Lower GI Suspected Cancer pathway.
4. In patients over the age of 50 who do not meet the criteria for suspected cancer referral to any site, but in whom you have ordered a FIT test giving a negative result.
a. Manage the patient in primary care with appropriate safety netting.
b. If symptoms persist or deteriorate, reassess the patient and consider referral as appropriate.
Referrals will be triaged, and this may result in the patient
Please prepare the patient for these possible outcomes, and explain that because they are being investigated for possible cancer it is important they attend the earliest possible appointment offered.
Publication date: November 2016
Updated: December 2022