Bowel Cancer and the new test very much FIT for purpose

NO PHARMACEUTICAL INFLUENCE
NO PHARMACEUTICAL INFLUENCE

Bowel Cancer and the new test very much FIT for purpose

Thank you so much to all of you who joined us for a great live webinar on cancer care last Saturday. With well over 300 colleagues logging in all the way from the Scottish Borders to the south of England, and everywhere in-between, we had a really stimulating day of cancer education led by Drs Kate Digby and Sarah Davies. The interactive nature of our webinars and the ability to field your questions and comments live is a real privilege. It was a humbling experience hearing your stories and reflections on cancer care (both personal and professional), and as always I learned a huge amount from the day, as I hope you did too. We would also like to thank Cancer Research UK again for their support of the event. If you were unable to join us live, why don’t you catch up with the on demand version?.

 At the end of the webinar, we asked our colleagues for three learning points from the day. One common learning point was the importance of considering FIT tests for bowel cancer in those presenting with non-specific bowel symptoms who don’t fit a 2-week wait referral pathway. The use of FIT testing has been an important learning point and change in management for me also over the last 18 months or so. Indeed I was discussing this with one of our ANPs this week in the practice - where to go next with a patient in their 50s with non-specific abdominal pain, no red flags, and normal bloods/coeliac screen. FIT test she suggested? Yes absolutely.

 This suggestion is supported by the recently updated NICE guideline on suspected cancer NG12 January 2021, clarifying that we should consider using FIT tests in adults without rectal bleeding who:

•   are aged 50 and over with unexplained:

•   abdominal pain or

•   weight loss, or

•   are aged under 60 with:

•   changes in their bowel habit, or

•   iron-deficiency anaemia, or

•   are aged 60 and over and have anaemia even in the absence of iron deficiency.

 The FIT test has really been a transformative test for helping to identify bowel cancer. Previous to this we, and our patients, were left with highly unsatisfactory options for people with low risk, but not no risk, bowel symptoms. Watch and wait? Risky. Three lots of gFOBTs? Total faff with many patients barely managing one, let alone three samples, and even if they managed all the samples there was a substantial false negative (and positive) rate. Refer for endoscopy? Not a pleasant investigation and not realistic for everyone given the number of presentations we see with bowel symptoms. So up steps the FIT test. A much easier to use single stool test that uses antibodies specific to human haemoglobin, so isn’t influenced by diet, and which gives an objective numerical value rather than relying on subjective estimates of colour change (as the previous gFOBT did). 

It is important to clarify that the NICE advice above relates to symptomatic people, as the cut off value for symptomatic FIT tests and that used in bowel cancer screening are different. The latest NHS England document quotes that if using the symptomatic level cut off of <10 mcg/g the FIT test has a >95% negative predictive value for bowel cancer. All of which brings us on to the other important learning point we had with FIT tests, namely their use in the Bowel Screening Programme. All areas of the UK that use FIT bowel screening have higher cut-offs compared to the symptomatic level (ranging from 80-150 mcg/g), meaning a slightly higher risk of false-negative tests. So we should not be falsely reassured if a patient presents with symptoms, but has had a recent negative screening test. We are going to see more FIT screening tests in England shortly. The flexible sigmoidoscopy screening that was being rolled out was stopped in April 2020. Although effective, the uptake had been lower than hoped and there were significant challenges training enough staff to perform the endoscopies, and then COVID hit. So from April 2021 all those in England that would have been invited for a flexi-sig screening will now be offered a FIT test screening, and the screening age will be dropped from 60 to 50. In Scotland, the screening age is already 50, but frustratingly it will remain at 60 for Wales and Northern Ireland. For excellent information on the bowel screen programmes and contact details if patients have questions, please see Bowel Cancer UK, and if you need further information on FIT testing in symptomatic people since the COVID pandemic, or indeed lots of information on cancer and COVID, please see the excellent Cancer Research UK page - Cancer COVID Hub.

Dr Rob Walker
10th February 2021

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