FIT for symptomatic patients Facilitator name

Context – colorectal cancer

Colorectal cancer in the UK 41,804 new cases in 2015 15,903 deaths in 2014 Fourth most common cancer Second most common cause of cancer death

Many patients with bowel cancer are diagnosed at a late stage, when the chances of surviving are poorer. For those patients diagnosed early (stage 1) – more than 9 in 10 patients survive their bowel cancer for 5 years or more - Starkly, for those patients diagnosed with late stage (stage 4) – less than 1 in 10 patients survive their bowel cancer for 5 years plus For 5-year survival by stage, until there’s a publication for England-wide stats in June 2018, we only have this data for the East of England area (hence the footnote in the infographic), and have to assume that it’s representative enough of the rest of England until we get better data.

HOW AND WHEN BOWEL CANCER PATIENTS ARE DIAGNOSED Though bowel screening is an important part of cancer control, the majority of bowel cancer patients are diagnosed symptomatically. This infographic is based on the latest Routes to Diagnosis information, illustrates both the route of referral to diagnosis – screening, 2WW, Routine GP etc., and also the recorded stage at the point of diagnosis. In colorectal cancer, only 44% of cancers are diagnosed at an early stage I & II).

Optimising recognition and referral

NICE Cancer Recognition and Referral guidelines – NG12 June 2015 NG12 released, giving new recommendations for recognition and referral of suspected cancer in primary care Patients with higher risk symptoms recommended for urgent suspected cancer referral (2WW) Faecal occult blood testing recommended for patients with ‘low risk but not no risk’ signs/symptoms Varied local implementation of low risk recommendation July 2017 Diagnostic guideline (DG) 30 released recommending use of Faecal Immunochemical Test (FIT), a type of faecal occult blood test, in low risk but not no risk patients DG30 replaced recommended 1.3.4 in NG12 In NG12 there were major changes to the suspected cancer pathway for colorectal cancer. The 6 week time period for change in bowel habit was removed along with the levels of haemoglobin for IDA and abdominal pain included. This was due to evidence from primary care studies that reflect the importance of mild anaemia and abdominal pain as important presenting symptoms. The biggest change was the inclusion of a positive faecal occult blood test as a criteria for placing a patient on a suspected cancer pathway. Willie Hamilton, who was involved in the development of the guidance, still believes that inclusion of a positive FIT will save the most lives.

Patients recommended for Suspected Cancer Pathway (2WW) Refer on 2WW if: ≥40y with unexplained weight loss and abdominal pain ≥50y with unexplained rectal bleeding ≥60y with iron deficiency anaemia (IDA) or change in bowel habit Positive faecal occult blood test Consider referral on a 2WW if: Rectal or abdominal mass <50y and rectal bleeding + any of: abdominal pain, change in bowel habit, weight loss or IDA In NG12 there were major changes to the suspected cancer pathway for colorectal cancer. The 6 week time period for change in bowel habit was removed along with the levels of haemoglobin for IDA and abdominal pain included. This was due to evidence from primary care studies that reflect the importance of mild anaemia and abdominal pain as important presenting symptoms. The biggest change was the inclusion of a positive faecal occult blood test as a criteria for placing a patient on a suspected cancer pathway. Willie Hamilton, who was involved in the development of the guidance, still believes that inclusion of a positive FIT will save the most lives.

For the ‘low risk’ but not no risk patients… Patients without rectal bleeding who: Are aged 50y or over with abdominal pain or weight loss Aged <60y and have a change in bowel habit or IDA Aged 60y or over and have anaemia, even in the absence of iron deficiency …...Offer them a FIT This is new to the suspected cancer pathway and is for those patients who do not currently meet the criteria for a 2WW referral due to either age or symptom profile. These patients are classed as low risk, but not no risk – and that is why this test has been included in the pathway for colorectal cancer in NG12 with the rationale that if any of these patients have cancer then it is more likely to be picked up at an early stage and in those patients who do not have cancer it means that they may not need to undergo a colonoscopy, thus reducing the demand on endoscopy services. Currently GPs have few options for their management and the Devon FIT audit suggested that a significant proportion of these patients are currently being referred into secondary care, including on a 2WW referral. After NG12 was published, lots of CCGs and health professionals were not happy with the guidance being vague about using ‘a faecal occult blood test’ and not specifying FIT for this – so they chose not to commission anything, meaning some patients were missing out on the FIT test, and others were being sent for a colonoscopy – basically inappropriately managed either way There was some backlash that NICE should have specifically said it should be FIT as the test to use (see this letter) http://www.bmj.com/content/350/bmj.h3044/rr-0 The DG30 guidance was prepared as a result Whether it increases or decreases demand on endoscopy depends on how the locality was dealing with this group of patients between NG12 and DG30 being published.

What is FIT? Specific to human haemoglobin (unlike the guaiac occult blood test) It is being rolled out into the bowel screening programme, but with a very different cut off to determine an abnormal test There are also some projects investigating its use as a triage test in more high risk symptomatic patients So there’s a lot of confusion to overcome FIT is a type of faecal occult blood test

To help address the confusion The National Clinical Director for Cancer, Chris Harrison, wrote to Cancer Alliances in February 2018 Advises Cancer Alliances to prioritise the full implementation of DG30 (use of FIT in the low risk but not no risk patients) Does not encourage the use of FIT in high risk patients (those meeting the criteria for 2WW suspected cancer URGENT referral) Where a CA is interested in exploring the use of FIT in high risk patients, they are advised to do so through the National Pilot Programme or the NIHR study

Facilitators to include here any local pathways and other local information relating to implementation. Local pathways

Broad Principles of how FIT will work locally GP offers test to eligible patient Patient completes test and returns the kit to the lab for processing Safety-netting Result to GP – communication with patient Negative FIT This is an example slide – Facilitators can remove this one and replace it with a diagram showing local pathways. Positive FIT ie [FHb] ≥10µg/g Safety-netting Symptoms persist Symptoms resolve Safety-netting 2WW pathway NFA Further investigations

What should GPs and the practice teams be aware of? Not all patients with bowel cancer will have a positive FIT test, so it’s important to remain vigilant Some of the symptoms in the low risk, not no risk group may be linked to cancers other than bowel cancer FIT thresholds used in screening is different to FIT thresholds in symptomatic patients This means that patients who have a negative screening result may still have bowel cancer and should be offered a symptomatic FIT test if appropriate This slide will be updated following further discussions around what FIT specific safety-netting will look like. If local arrangements have already been agreed then they can be put in here in place of this slide. Or the slide removed if this has yet to be discussed. Will somewhat depend on the pathway that the local Trusts are using eg is the GP giving the patient the test directly or will the patient need to phone up to be sent one/GP arrange for patient to be sent a kit. This can be replaced with a local slide if as part of local implementation specific safety-netting processes have been introduced.

How CRUK facilitators can support

How can our local Facilitators support FIT implementation? Promotion of symptomatic FIT at practice visits Supporting the organisation and delivery of GP education events Supporting practices to increase familiarity with local pathways Facilitating discussions around symptomatic FIT specific safety-netting to practices Supporting practices to conduct appropriate audits and SEAs

Thank you. Any questions? Local facilitator contact details